Citation Nr: 0310010 Decision Date: 01/09/03 Archive Date: 06/02/03 BOARD OF VETERANS' APPEALS DEPARTMENT OF VETERANS AFFAIRS WASHINGTON, DC 20420 DOCKET NO. 97-12 825 ) DATE jan 09, 2003 ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana THE ISSUE Entitlement to service connection for a cardiovascular disability to include hypertension, claimed as secondary to post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Parakkal, Counsel INTRODUCTION The veteran served on active duty from December 1969 to October 1971. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a March 1995 RO decision which denied the veteran’s claim of service connection for “hypertension with a permanent pacemaker.” In the March 1995 decision, it was concluded that the veteran’s hypertension was not secondary to PTSD. The Board has broadened the issue (as styled on the cover page) in order to better represent the veteran’s interests. It is noted that the Board, in a July 1981 decision, denied service connection for hypertension on a direct basis, only. As such, the veteran’s claim of service connection for hypertension, claimed as secondary to PTSD, is not subject to finality considerations. Spencer v. Brown, 17 F3d. 368 (Fed. Cir. 1994); Harder v. Brown, 5 Vet. App. 183 (1993). FINDING OF FACT The veteran has coronary artery disease and hypertension which was caused by PTSD. CONCLUSION OF LAW Coronary artery disease and hypertension were caused by PTSD. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.310 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty from December 1969 to October 1971. A review of the veteran’s service medical records shows that in July 1969, the veteran was seen for complaints of dizziness and it was noted that his blood pressure was 124/84. A December 1969 examination report shows that the veteran’s heart was normal, and his blood pressure was 138/88. In April 1970, the veteran complained of dizziness, and a pounding heart. He related he had experienced such problems for the previous four months. Blood pressure readings over a three day period were 160/80, 160/80, 140/76, 120/60, 140/110, and 108/70. The diagnosis was hypertension. A September 1971 separation examination report shows that the veteran’s blood pressure was 124/82, and his heart was noted as normal. In March 1972, a blood pressure reading was 140/80. On VA examination in July 1975, the veteran’s blood pressure was 150/82. By a July 1981 decision, the Board denied service connection for hypertension. A July 1982 VA examination report shows that the veteran complained of high blood pressure. Following an examination, the diagnoses included hypertension. Private and VA treatment records, dated in the 1990s, 2000, and 2001, show that the veteran was treated for both hypertension and psychiatric problems. In December 1990, the veteran underwent a pacemaker and lead change. By a September 1994 RO decision, service connection for PTSD was granted and a 30 percent rating was granted effective September 28, 1992. In an August 1995 statement, a licensed clinical professional counselor indicated she had worked with the veteran for one year, dealing with his issues of PTSD. It was noted his flashbacks and dreams had been so overpowering that they had caused a great deal of physical stress. It was noted that his (psychiatric) symptoms may appear with his heart condition and his high blood pressure. She indicated that she hoped that as his psychiatric problems were dealt with, his blood pressure would lower. At an April 1996 RO hearing, the veteran testified he had hypertension for 20 years. He said a PTSD counselor, among other doctors, had linked his hypertension with his PTSD. At March 1998 and December 1998 RO hearings, the veteran testified that he was diagnosed as having hypertension in 1981. He said that hypertension was tied to PTSD. The veteran was hospitalized in a VA facility in March 2000 for treatment of psychiatric problems. It was noted that when he would talk about his war experience he would start breathing heavily and experience chest pain. The final diagnoses include PTSD, hypertension, coronary artery disease with a history of myocardial infarct, unstable angina, and status-post pacemaker (times four). A December 2001 VA cardiology examination report reflects the opinion that the veteran’s heart disease was not caused by his PTSD and was not significantly affected in its progression by PTSD. The examiner indicated he was not aware of any causal relationship between PTSD and coronary atherosclerosis. A November 2002 VA hypertension examination report reflects that the examiner reviewed all four claims folders, examined the veteran, and took a history from him. The report shows that the veteran reported having hypertension since the mid 1970s, which was when he first started having his PTSD problems. It was noted that in April 1970, he had a systolic reading of 160 and a diastolic reading of 110, over five blood pressure readings. It was also noted that his pulse rate changed from 92 to 130, suggesting that hypertension was of the reactive type. Following an examination and a review of the claims folder, the impressions were: 1) well-established PTSD and a history of major depression; 2) a history of reactive blood pressure as early as in service and in the mid 1970s, and then evidence of sustained hypertension since the mid 1990s; and 3) coronary artery disease (by history), which has not required surgical intervention. Stress tests were noted as non-diagnostic. An EKG was noted as currently showing evidence of ischemic heart disease, and a normal sinus rhythm with first degree AV block with left axis deviation of approximately minus 90 degrees. It was noted that the findings of 1+ pitting edema with venous statis dermatitis suggested congestive heart failure. The examiner opined that it was as likely as not that the veteran’s PTSD caused hypertension since hypertension correlated fairly well with anxiety and then later PTSD. It was opined that the progression of the PTSD had effected the progression of hypertension. It was opined that the veteran’s heart block was not related to PTSD. It was related that his coronary artery disease (which was non-specific) was probably related to his hypertension which in turn was related to his PTSD. As support for his rationale, the examiner noted that the veteran did not have a family history of hypertension. II. Legal Analysis Veterans Claims Assistance Act of 2000 (VCAA) There has been a significant change in the law during the pendency of this appeal with the enactment of the VCAA. 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107; 66 Fed. Reg. 45,620 (Aug 29, 2001) (to be codified as amended at 38 C. F. R. § 3.159. The new law includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. 38 U.S.C.A. § 5107 note (Effective and Applicability Provisions). See also Karnas v. Derwinski, 1 Vet. App. 308 (1991). In this case, the veteran was notified in a Supplemental Statement of the Case of the provisions of the VCAA and the evidence needed to prove his claim. The Board notes that the veteran and his representative were afforded ample opportunity to present evidence and argument in support of his claim. There is sufficient evidence of record to decide the claim, and VA has satisfied its duties to notify and to assist the veteran. More importantly, there is no prejudice to the veteran in proceeding with this appeal as this decision results in a grant of the benefit sought on appeal. Bernard v. Brown, 4 Vet. App. 384 (1993). Basic Laws and Regulations Regarding Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service incurrence for hypertension will be presumed if manifest to a compensable level within one year of the veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection will be granted when a disability is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection may be established for a disability which is aggravated by a service-connected disability. Allen v. Brown, 8 Vet. App. 374 (1995). In the instant case, the record reveals that during service, in April 1970, the veteran complained of a pounding heart and the following blood pressure readings were noted: 160/80, 160/80, 140/76, 120/60, 140/110, and 108/70. It was concluded that he had hypertension. On separation examination in September 1971, it was noted that his heart was normal; his blood pressure was listed as 124/82; and hypertension was not diagnosed. Over the years, the veteran has undergone multiple VA examinations, some of which address the etiology of his heart and blood pressure problems. Specifically, a December 2001 VA cardiology examination report reflects the opinion that the veteran’s heart disease was not caused by his service-connected PTSD. A November 2002 VA hypertension examination report reflects the opinion that the veteran had sustained hypertension beginning in the mid-1990s. Further, it was opined that it was as likely as not that PTSD caused hypertension since hypertension correlated fairly well with anxiety and PTSD. It was also noted that coronary artery disease was probably related to his hypertension. Finally, it was noted that the veteran’s heart block was not related to PTSD. In sum, it is noted that there are multiple etiological opinions on file which regard hypertension. The December 2001 VA opinion is to the effect that there is no causal relationship between hypertension and service-connected PTSD. Conversely, the November 2002 VA opinion is to the effect that there is a causal relationship between hypertension and service-connected PTSD, and a probable casual connection between hypertension and coronary artery disease. The Board finds the November 2002 opinion to be more probative than the December 2001 opinion. Further, it is consistent with other medical evidence on file including the August 1995 statement from a professional counselor. Specifically, the November 2002 VA examination report was very thorough and not only included a review of the veteran’s medical records, but also an examination. Further, the examiner provided a rationale for the given opinion, noting that the veteran did not have a family history of hypertension and noting that hypertension tracked his psychiatric problems. The 2001 opinion is not nearly as thorough as the 2002 opinion and provides little rationale for the provided conclusory opinions. Giving the veteran the benefit of the doubt, the Board concludes that coronary artery disease and hypertension were caused by service-connected PTSD, and the claim is allowed. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.310. ORDER Service connection for coronary artery disease and hypertension is granted. H.N. SCHWARTZ Member, Board of Veterans’ Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled “Appeal to the United States Court of Appeals for Veterans Claims.” (1) A “Notice of Disagreement filed on or after November 18, 1988” is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA’s General Counsel. ? In the section entitled “Representation before VA,” filing a “Notice of Disagreement with respect to the claim on or after November 18, 1988” is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.