Citation Nr: 1311792 Decision Date: 04/09/13 Archive Date: 04/19/13 DOCKET NO. 04-42 625 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for heart disease, to include as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from August 1973 to June 1977. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin, which denied service connection for a heart condition. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran if further action on his part is required. REMAND Unfortunately, an additional remand of the Veteran's claim for service connection is warranted. Although the Board regrets the additional delay associated with this remand, further development of the record is required before the Board may render a decision in the instant case. When the Board's remand requests are not satisfied, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). In July 2012, the Board remanded the Veteran's claim in order to obtain additional treatment records and to provide the Veteran with an additional examination in order to determine the etiology of the Veteran's heart disease. The examiner was asked to provide an opinion as to whether the Veteran's current heart disease is at least as likely as not related to a disease or injury in service. The examiner was additionally asked to opine as to whether it is at least as likely as not that the Veteran's current heart disease was caused or aggravated by his service-connected PTSD. With regard to the possibility of a direct relationship between the Veteran's heart condition and his military service, the examiner opined that the Veteran's heart disease was not caused by or a result of disease or injury in-service. As a rationale, the examiner stated that the Veteran's service treatment records did not "provide evidence to show a nexus between disease or injury in active service . . . and heart disease." The examiner stated that current medical literature did not relate the process of heart disease to diseases or injuries incurred in active duty service. The examiner noted that the putative roles of cigarette smoking and imprudent diet were factors in the development of atherosclerosis that were beyond the scope of the opinion. The Board finds the examiner's conclusion to be inadequate. Without any specific reference to the Veteran's in-service experiences or assertions, the examiner's rationale appears to be a blanket assertion that heart disease cannot ever be related to disease or injury in active duty service. Furthermore, contrary to the assertion of the examiner, the putative roles of cigarette smoking and imprudent diet are not beyond the scope of the opinion. The Board's July 2012 remand asked the examiner to determine the etiology of the Veteran's current heart disease, and this analysis should consider all relevant information in the claims file, to include the Veteran's history, if any, of cigarette smoking and consuming an imprudent diet. With regard to the possibility of a secondary relationship between the Veteran's heart disease and his service-connected PTSD, the examiner opined that the Veteran's heart disease was not caused by or a result of the Veteran's PTSD, nor was it aggravated by service-connected PTSD. As a rationale, the examiner stated that current medical literature and teaching did not relate the process of ischemic heart disease to PTSD or related mental health conditions. The examiner noted that the electronic clinical resource tool "UpToDate" provided no information linking PTSD and heart disease. The Board finds the examiner's conclusion regarding the secondary relationship between the Veteran's heart condition and his PTSD to be inadequate. The examiner's rationale appears to be that there is no suggested link between PTSD and heart disease in the medical literature. The Board finds that this does not adequately address the evidence of record suggesting such a link. For example, private medical records from Family Counseling Services in February 2002 and C.A.G., M.D. in August 2004 discuss both the Veteran's panic-like episodes associated with his PTSD and his chest pains. The examiner did not address these episodes at all, nor did he address the relevance of these events, if any, to the Veteran's heart disease. Furthermore, the Board acknowledges that it is prohibited from exercising its own independent judgment to resolve medical questions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). While mindful of the guidance in Colvin, the Board must also note that VA's own website suggests that there may be a possible link between PTSD and the development of heart disease. VA, National Center for PTSD, "PTSD and Physical Health", available at http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp (last accessed Mar. 26, 2013) (stating that "PTSD may promote poor health through a complex interaction between biological and psychological mechanisms . . . neurochemical changes in the brain . . . may create a vulnerability to hypertension and atherosclerotic heart disease that could explain in part the association with cardiovascular disorders"). While, pursuant to Colvin, the Board renders no judgment as to the applicability or probity of this statement given the facts in the instant case, the Board must also note that this finding is inconsistent with the examiner's blanket statement that there is simply no suggested medical link between PTSD and heart disease. Accordingly, the Board must again remand the Veteran's claim in order to obtain an additional etiological opinion from a VA cardiologist, with the option for an additional examination, if necessary. Accordingly, the case is REMANDED for the following actions: 1. Copies of updated treatment records should be obtained and added to the claims file. 2. Following completion of the above, forward the Veteran's claims file to a cardiologist to determine the etiology of the Veteran's current heart disease. If the cardiologist determines that an additional examination is required before the following opinions may be rendered, then such examination should be conducted. The claims folder must be reviewed by the examiner before rendering the requested opinions. Following a review of the Veteran's service and post-service medical records, the examiner must offer the following opinions: a) Is it at least as likely as not (that is, a 50 percent probability or greater) that the Veteran's heart condition had its onset in service or is otherwise related to service? b) Is it at least as likely as not that the Veteran's heart condition was caused by the Veteran's service-connected PTSD? c) Is it at least as likely as not that the Veteran's heart condition was aggravated (that is, permanently worsened beyond the natural progression) by the Veteran's service-connected PTSD? The cardiologist is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. A complete rationale should be given for all opinions and conclusions expressed. 3. Readjudicate the claim. If the benefit sought on appeal is not granted, the agency of original jurisdiction should issue a supplemental statement of the case. The case should be returned to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). _________________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. See 38 C.F.R. § 20.1100(b) (2012).