Citation Nr: 1030366 Decision Date: 08/13/10 Archive Date: 08/24/10 DOCKET NO. 08-10 027 ) DATE ) ) On appeal from the Department of Veterans Affairs THE ISSUE Entitlement to service connection for coronary artery disease (CAD). REPRESENTATION Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from June 1943 to March 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating determination of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. A hearing was held at the RO before the undersigned Acting Veterans Law Judge of the Board in June 2010. At that time, there had been other rating decisions on other issues and the Veteran indicated the appeals regarding all other issues were withdrawn. FINDINGS OF FACT 1. CAD was not manifest in service and is unrelated to service. 2. Arteriosclerosis was not manifest to a degree of 10 percent within one year of service discharge. 3. CAD was not caused or aggravated by the Veteran's service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for CAD, including as secondary to service-connected PTSD, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; (3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the Veteran pre-adjudication notice by a letter dated in August 2009. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA also has a duty to assist a claimant under the VCAA. VA has obtained service treatment records; assisted the Veteran in obtaining evidence; afforded the Veteran an examination in September 2009 which contains a medical opinion as to the etiology of his CAD; and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Arteriosclerosis may be presumed to have been incurred in service if it is manifest to a degree of 10 percent within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Disability which is proximately due to or is the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310. Secondary service connection can be granted for disability to the extent that it is chronically made worse/aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In this case, the Veteran claims service connection for CAD secondary to his service-connected PTSD. Service treatment records are silent for reference to CAD or arteriosclerosis. The Veteran reported palpitations with excessive smoking on VA treatment in August 1956. His blood pressure was 120/84, his heart was clear, and a chest X-ray was normal. On VA examination in May 1980, the Veteran reported that he had had a heart attack in January 1980. The diagnoses on examination were arteriosclerotic heart disease with recent myocardial infarction and myocardial ischemia, and generalized arteriosclerosis. E. W. Allensworth, M.D. reported in March 2001 that the Veteran had episodes of chest pain with marked anxiety and stress. In September 2009, Dr. Allensworth reported the Veteran's history of treatment since a myocardial infarction in January 1980. He indicated that the Veteran has severe arteriosclerotic heart disease and supported the Veteran's contention that his heart disease was likely caused by his service-connected PTSD. The Veteran was typical of many Veterans diagnosed with PTSD. They struggle for many years before seeking help, which is often when the damage occurs. Harrisons Principles of Internal Medicine states that PTSD causes an increase in norepinephrine, commonly called adrenaline. After many years the increase in adrenaline is well known to cause hypertension and heart difficulties. Dr. Allensworth felt that the Veteran's current condition was the result of longstanding hypertension. A VA publication was noted to show that PTSD is associated with significant biological strain on the body. A New York Academy of Science article was noted to state that studies had linked PTSD to cardiovascular disease. The November 2009 VA examination report shows that the Veteran's claims folder including private records was reviewed. The report reveals that the Veteran had smoked 2 packs per day of cigarettes for 40 years, leaving him with an 80 pack year history of smoking, and that there was a history of heart disease in the Veteran's family. He had had a myocardial infarction in 1980. He had evidence of a right endarterectomy and coronary artery bypass grafting. The examiner felt that it was less likely than not that the Veteran's CAD was caused or aggravated by his service-connected PTSD. The examiner noted that the Veteran's tobacco abuse, hyperlipidemia, and his family history of heart and vascular disease were all significant risk factors for CAD, and that a review of the medical literature showed no articles to support a strong association between coronary heart disease and PTSD. Medical literature was reviewed. Based on the evidence, the Board finds that service connection is not warranted for CAD. The Board finds that the VA examiner's opinion is more probative than the opinion from Dr. Allensworth. The VA publication Dr. Allensworth cited does not reportedly pertain to PTSD causing CAD. Dr. Allensworth did not consider the Veteran's smoking history, nor his family history of heart disease or his hyperlipidemia, which are all significant risk factors. Additionally, it is unclear that the Veteran had hypertension before his CAD. His blood pressure had been normal in 1956 and his blood pressure was 122/82 on VA examination in May 1980, when hypertension was not diagnosed but arteriosclerotic heart disease and generalized arteriosclerosis were. Moreover, the VA examiner in 2009 indicated that there are no studies which show a strong association between PTSD and coronary heart disease. The VA publication mentioned by Dr. Allensworth did not specifically mention PTSD causing CAD, and while a New York Academy of Science article had stated that studies had linked PTSD to cardiovascular disease, the examiner in 2009 considered the Veteran specific history and risk factors in reaching the conclusion that the Veteran's PTSD did not cause or aggravate his CAD. The 2009 VA examination report is more thorough and specific to the Veteran and the issue at hand, which is whether the Veteran's PTSD caused or aggravated his CAD, and so the Board accords it more weight. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for determining probative value of medical opinions include their thoroughness and detail, whether they discussed why contrary opinions were not persuasive, and the opinion-writer's access to relevant records). The Veteran may feel that his PTSD caused his CAD. However, while he testified in June 2010 that he had been a medic, there is no indication that he has any special training on the issue of whether PTSD causes or aggravates CAD, and so his opinion is considered to have little, if any, probative value. The preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). ORDER Service connection for CAD including as secondary to service-connected PTSD is denied. ____________________________________________ THOMAS JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs