Citation Nr: 1332175 Decision Date: 10/17/13 Archive Date: 10/21/13 DOCKET NO. 12-24 908 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to service connection for coronary artery disease (CAD), claimed as secondary to service-connected ankylosing spondylitis. REPRESENTATION Appellant represented by: John S. Berry, Attorney at Law ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1965 to May 1972. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision of the Buffalo, New York Department of Veterans Affairs (VA) Regional Office (RO). In June 2013, the Veteran's attorney submitted additional evidence, including a medical opinion from Dr. L.A. Wasserman and medical literature addressed in Dr. Wasserman's opinion, directly to the Board, with a waiver of initial Agency of Original Jurisdiction consideration of the evidence. Duplicates of these submissions were received later in June and again in July 2013. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The Veteran's attorney also submitted additional evidence, a statement from the Veteran directed to his VA medical providers about changes in his prescription heart medication, to the Board in May 2013. This evidence did not include a waiver; however, given the Board's favorable determination below, no waiver is needed. FINDING OF FACT Resolving all doubt in favor of the Veteran, the criteria for the establishment of service connection for CAD have been met. CONCLUSION OF LAW Service connection for CAD is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION In light of the fully favorable determination in this case, no further discussion of compliance with VA's duty to notify and assist is necessary. The Veteran asserts that he suffers from CAD as a result of coronary calcification which is "related and caused by the ankylosing spondylitis." See Veteran statement, dated September 2012. The Veteran is a psychiatrist. See DD Form 214. The Board notes that the Veteran is not a specialist in cardiology; even so, given his medical background and training and his profession as a doctor of medicine, the Board has given his opinion more probative value than that of a lay person with no medical expertise. For secondary service connection to be granted, generally there must be (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (2012); see Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The evidence of record, including the March 2012 VA examination report, the June 2013 VA opinion and treatment records from Dr. Wasserman, reflect diagnoses of CAD. A June 2013 medical opinion from Dr. Wasserman notes that the Veteran has "documented severe coronary artery disease" manifested by "severe coronary calcification which resulted in multiple severe coronary artery stenosis." The Veteran is also service-connected for ankylosing spondylitis. In June 2013 Dr. Wasserman noted that the Veteran "has ankylosing spondylitis, also known as rheumatoid spondylitis." Therefore, the first and second Wallin elements have clearly been satisfied. What remains to be established is whether the Veteran's CAD was caused or aggravated by his service-connected ankylosing spondylitis. The record contains both positive and negative evidence in this regard. A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. Entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. When the evidence is in "relative equipoise, the law dictates that the Veteran prevails." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The positive opinion by Dr. Wasserman, a cardiologist, stated, "[i]t is my professional opinion that the severe coronary calcification and the resultant severe coronary artery stenoses are very likely and causally related to [the Veteran's] rheumatoid spondylitis." He supported his opinion by noting that the literature supporting the causal relationship between rheumatoid spondylitis and the increased incidents of severe CAD "is very compelling and conducted in the setting of well-controlled studies." He attached medical literature to his opinion, specifically an article entitled "Cardiovascular Disease and Risk Factors in Patients with Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis," in addition to a case study published by the American College of Chest Physicians, entitled "Rheumatoid spondylitis, aortic insufficiency, and coronary artery disease: an operable combination." The former article included the statement that "[r]esults of previous studies have suggested a strong relationship between RA [rheumatoid arthritis] and cardiovascular diseases." Further, Dr. Wasserman explained that the Veteran's "rheumatoid spondylitis is an inflammatory disease which dramatically increased the risk of [the Veteran] developing coronary calcification and the presence of severe and very symptomatic coronary artery disease which required [him] to undergo four-vessel coronary artery bypass graft surgery on December 22, 2009." Dr. Wasserman noted that he has been the treating cardiologist for the Veteran since March 1999. The negative evidence includes a March 2012 VA examiner's opinion that it was less likely than not that the Veteran's CAD was incurred in or caused by the service-connected ankylosing spondylitis. The examiner, a family nurse practitioner, noted that "both hypertension and ankylosing spondylitis can be associated with a slightly higher incidence of CAD, but neither has been shown to be causative." She stated that the more likely cause is the link with heredity, as the Veteran's father had severe CAD. She noted that she consulted on this opinion with a VA cardiologist. An addendum opinion was obtained in January 2013 from the March 2012 nurse practitioner. She again concluded, in consultation with the VA cardiologist, that the record does not support a causal relationship between CAD and ankylosing spondylitis. The addendum cited to two medical articles, "Genetics is a Key Factor in Coronary Artery Disease," (Sundquist, August 2011), which noted studies found the risk of heart disease most strongly related to genes, and "Executive Summary: Heart Disease and Stroke Statistics," which noted that CAD is the leading cause of death in the United States. Significantly, she also noted that ankylosing spondylitis was associated with a higher incidence of CAD. The Board acknowledges that the VA examiner indicated that there were other risk factors for CAD in addition to the Veteran's service-connected ankylosing spondylitis. Nevertheless, the law provides that when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding the etiology of a disability, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The Board further notes that, in Alemany v. Brown, 9 Vet. App. 518 (1996), the United States Court of Appeals for Veterans Claims (CAVC or Court) held that in light of the benefit of the doubt provisions of 38 U.S.C.A. § 5107(b), an accurate determination of etiology is not a condition precedent to granting service connection; nor is "definite etiology" or "obvious etiology." Resolving all doubt in favor of the appellant, the Board concludes that competent medical evidence reflects that it is at least as likely as not that the Veteran's current CAD is secondary to his service-connected ankylosing spondylitis. Therefore, service connection is warranted for this disability. ORDER Service connection for CAD is granted. ____________________________________________ M.C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs