Citation Nr: 1301909 Decision Date: 01/17/13 Archive Date: 01/23/13 DOCKET NO. 09-50 205 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Fargo, North Dakota THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran had active service from October 1987 to January 1988 and September 1990 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision by the Department of Veterans Affairs (VA) Medical and Regional Office (RO) Center in Fargo, North Dakota. In June 2010, the appellant testified during a Board hearing before the undersigned Veterans Law Judge at the RO. At that time, she submitted additional evidence with a waiver of RO review. She also indicated that she would waive RO review of additional VA medical records to be submitted later. Those records were associated with the claims file in July 2010. In February 2012, the Board requested a Veterans Health Administration (VHA) opinion regarding the appellant's death benefits claim. The Board received the opinion in June 2012. As the opinion was incomplete, the Board requested another VHA opinion in July 2012. The Board received that opinion in September 2012. A copy of that VHA opinion was sent to the appellant in October 2012. At that time, the Board also advised her that she had 60 days to submit additional evidence in connection with her claim. FINDINGS OF FACT 1. The Veteran died in August 2008. The certificate of death lists the cause of death as acute myocardial infarction as a consequence of coronary artery disease, with hypertension, posttraumatic stress disorder, and anxiety as contributing factors. 2. At the time of the Veteran's death, service connection was in effect for bipolar disorder and posttraumatic stress disorder. 3. Resolving reasonable doubt in favor of the appellant, the Veteran's service-connected bipolar disorder and posttraumatic stress disorder contributed substantially or materially to cause his death. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death have been met. 38 U.S.C.A. §§ 1110, 1131, 1310, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION To establish service connection for the cause of the Veteran's death, the evidence must show that a service-connected disability was either the principal cause or contributory cause of death. 38 U.S.C.A. § 1310 (West 2002 & Supp. 2012); 38 C.F.R. § 3.312 (2012). A service-connected disability will be considered the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b) (2012). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially, that it combined to cause death, or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c) (2012). It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c) (2012). In this case, the appellant contends that the Veteran's service-connected posttraumatic stress disorder (PTSD) contributed to his death. The Veteran died in August 2008. The certificate of death lists the cause of death as acute myocardial infarction as a consequence of coronary artery disease, with hypertension, PTSD, and anxiety as contributing factors. The original certificate of death, which only listed hypertension as a contributing factor, was amended in November 2010. At the time of the Veteran's death, service connection was in effect for bipolar disorder and PTSD. Service connection for bipolar disorder had been in effect since July 30, 1991, rated at 30 percent disabling. Service connection for PTSD was granted in May 2007 and rated, together with bipolar disorder, 100 percent, effective June 23, 2006. VA medical records show that in July 2008 the Veteran complained of having chest pain for the past two days. A long history of uncontrolled anxiety disorder was noted. Also noted was a history of coronary artery disease. The Veteran stated that the pain was worse with exertion and went away with rest. He reported having a complete cardiac workup a month earlier that was negative. He denied having any current chest pain. The assessment was that the Veteran had been ruled out for cardiac disease but still reports events of chest pain. It was noted that after some time in the emergency room the Veteran calmed down and the pain was completely gone. An acute anxiety attack was suspected. Private medical records show that in August 2008, the Veteran was taken to the emergency room via ambulance in full cardiac arrest after collapsing and efforts at resuscitation were unsuccessful. He was pronounced dead and the diagnosis was of sudden cardiac arrest. A past medical history of cardiovascular disease was noted. Diagnoses of sudden cardiac arrest, history of hypertension, PTSD per records, and hypercholesterolemia were provided. In a September 2010 letter, Dr. D., the attending physician at the time of the Veteran's death, noted that a review of the Veteran's VA records clearly showed that the Veteran had PTSD and anxiety. Dr. D. opined that the anxiety and PTSD most certainly contributed to some degree to the Veteran's coronary artery disease and were related to his sudden death. Dr. D. noted that he had been attempting to add the above conditions to the Veteran's certificate of death as contributing factors. As indicated above, Dr. D. was eventually successful. As the above letter indicated that the Veteran's service-connected psychiatric disability may have contributed substantially or materially to cause his death, the Board requested a VHA medical opinion. In a June 2012 VHA opinion, Dr. M. noted that the Veteran suffered from severe PTSD and significant cardiac disease, with a history of coronary artery disease and percutaneous interventions in 2003 and 2004. Dr. M. noted that the Veteran died in 2008 at the age of 45 after presenting with sudden cardiac death. After noting that the Veteran had multiple risk factors for premature coronary artery disease, including heavy tobacco use, hypertension, hyperlipidemia, and PTSD with chronic anxiety, Dr. M. stated that it was not possible for him to determine the relative extent to which the Veteran's PTSD contributed to the development of his coronary artery disease without resorting to mere speculation. Dr. M. then opined that the Veteran's PTSD and bipolar disorder did not cause his death but the possibility that they contributed substantially or materially to the cardiovascular disorder that caused his death could not be excluded. As Dr. M. did not provide a definitive opinion on whether the Veteran's PTSD and bipolar disorder contributed substantially or materially to cause his death, the Board requested another VHA opinion. In a September 2012 VHA opinion, Dr. F. noted that the Veteran undoubtedly suffered from an aggressive form of severe atherosclerotic coronary artery disease, initially presenting at age 39 and requiring percutaneous revascularization in 2003 and 2004 due to progressive exertional chest discomfort. Dr. F. noted that the Veteran had more exertional chest discomfort in 2006 and underwent a nuclear myocardial perfusion study that suggested further disease in the left coronary artery. Dr. F. further noted that the Veteran suffered from chest pain several times over the ensuing years, often attributed to anxiety, and died in August 2008 after a witnessed collapse. Dr. F. then noted the Veteran's concurrent conditions of poorly controlled dyslipidemia, hypertension, and smoking, and very active forms of PTSD and bipolar disorder that required hospitalizations and ongoing psychiatric care. After noting that studies had shown that traditional risk factors for coronary artery disease may or may not be related to actual coronary artery disease in an individual patient, Dr. F. stated that it was impossible to know which, if any, of the Veteran's traditional risk factors was responsible for his coronary artery disease. Dr. F. noted that the aggressive and early onset nature of the Veteran's presentation suggested that he was somehow predisposed to coronary artery disease, but observed that how that predisposition worked was entirely unclear. Dr. F. stated that it therefore becomes speculative to offer an opinion on the relative additional risk imposed by PTSD and bipolar disorder. Dr. F. acknowledged that PTSD and bipolar disorder were strongly associated with unhealthy coping mechanisms such as poor diet, smoking, and poor adherence to exercise and medications that led to obesity and hypertension, all of which accelerated the coronary artery disease process. Dr. F. also acknowledged that successful treatment of PTSD and bipolar disorder may result in successful management of the traditional risk factors, thereby decreasing the risk of further coronary artery disease events. However, Dr. F. concluded that, knowing so little about the disease process in the Veteran, the association of PTSD and bipolar disorder to coronary artery disease was unknown. Dr. F. noted that the inciting event for most acute coronary syndromes and sudden cardiac death was plaque rupture and that there was some evidence that acute anxiety producing events ruptured plaques. However, Dr. F. concluded that without a direct correlation, it was unknowable whether the Veteran's PTSD and bipolar disorder predisposed him to be more vulnerable to acute anxiety producing events and coronary artery disease events. Dr. F. acknowledged Dr. D.'s confident opinion attributing the Veteran's PTSD as a causative factor in his death. Dr. F. noted that he could see clearly how one could connect the Veteran's psychological issues to his aggressive coronary artery disease but stated that he was unable to share in Dr. D.'s confidence due to how little was known about coronary artery disease and its course in the Veteran. Dr. F. then stated that, if forced to guess, he would remain non-committal. Dr. F. expressed his agreement with the tone and conclusions of the June 2012 VHA opinion. Lastly, Dr. F. stated that the medical treatise evidence submitted with the June 2012 VHA opinion did not change his opinions. Initially, the Board observes that it appears that Dr. D. reviewed the Veteran's claims file. In this regard, the appellant requested, and was provided with, a copy of the claims file in July 2010 and Dr. D.'s subsequent opinion of September 2010 noted a review of the Veteran's VA records. Thus, after a review of the Veteran's claims file, Dr. D. opined that the Veteran's anxiety and PTSD, the former being a symptom of the latter, contributed to his coronary artery disease and are related to his death. In essence, Dr. D. opined that the Veteran's PTSD contributed to the cause his death. However, Dr. D. was unable to determine the precise degree to which the Veteran's psychiatric disability contributed to his coronary artery disease that led to his death. Although Dr. D. did not provide a rationale for the opinion, his opinion is still competent and probative. His rationale became evident in Dr. F.'s detailed opinion. The Board notes that the Veteran's service-connected PTSD and bipolar disorder were severe in nature. VA acknowledged the severity of his psychiatric disability by assigning a 100 percent rating effective June 23, 2006. The anxiety associated with PTSD had also been associated with cardiac symptoms during a panic attack. In addition to Dr. D.'s favorable opinion, the amended death certificate indicates that the Veteran's PTSD and associated anxiety contributed significantly to cause his death. The Board notes that the amendment of the death certificate itself is of probative value. Further, Drs. M. and F. were unable to opine that the Veteran's PTSD and bipolar disorder did not contribute substantially or materially to cause his death. Dr. M. concluded that the possibility could not be excluded, and Dr. F. stated that he would remain non-committal and expressed his agreement with the tone and conclusions of Dr. M. The Board finds that the above evidence supports a finding that the Veteran's service-connected psychiatric disabilities contributed substantially or materially to cause his death. The Board also notes Dr. F.'s statement that PTSD and bipolar disorder are strongly associated with the acceleration of the coronary artery disease process and that their successful treatment may decrease the risk of further coronary events. The record indicates that the Veteran's PTSD and bipolar disorder had not been successfully treated. His disabilities had been rated at 100 percent by VA. The July 2008 VA treatment note shows a long history of uncontrolled anxiety disorder. Dr. M. indicated that the Veteran had severe PTSD with chronic anxiety. Dr. F. noted that the Veteran had severe PTSD and bipolar disorder that required hospitalizations and ongoing psychiatric care. Although not elaborated on by Dr. F., the Board finds that the above evidence supports a finding that the Veteran's service-connected psychiatric disabilities contributed substantially or materially to cause his death. In conclusion, the evidence of record indicates that the Veteran's psychiatric disabilities contributed to cause his death. Resolving reasonable doubt in favor of the appellant, the Board finds that the Veteran's service-connected bipolar disorder and PTSD contributed substantially or materially to cause his death. Accordingly, service connection for the cause of the Veteran's death is warranted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for the cause of the Veteran's death is granted. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs