Citation Nr: 0912815 Decision Date: 04/07/09 Archive Date: 04/15/09 DOCKET NO. 04-16 551A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for cardiovascular disability (to include coronary artery disease and/or hypertension) as secondary to the veteran's service connected post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Rebecca Patrick, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The veteran served on active duty from May 7, 1973 to May 18, 1973; and from October 1973 to September 1982; and from November 1990 to April 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The veteran presented testimony at a Board hearing in February 2009. A transcript of the hearing is associated with the veteran's claims folder. FINDING OF FACT The evidence of record is in equipoise on the question of whether the Veteran's coronary artery disease and hypertension are secondary to his service-connected PTSD. CONCLUSION OF LAW Coronary artery disease and hypertension are proximately due to the veteran's service-connected PTSD. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.310(a) (2008). REASONS AND BASES FOR FINDING AND CONCLUSION Service Connection The issue before the Board involves a claim of entitlement to service connection. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular disease, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service- connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet.App. 439 (1995). The veteran contends that his current heart problems, to include coronary artery disease, were caused by or aggravated by his service connected PTSD. At his February 2009 Board hearing, he pointed out that he has presented four medical opinions that substantiate his belief. These opinions are discussed below. The veteran submitted a January 2005 correspondence from a VA outpatient treatment physician (Dr. M.B.G.) that states in toto: "To Whom It May Concern: I have been treating the veteran for coronary artery disease. I have reviewed the previous medical records and my current treatment records and believe that it is more likely than not that the cardiac conditions are directly related to and aggravated by PTSD, a service connected condition." The veteran subsequently submitted the results of an internet search from the georgia.gov website. The printout reflects that according to the Composite State Board of Medical Examiners, Dr. M.B.G.'s specialty is "Cardiovascular Disease/Cardiology." The veteran underwent a VA examination in January 2006. The claims file was not available for review. At the time of the examination, the veteran believed that his coronary artery disease and cerebrovascular disease was caused by exposure to toxic chemicals while in the military. The examiner stated that he did not agree with the veteran. He pointed out that the veteran had a long history of cigarette smoking and hyperlipidemia. He stated that "it is my opinion that he has had premature atherosclerotic disease that is unrelated to military service. I believe that it is less likely than not that his coronary artery disease, myocardial infarction, and cerebrovascular accident is related to military service." The veteran underwent another VA examination in June 2006. The examiner reviewed the claims file in conjunction with the examination. The examiner opined that the veteran's coronary artery disease is less likely as not a result of or aggravated by PTSD. Her rationale was that "there is no current scientific evidence to support a connection between [PTSD] and coronary artery disease. On the contrary; however, persons who have coronary artery disease events are more likely to develop [PTSD]." The veteran submitted an article from a medical journal in which Dr. Joseph A. Boscarino discusses the results from clinical and epidemiologic studies regarding PTSD and physical illness. Dr. Boscarino noted that "there is growing evidence that exposure to psychologically traumatic events is related to increased medical morbidity, including the onset of different diseases and premature mortality. The evidence for cardiovascular disease is particularly strong and comes from a wide range of studies spanning different populations with traumatic exposures." Dr. Boscarino's studies and their findings have been noted in the Federal Register. The veteran submitted a September 2007 report from Dr. J.S.K., who is a retired Colonel in the US Army Medical Corps. and a Clinical Assistant Professor in Psychiatry at the UCLA Neuropsychiatry Institute. He stated that "Although I have not been able to examine [the veteran] directly, I have had a lengthy series of Email exchanges with him and reviewed copies of his records." Dr. J.S.K. noted that he was consulted because the veteran originally hypothesized that his various medical problems were caused by his tour at Edgewood Arsenal in 1974. The veteran hoped that Dr. J.S.K. could confirm this hypothesis since Dr. J.S.K. had recently published a book describing the detailed history of the Edgewood volunteer program. Dr. J.S.K. reported that he could not confirm this hypothesis. However, he did note that the veteran had suffered some genuine traumatic events in service. He provided a thorough history of the veteran from 1973 to the present as well as large excerpts from email exchanges between him and the veteran. Regarding the central issue of whether the veteran's heart problems were caused or aggravated by PTSD, he noted that "Dr. Boscarino's studies, widely accepted scientifically, reveal a previously unexpected but highly significant association between PTSD and medical disorders, including hypertension and arteriosclerotic heart disease...the demonstration of specific impairments of the immune system and abnormalities of hormonal balance resulting from PTSD had not, to my knowledge, been clearly demonstrated before his studies." He ultimately concluded that "In my opinion [the veteran's] hypertension and early onset of arteriosclerotic heart disease is more likely than not caused, or at least severely aggravated, by service connected PTSD." The veteran submitted a March 2008 correspondence from D.W., D.O. (Doctor of Osteopathy). In it, D.W. stated that that he performed an extensive review of the veteran's claims file and the existing medical literature. He did not examine the veteran himself. D.W.'s correspondence included a thorough summary of the veteran's military history and past medical history. He noted that primary risk factors for coronary artery disease include: age, family history, smoking, hypertension, diabetes mellitus and hyperlipidemia. He also noted that males and postmenopausal females are at greater risk. Finally, he noted that generally accepted secondary risk factors include: race, obesity, metabolic syndrome, vascular inflammation, sedentary lifestyle, autoimmune disorders, stress, alcohol, and renal failure. He noted that the veteran has the following risk factors: male gender, smoking history, hypertension, hyperlipidemia, obesity, autoimmune disorder (psoriasis), stress, and alcohol. D.W. opined that it was more likely than not that the onset of the veteran's coronary artery disease occurred (but was undiagnosed) during service. He pointed out that in July 1974, the veteran was diagnosed with a grade 2 systolic ejection murmur; and that he was diagnosed with hypertension in 1982. He noted that the veteran began smoking while in service, thus adding another risk factor for coronary artery disease. He noticed that on several military medical examinations, the veteran complained of fatigue and dyspnea on exertion which are symptoms of ischemic heart disease. Finally, he noted that the veteran suffered his first acute myocardial infarction in 1994 (just three years after service). He stated that cardiovascular disease is a slowly progressive disease in which atherosclerotic plaque deposition over many years leads to an acute cardiac event. As such, the onset of the 1994 acute myocardial infarction likely began years earlier, while the veteran was still in service. He opined that that it was as likely as not that the veteran developed coronary artery disease (which was left undiagnosed) during military service, and that it may have begun as early as 1974, when he was diagnosed with a heart murmur. D.W. also opined that "[the veteran's] posttraumatic stress disorder is a major contributing factor leading to his accelerated (aggravated) coronary artery disease." He once again noted that "It is generally accepted in the medical literature that stress is a secondary factor for the development of coronary artery disease." He referenced the aforementioned studies by Dr. Joseph A. Boscarino. The veteran underwent another VA examination in April 2008. The examiner reviewed the claims file in conjunction with the examination. The examiner opined that it is less likely than not that the veteran's PTSD exacerbated hypertension and his heart condition. The examiner also did not believe that the heart condition was first manifested in service. He explained that "An extensive review was performed on Cochran Library, as well as up to date and I can find no definite scientific evidence to support a connection between [PTSD] and coronary artery disease or hypertension." The veteran submitted a January 2009 correspondence from Dr. J.R.H. (Managing Partner at Palmetto Cardiology Associates and Chief of Cardiology at Providence Hospital) along with his curriculum vitae which reflects substantial training and expertise in the field of cardiology. Dr. J.H.R. conducted an examination of the veteran and he reviewed the veteran's claims file. After examination of the veteran and the claims file, Dr. J.H.R. stated that "I do believe that there is some correlation between stress and cortisol levels. Elevated cortisol levels have been shown to have deleterious side effects on health in general. I do believe that long term administration of corticosteroids can elevate cholesterol and triglyceride levels, both of which are as likely as not to promote cardiovascular disease in general and epicardial coronary disease specifically. It is fairly well established that posttraumatic stress disorders indeed do elevate endogenous cortisol levels...Final summary is that this patient with extensive epicardial coronary artery disease laid down the substrate for coronary artery disease while he was in service. It is as likely as not [the veteran's] PTSD exacerbated his epicardial coronary artery disease and the severity thereof and thus contributed to his epicardial coronary artery disease." The Board notes that the medical evidence (specifically the various opinions regarding a medical nexus) is in conflict. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The Board has carefully considered the conflicting medical opinions of record. The underlying question is clearly medical in nature. The opinions of record all claim to be based on extensive review of medical literature, and they all appear to be supported by a rationale. The Board notes with interest the fact that one medical study apparently recognizing a causal relationship between PTSD and cardiovascular disease was determined to be significant enough to warrant inclusion in the Federal Register. Under the circumstances of this particular case, the Board finds that at the very least, the evidence with respect to secondary service-connection is in approximate balance, with no sound basis for choosing one medical opinion over the other. As the weight of the evidence for and against the claim is at least in relative equipoise on the question of whether the veteran's service-connected PTSD caused or contributed to his development of coronary artery disease and hypertension, service connection for coronary artery disease and hypertension secondary to service-connected PTSD is warranted. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA) requires certain notice and assistance to a claimant for VA benefits. See generally 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). A discussion of compliance with VCAA is not necessary since there is no resulting prejudice to the appellant as a result of any possible VCAA deficiency in light of the Board's favorable decision. The Board notes that required notice regarding effective dates and disability evaluations was furnished to the Veteran by letter in April 2008, followed by readjudication of the claim. See generally Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). ORDER Service connection for coronary artery disease and hypertension secondary to the veteran's service connected PTSD is warranted. The appeal is granted. ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs