Citation Nr: 9813272 Decision Date: 04/28/98 Archive Date: 05/08/98 DOCKET NO. 93-18 260 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for cardiovascular disability secondary to the veteran’s service-connected post- traumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The veteran served on active duty from January 1966 to January 1968. This case was remanded by the Board of Veterans' Appeals (Board) in June 1995 to the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, for additional development. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he should be granted service connection for cardiovascular disease secondary to his service-connected post-traumatic stress disorder (PTSD) because there is medical evidence on file that supports his claim. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence supports the grant of service connection for cardiovascular disability secondary to service-connected PTSD. FINDINGS OF FACT 1. All available evidence necessary for an equitable determination of the veteran’s claim has been obtained. 2. There has been an increase in severity of the veteran’s cardiovascular disease due to his PTSD. CONCLUSION OF LAW Cardiovascular disability is proximately due to or the result of service-connected PTSD. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991); 38 C.F.R. § 3.310(a) (1997); Allen v. Brown, 7 Vet.App. 439 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection is granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. Service connection may be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The United States Court of Veterans Appeals (Court) has held that the term "disability" as used in 38 U.S.C.A. § 1110 (West 1991) refers to impairment of earning capacity, and that such definition of disability mandates that any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, shall be compensated. Thus, pursuant to 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310(a), when aggravation of a veteran's nonservice- connected condition is proximately due to or the result of a service-connected disability, such veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Medical records from the University of Tennessee Medical Center and Charles M. Wender, M.D., reveal that the veteran underwent angioplasty of a diseased right coronary artery in early February 1991 and was hospitalized again later in February 1991 for left heart catheterization, coronary arteriography, which showed partial obstruction of a small branch of the of the left anterior descending coronary artery. Arteriosclerotic heart disease with angina pectoris was diagnosed. According to an April 1992 statement from Carroll E. Rose, M.D., he treated the veteran in January 1991 for an acute myocardial infarction. Dr. Rose concluded in his April 1992 statement and in another statement received by the VA in February 1993 that the extent of the veteran’s cardiovascular disease was causally related to his PTSD. The examiner concluded on VA heart examination in November 1992 that there is no direct relationship between PTSD and coronary artery disease. A May 1993 statement from the Director of the VA Compensation and Pension Service concluded that the veteran’s cardiovascular disease was not due to his PTSD; the statement cited medical texts to the effect that stress may increase the symptoms of a heart condition. According to an August 1995 statement from Dr. Wender, the veteran had apparently incurred significant stress in the past and did not have any “other critical issues that would seem to predispose him to the development of heart disease.” According to a September 1995 statement from Richard D. Clark, M.D., the veteran had been treated for heart disease and stress during the previous several years by his office and by other physicians. Dr. Clark also noted that the veteran’s stress would predispose him to heart problems. In May 1996, the VA examiner who examined the veteran in November 1992 reiterated his opinion that there was no direct relationship between the veteran’s service-connected PTSD and his heart disease. On VA heart examination in September 1996, it was concluded that PTSD and stress were not known factors for coronary artery disease but that stress could precipitate anginal attacks. The examiner noted that although he could not say that the veteran’s coronary artery disease was caused by PTSD, he felt that stress or PTSD might exacerbate angina and, therefore, if the veteran still had residual coronary artery disease, it might make his cardiac symptoms worse. The diagnoses on VA cardiovascular examination in June 1997 were coronary artery disease, as diagnosed by catheter and angioplasty in 1991; status-post myocardial infarction in 1991; paroxysmal atrial fibrillation; and PTSD. The examiner noted that the veteran’s symptoms of chest pain and anxiety were daily occurrences and that it was reasonable to suppose that the two conditions were related. The examiner also indicated that the veteran’s PTSD could indirectly increase the veteran’s symptoms of atrial fibrillation by increasing his chest pain. The examiner noted that the relationship between stress and angina was becoming more medically defined. The veteran underwent a VA exercise treadmill stress test in July 1997, in which the veteran achieved 13 METS of activity with a peak heart rate of 119, which was 70 percent of the predicted maximum. There were no ischemic ST or T wave changes during the treadmill test; and the veteran did not show any typical anginal symptoms, although he did have a slight sensation of skipping in his chest. The examiner’s impression was that the veteran’s coronary artery disease was not an active disease and that although the exercise treadmill test did not reveal any signs of provoked ischemia, it was considered non-diagnostic because the veteran only achieved 70 percent of his predicted maximum. Although a VA examiner concluded in November 1992 and May 1996 that there was no causal relationship between the veteran’s service-connected PTSD and his heart disease, Dr. Rose, Dr. Clark and Dr. Wender have all submitted statements indicating that there is a link between the veteran’s PTSD and heart disease. While another VA examiner indicated that PTSD did not cause heart disease, he did note that PTSD could precipitate or exacerbate anginal attacks. Moreover, when examined by the VA in June and July 1997, which included a treadmill test, it was concluded that even though the veteran’s coronary artery disease had been effectively treated and was not considered an active disease, there was a connection between the veteran’s service-connected PTSD and his cardiovascular disease. Consequently, because the Board finds that the preponderance of the evidence supports the conclusion that the veteran’s cardiovascular disease was aggravated by his service-connected PTSD, service connection is warranted under 38 C.F.R. § 3.310(a) and Allen. ORDER Service connection for cardiovascular disability is granted. SHANE A. DURKIN Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -