IN THE CASE OF: BOARD DATE: 28 July 2020 DOCKET NUMBER: AR20180010564 APPLICANT REQUESTS: correction of his records to show his atrial fibrillation occurred in the line of duty (LOD) APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * 2 Memorandum pertaining to a LOD determination * Medical documents * DD Form 24 (Certificate of Release or Discharge from Active Duty) * Orders * Email FACTS: 1. The applicant states his diagnosis of atrial fibrillation remains not in LOD. According to the governing regulation "An injury, disease, or death is presumed to be in LOD unless refuted by substantial evidence contained in the investigation." Despite this requirement, the approving authority wrote, "nothing in service-member's military duties/activities would have cause a change in heart rhythm," which is a direct contradiction of the facts included in the investigation. He submitted evidence documenting his diagnosis and treatment for high blood pressure while deployed to Iraq. It is well documented that high blood pressure is a cause of atrial fibrillation, as provided by the Mayo Clinic, the American Heart Association, and the National Heart, Lung, and Blood Pressure Institute under the National Institutes of Health, in addition to his attending physician. 2. The applicant is currently serving in the Army National Guard. 3. The applicant was order to active duty in support of Operation Iraqi Freedom. He entered active duty on 25 April 2009. He served in Kuwait and Iraq from 21 July 2009 to 22 April 2010. 4. On 21 June 2010, he was honorably released from active duty due to completion of required active service. He completed 1 year, 1 month, and 27 days of net active service this period. 5. The LOD investigation is not available for review; however, the applicant provides a memorandum he composed appealing his LOD determination, dated 9 November 2017. The memorandum states, in part: a. The approving authority points to the governing regulation as the reason for her determination. He believes this to be a misinterpretation of the regulation, however, because it is taken out of context, and because it ignores the plain language of the rest of the regulation. Further, there is no refutation of the evidence presented that the atrial fibrillation was, at the very least, an aggravation of a condition that occurred while he was deployed to Iraq in 2009. While the governing regulation states simply being in an authorized status does not ensure an LOD determination, it also devotes several more paragraphs to making clear there is a presumption that an injury or disease is in the LOD and the LOD determination should be upheld unless overcome by substantial evidence. b. The governing regulation states an injury, disease, or death is presumed to be in the LOD unless refuted by substantial evidence contained in the investigation. This makes clear there is a presumption that an injury is LOD, unless some stronger evidence proves that it is not. Therefore, the bar is at LOD and can only be found not LOD if there is significant evidence pointing to the contrary. The only evidence the approval authority points to is the cardiologist was unable to determine an exact date for when the atrial fibrillation began. Not only does that not disprove LOD, but it does not rise to the level of evidence required to find not in the LOD, and it disregards the presumption of health upon entering the military. The presumption is a Soldier was in sound physical condition when he entered the military service. This presumption can be overcome only by substantial evidence. c. He entered active duty in the Air Force in 1982, and had no signs or symptoms of atrial fibrillation. He joined the North Carolina National Guard in 1987 with no signs or symptoms of atrial fibrillation. He deployed to Kuwait in 1998 and then to Afghanistan in 2003-after having attended multiple Soldier Readiness Processing events all with medical components that never detected atrial fibrillation. He then deployed to Iraq in 2009, did not have any signs or symptoms of atrial fibrillation. During his deployment to Iraq in 2009, he was diagnosed with high blood pressure-not having been diagnosed with such ever before-which was a result from the stresses of that deployment. He was prescribed medications for the high blood pressure and finished that deployment. It is well-established that high blood pressure is a contributing factor to atrial fibrillation. There is zero evidence otherwise included with this investigation, let alone anything that would rise to the standard of "substantial evidence." Therefore, the determination is required to be LOD. The complete memorandum is available for the Board's review and consideration. 6. In response the memorandum for appeal of the applicant's LOD determination, the applicant provides a memorandum, dated 5 June 218, from the Adjutant General, U.S. Army Human Resources Command (AHRC), which states: a. AHRC Casualty and Mortuary Affairs Operations Division received your request for an appeal regarding the finding of your Line of Duty Investigation related to your condition of asymptomatic atrial fibrillation with rapid ventricular response. Your appeal letter dated 9 November 2017, was a part of the original case file reviewed by the National Guard Bureau. b. After a completed review and in accordance with Army Regulation 600-8-4 (Line of Duty Policy, Procedures, and Investigations), paragraph 4-17 (a) (1 ), substantial new evidence must be submitted for our office to analyze your case and render a determination. Your appeal does not include any new evidence from the initial investigation. Based on AR 600-8-4, AHRC is unable to consider your appeal for a different LOD finding. c. Should you wish, you may appeal to the Army Review Boards Agency, 251 18th Street South, Suite 385, Arlington, VA 22202-3531. Along with your appeal, a DD Form 149 (Application for Correction of Military Records), any additional evidence, and this letter must accompany your paperwork. 7. Army Regulation 600-8-4 prescribes policies and procedures for investigating the circumstances of disease, injury, or death of a Soldier providing standards and considerations used in determining LOD status. 8. The Army Review Board Agency (ARBA) Medical Advisor reviewed the supporting documents and the applicant's records in iPERMS, the Armed Forces Health Longitudinal Technology Application (AHLTA), Health Artifacts Image Management Solutions (HAIMS) and the VA's Joint Legacy Viewer (JLV) and made the following findings and recommendations: a. This applicant is currently awaiting a Non Duty Related Formal PEB to take place on 31Jul2020 concerning a fitness determination for the Atrial Fibrillation condition. The Formal Line of Duty (LOD) Investigation ruled Not in LOD-Not due to Misconduct. The applicant is requesting a reconsideration of the LOD determination contending both that the Atrial Fibrillation was diagnosed while he was on duty and secondly, that the Atrial Fibrillation was secondary to his Hypertension condition which the VA has service connected. The cardiologist indicated the start of the arrhythmia is unknown. It is known that it began sometime between May 2016, when the applicant had normal sinus rhythm during a pre operative evaluation by anesthesiologist; and 05Nov2016 when the applicant had an EKG for a routine age related National Guard physical exam and the Atrial Fibrillation was found. It was an incidental finding, the applicant had no symptoms. b. There is no LOD for the Hypertension condition. The 11Feb2010 Theatre Clinic note annotates “sm with previous diagnosis of hypertension is here for follow up. He feels his blood pressure is increased. He can’t verbalize what he feels that isn’t right he can just tell because he feels ‘off’ when it’s elevated”. During that visit he reported a 1.5 year history of blood pressure problems and being prescribed medication for treatment for 1 year. The reviewer found no military records prior to this visit for blood pressure treatment. During the 22Nov2010 C&P Hypertension exam, it is recorded that the condition onset was in 2004 when at that time he was having chest pain and he was told by a physician he had high blood pressure and was placed on medication. It is the opinion of the reviewer that the applicant’s Hypertension condition is not service incurred because the applicant reported he had the diagnosis and treatment for such before the first military treatment visit. c. As previously mentioned, the applicant had no symptoms associated with the atrial fibrillation. The applicant did have non-cardiac factors risk factors (Essential Hypertension, and Obstructive Sleep Apnea) that could contribute to atrial structural abnormalities that may lead to atrial fibrillation; but his echocardiogram (ECHO) showed no structural abnormalities in the atria, ventricles or valves. Specifically with hypertension, the ECHO might show ventricular hypertrophy or dilatation, or secondary atrial enlargement, but the applicant’s ECHO did not. It did show mild decreased systolic ejection fraction. It should also be noted, in the 12Jan2017 follow up visit with his cardiologist, the applicant divulged that his brother had mitral valve disease and atrial fibrillation. Early onset (less than age 60) and having no cardiac structural abnormalities is associated with familial atrial fibrillation. Again, it is unknown when the applicant developed the atrial fibrillation but it is likely due to his Hypertension, OSA, or genetics or a combination of these. To determine the true etiology would be speculation on the reviewer’s part as well as outside the expertise. d. Although it does not appear that there was an event or incident in the military that caused or aggravated the atrial fibrillation condition, in determining whether the Atrial Fibrillation condition is in LOD or not, the medical evidence should be weighed against the fact that the condition was discovered while the applicant was on duty for the National Guard. The 17Oct2017 Permanent P3 Profile for Atrial Fibrillation showed the applicant had significant physical limitations per civilian cardiologist. The condition does not meet retention medical standards IAW AR 40-501. BOARD DISCUSSION: After review of the application and all evidence, including the applicant’s statements, supporting documents, prior HRC decisions, and the ARBA Medical Advisory opinion, the Board determined there is insufficient evidence to grant relief. The Board found no error or injustice in the prior determination by the HRC regarding the applicant's LOD determination. The applicant did not provide and the record is void of the original LOD investigation and determination, which may have provided important evidence for the Board to consider. The Board agreed with the ARBA Medical Advisory that there is insufficient evidence that the applicant’s hypertension or atrial fibrillation is service connected as the applicant reported he had the diagnosis and treatment for such in 2004, before the first military treatment visit on 11Feb2010. ? BOARD VOTE: Mbr 1 Mbr 2 Mbr 3 : : : GRANT FULL RELIEF : : : GRANT PARTIAL RELIEF : : : GRANT FORMAL HEARING : : : DENY APPLICATION BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. REFERENCES: Army Regulation 600-8-4 (Line of Duty Policy, Procedures, and Investigations) prescribes policies and procedures for investigating the circumstances of disease, injury, or death of a Soldier providing standards and considerations used in determining LOD status. a. A formal LOD investigation is a detailed investigation that normally begins with DA Form 2173 (Statement of Medical Examination and Duty Status) completed by the medical treatment facility and annotated by the unit commander as requiring a formal LOD investigation. The appointing authority, on receipt of the DA Form 2173, appoints an investigating officer who completes the DD Form 261 and appends appropriate statements and other documentation to support the determination, which is submitted to the General Court Martial Convening Authority for approval. b. The worsening of a pre-existing medical condition over and above the natural progression of the condition as a direct result of military duty is considered an aggravated condition. Commanders must initiate and complete LOD investigations, despite a presumption of Not In the Line of Duty, which can only be determined with a formal LOD investigation. c. An injury, disease, or death is presumed to be in LOD unless refuted by substantial evidence contained in the investigation. LOD determinations must be supported by substantial evidence and by a greater weight of evidence than supports any different conclusion. The evidence contained in the investigation must establish a degree of certainty so that a reasonable person is convinced of the truth or falseness of a fact. d. In determining whether an injury, illness or death of a Reserve Component Solider was caused by any incident while traveling to or from an active duty order or duties defined above, consider * whether training was authorized or required, that is complying with orders * the hour travel began * the time when the Soldier was scheduled to arrive for duty, or when the Soldier ceased to perform such duty * the method of travel * the travel time authorized * whether the best or most direct route was used * the immediate cause of injury, illness, or death e. Chapter 5 outlines LOD procedures for U.S. Army Reserve and Army National Guard Soldiers and states a Soldier requiring treatment for an emergency medical or dental condition while in a qualified duty status is authorized an interim LOD determination for initial medical care only. This authorizes emergent care, unless clear and unmistakable evidence shows the condition was the result of the member’s gross negligence or misconduct. An interim LOD must be initiated within 10 days following completion of qualified duty to continue treatment, if indicated, for covered conditions. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20180010564 6 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1