Citation Nr: 1333070 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 03-31 493 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for coronary artery disease, (CAD). 2. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. Childers, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty from February 1953 to December 1954; and he is a Korean War veteran. Commendations and awards include a United Nations Service Medal, a Korean Service Ribbon, and a Republic of Korea Presidential Unit Citation. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in March 2002 and November 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The 2002 rating decision denied service connection for coronary artery disease; the 2007 rating decision denied entitlement to TDIU. In October 2004, the Veteran appeared at the St. Petersburg RO and testified before a Decision Review Officer regarding the issue of service connection for coronary artery disease. A transcript of that hearing is in the claims file. This case has been before the Board a number of times. In May 2006, the Board denied the Veteran's claim concerning coronary artery disease, and in January 2007 the Veteran appealed the Board's May 2006 decision to the Court of Appeals for Veterans Claims (Court). In February 2008, the parties filed a Joint Motion for Remand, which the Court granted in an Order dated in February 2008. Pursuant to the February 2008 Joint Motion for Remand and Court Order, in September 2008 the Board remanded the claim for further development. In March 2010, the Board again denied the issue of service connection for coronary artery disease; and remanded the issue of TDIU for further development; and in July 2010 the Veteran appealed the Board's March 2010 decision to the Court. In May 2011 the parties again failed a Joint Motion for Remand, which the Court granted in an Order dated in June 2011. In April 2012, the Board remanded the issue of service connection for coronary artery disease for further action consistent with the May 2011 Joint Motion for Remand directives; along with the pending appeal for entitlement to TDIU. In June 2013, the Board referred the issue of service connection for coronary artery disease for a VHA expert medical opinion. No further development with regard to the issue of service connection for coronary artery disease is needed. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC, in Washington, D.C. VA will notify the appellant if further action is required. FINDING OF FACT There is a balance of medical evidence on whether the stress associated with the Veteran's PTSD produced a progression of his coronary artery disease process. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, service connection for coronary artery disease is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) In light of the fully favorable determination in this decision, no discussion of compliance with VA's duty to notify and assist set out under the VCAA is necessary. II. Merits Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 C.F.R. § 3.303. Disorders diagnosed after discharge may also be service connected if all the evidence, including that pertinent to service, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Disability which is proximately due to, or aggravated by a service connected disability shall be service connected. 38 C.F.R. § 3.310. In deciding a claim for service connection on the merits, the Board must assess the credibility and weight of all evidence, including the Veteran's statements and the medical evidence to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. See Owens v. Brown, 7 Vet. App. 429 (1995) (it is the Board's fundamental responsibility to evaluate the probative value of all medical and lay evidence); see also Evans v. West, 12 Vet. App. 22, 30 (1998) (providing that it is the responsibility of the Board to weigh the evidence and determine where to give credit and where to withhold the same). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. See Cartwright v. Derwinski, 2 Vet. App. 24, 26 (1991); Hatlestad v. Derwinski, 1 Vet. App. 164, 169-70 (1991); Gilbert v. Derwinski, 1 Vet. App. 49, 59 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran seeks service connection for coronary artery disease, which he posits may be the result of battlefield stress. He reports that he worked as a guard at a prisoner-of-war (POW) prison from July to November 1953, and adds that physical force and tear gas were frequently needed to keep order; that many guards were killed by the captives. He states that he was under constant stress and anxiety; not just from the danger involved in guarding POWs, but from the severe cold conditions during his service in Korea, and from his assignment to a camp in Korea that was surrounded by land mines. DD-214 confirms that he is a Korean War veteran, and the U. S. Army & Joint Services Records Research Center confirms that the Veteran's unit was charged with guarding POWs. The Board accordingly finds the Veteran's allegation of constant stress and anxiety during service to be consistent with the circumstances of his service; and, point in fact, the Veteran has been service-connected for in-service-stress related duodenal ulcer disease and PTSD. In or around 1986, the Veteran was diagnosed with coronary artery disease (see April 2002 letter from Veteran's private cardiologist), and in 1992 he underwent coronary artery bypass surgery. On review of the record, the recurrent theme is that the stress related to the Veteran's service-connected peptic ulcer disease and his service-connected PTSD also contributed to the Veteran's coronary artery disease. See, e.g., attorney's June 2012 argument/Statement of the Case. Evidence in favor of this proposition includes a letter, dated in April 2002, from the Veteran's longtime cardiologist, who opined that the stress that caused the Veteran's peptic ulcer disease partially contributed to his development of coronary artery disease (see also September 2006 letter from Veteran's cardiologist) ("the stress and poor cardiac diet or lack of same, in my opinion, contributed very significantly to his development of coronary atherosclerosis resulting in coronary artery bypass surgery"). Additionally, in a letter dated in October 2003, a VA provider stated that on review of the Veteran's history, it was more likely than not that his coronary artery disease started while the Veteran was in Korea; when the Veteran "started developing his other problems associated with the high fat diet and stressors of war." In addition to the foregoing, in a letter dated in July 2006, another private primary care provider advised as follows: It is a known fact that the adrenal cortical system is at a heightened response when under stress and that the adrenal cortical system has a direct response as a vasopressor therefore elevating one's blood pressure. Back in 1953 or 1954 when he was a young man and under stressful circumstances while serving on active duty the vasopressor response undoubtedly elevated his blood pressure in addition to being a male, a smoker, and having high lipids including in his multiple cardiac risk factors that directly resulted in his coronary artery by-pass grafting in 1992. Another private physician, in a letter dated in May 2008, noted that the Veteran had experienced and witnessed events during his service in Korea that would cause any individual to be traumatized, and surmised that the Veteran had been under chronic tension, anxiety, and stress. He then advised as follows: When the body is stressed clearly defined hormonal changes occur, including the secretion of adrenalin (Epinephrine) and detrimental levels of other blood components such as LDL, HDL, CRP and homocysteine leading to acceleration of atherosclerosis and heart disease. Adrenalin generates the "fight or flight" response, stimulating the heart to work harder and beat faster. Another well-known action of adrenalin is constriction of blood vessels which in turn causes hypoxia. Stress and the above hormonal changes result in less oxygen delivered to the heart and thus the development of heart disease by placing excessive demands on the heart itself over time. Most recently, a VHA cardiologist in 2013 has also weighed in on the relationship between stress and the development of coronary artery disease. According to this VHA expert, "the weight of the evidence suggests that there is very likely a link between PTSD and progression of atherosclerotic coronary artery disease." She added that "this hypothesis makes sense given the documented alterations in 'stress hormones' in patients with PTSD . . . which "are likely to be related to hypertension and other direct risk factors for development of atherosclerosis." As for the evidence against the claim, according to a VA examiner in November 2008, and a VHA cardiologist in October 2009, the Veteran's coronary artery disease did not begin during active duty service because he had no symptoms of heart disease during service; and his coronary artery disease is not related to his PTSD because PTSD is not a recognized risk factor for coronary artery disease. Board decisions do not resolve questions of science, but weigh the evidence it has before it addressing claims for entitlement to VA benefits. Here, that evidence is essentially balanced on whether the stress associated with the Veteran's PTSD aggravated his coronary artery disease process. When the evidence is so balanced, the benefit of the doubt is resolved in favor of the Veteran. Resolving this doubt in this case in favor of the Veteran, a basis to award service connection for coronary artery disease has been presented. ORDER Service connection for coronary artery disease is granted. REMAND In view of the just awarded grant of service connection for coronary artery disease, the Veteran's service-connected disability picture has changed. The claims file should therefore be sent for an opinion as to whether, based on this new service-connected picture, these service connected disabilities, singularly or in combination, are of sufficient severity to cause unemployability. 38 C.F.R. § 3.327. Before this is accomplished, all VA treatment records dated after November 2008 must be associated with the claims file. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Associate all of the Veteran's VA medical records dated after November 2008 with the claims file. Any additional pertinent private treatment records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran. 2. After associating all outstanding records with the claims file, send the claims file to a person with the appropriate credentials for review and an opinion on the issue of entitlement to TDIU. After review of the claims file, and taking into account this Veteran's education, training, and work history (but not his age or the effect of any nonservice-connected disabilities), an opinion should be offered as to whether it is at least as likely as not that the Veteran's service-connected disabilities (identified below) are, singularly or in combination, of sufficient severity to preclude the Veteran from obtaining and retaining substantially gainful employment. The Veteran is service-connected for the following disabilities: coronary artery disease; duodenal ulcer; labyrinthis and dizziness; post-traumatic stress disorder; tinnitus; and bilateral hearing loss In formulating the requested opinion, the examiner should note that in a decision dated in May 1997, the Veteran was determined, by the Social Security Administration, to have been unable to secure or follow substantially gainful employment since December 18, 1995, due to coronary artery disease status post triple vessel coronary bypass surgery; history of peptic ulcer disease; and depression. See May 1997 Social Security Administration disability decision. A complete rationale for all opinions should be set forth in the report provided. 3. After completion of all of the above and any other development deemed necessary, readjudicate the claim for TDIU. If this benefit remains denied, issue a supplemental statement of the case and provide the Veteran and his representative an opportunity to respond before returning the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. 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 of Veterans' Appeals 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 Supp. 2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs