Citation Nr: 1336579 Decision Date: 11/08/13 Archive Date: 11/22/13 DOCKET NO. 09-44 298 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for coronary artery disease, to include as secondary to the service-connected nephritis with hypertension. 2. Entitlement to service connection for bilateral peripheral vascular disease, to include as secondary to the service-connected nephritis with hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from November 1955 to December 1957 and from November 1961 to October 1964. This appeal comes before the Board of Veterans' Appeals (Board) from an August 2006 rating decision of a Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio. In a July 2007 substantive appeal, the Veteran requested a hearing before a Veterans Law Judge (VLJ). In correspondence in July 2012, the Veteran withdrew his request for a hearing. 38 C.F.R. § 20.704(e) (2013). In March 2013, the RO granted service connection for tinnitus. Therefore, this issue is no longer on appeal. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). The Virtual VA paperless claims processing system contains additional VA outpatient treatment records that have been considered. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The weight of competent and credible evidence is that the Veteran's coronary artery disease was proximately aggravated beyond the normal progression of the disease by service-connected hypertension. 2. The weight of competent and credible evidence is that the Veteran's peripheral vascular disease was proximately aggravated beyond the normal progression of the disease by service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection on a secondary basis for coronary artery disease are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection on a secondary basis for peripheral vascular disease are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). In this case, the Board is granting in full the benefits sought on appeal As the Board is granting the claims for service connection, the claims are substantiated, and there are no further notice and assistance. Wensch v. Principi, 15 Vet App 362, 367-68 (2001). The Veteran served as a U.S. Army infantryman and paratrooper. He contended in notices of disagreement in September 2006 and January 2007 and in correspondence in December 2007 that his coronary artery disease and bilateral peripheral vascular disease are secondary to service-connected chronic nephritis and hypertension or are caused by high doses of prednisone used to treat Reiter's Disease in service in 1957. In correspondence in September 2013 with a waiver of consideration by the RO, the Veteran also contended that his coronary artery disease is secondary to aortic stenosis that is a residual of service connected Reiter's Disease (now known as reactive arthritis). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, certain chronic disabilities including cardiovascular-renal diseases are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). There was an amendment to the provisions of 38 C.F.R. § 3.310 in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is rated requiring the establishment of a baseline level of disability prior to aggravation and a showing that the secondary condition was not due to the natural progression of a disease. 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 claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). During his first period of active service from November 1953 to December 1957, the Veteran was hospitalized for eight months and treated for Reiter's Disease, keratosis blennorrhagica, and chronic nephritis. During the hospitalization, the Veteran was treated with prednisone at an initially high dose that was later reduced during the course of treatment. There were no clinical observations or diagnoses of hypertension, heart, or vascular disease. The Veteran was placed on a temporary disability retirement list and scheduled for a military evaluation in one year. The Veteran was examined by VA clinicians in March 1958, and in April 1958, the RO granted service connection and a 30 percent rating for Reiter's disease with keratosis, conjunctivitis, urethritis, and arthritis, and service connection and a noncompensable rating for chronic nephritis. In November 1959, the Veteran was reevaluated at a military hospital. A military physician noted no evidence of urethritis, conjunctivitis, arthritis, or heart abnormalities. In a second evaluation in May 1961, a military physician noted the Veteran's report of occasional swelling and tenderness of both shins after extended standing. He was not receiving any treatment or therapy. The examiner noted questionable clubbing of proximal joints of the hands and a few lesions resembling keratosis but no other symptoms. X-rays and laboratory testing were normal. The examiner noted, "It is my feeling at this time that this patient has little if any disability and he should be allowed another trial of military duty." He diagnosed no active Reiter's Disease. In August 1961, a private physician did not note any residuals of Reiter's disease or nephritis but noted the presence of a grade 2 aortic systolic murmur. He concluded that the Veteran was not in a satisfactory condition for further service. However, military examiners concluded that the Veteran's disorders had resolved. The Army removed the Veteran from the temporary disability retirement list and offered him the opportunity to reenlist. The Veteran voluntarily reenlisted and successfully served on active duty for three additional years. In a December 1964 discharge medical history questionnaire, the Veteran reported his history of joint pain and swelling, arthritis, and chest pain with heart palpations. The Veteran denied a history of high blood pressure. An electrocardiogram was normal. The examining physician noted no heart, kidney, skin, or joint abnormalities except a traumatic amputation of the right great toe. The Veteran was diagnosed and treated for high cholesterol since at least 1976. Starting in late 1980, the Veteran was diagnosed with coronary artery disease and underwent a four vessel coronary bypass graft. The Veteran was also diagnosed with hyperlipidemia and reported a family history of heart disease. The Veteran subsequently underwent many additional procedures including angioplasty, renal artery stents, and revisions of the bypass grafts. Clinicians continue to note the heart murmur but no symptoms of nephritis. In the late 1980s after the first coronary bypass grafts, the Veteran was diagnosed with hypertension that has remained under poor control. In the late 1990s, the Veteran was diagnosed with peripheral arterial disease in the lower extremities. In 1996, the Social Security Administration granted disability benefits for chronic ischemic heart disease. In 2000, the Board granted service connection for hypertension as secondary to chronic nephritis. Although there was no supporting evidence from clinicians in the file addressing current nephritis or a secondary relationship, the Board noted that the then-current version of 38 C.F.R. § 4.115a, Diagnostic Code 7502 (1999) included a reference to hypertension as a symptom of nephritis. The RO received the Veteran's current claims for service connection for coronary artery disease and peripheral vascular disease in January 2005. In June 2006, a VA physician noted that he was unable to review the claims file and could not find evidence of chronic nephritis. The physician acknowledged the treatment for Reiter's disease with steroids in service but noted no steroid treatment since that time. The records do show on-going treatment for kidney dysfunction and joint pain. The physician noted the diagnoses of coronary and peripheral artery diseases and concluded that hypertension had two components: essential and secondary to renal artery stenosis. The physician concluded that coronary artery disease was secondary to hypercholesterolemia and long-standing hypertension, but not to chronic nephritis. He did not discuss peripheral artery disease, the use of steroids in 1957, or the relevance of the heart murmur identified in 1961. In July 2006, another VA physician noted a review of the claims file, accurately summarized the history of diagnoses and treatment for Reiter's disease, coronary artery disease, and poorly controlled hypertension. The physician concluded that the coronary artery disease was caused by hypertension. The physician did not discuss peripheral artery disease, use of steroids, or the heart murmur. In August 2006, the RO denied service connection for coronary artery disease and peripheral vascular disease without noting consideration of the July 2006 VA examination report. In November 2012, the Board remanded the claims to obtain another examination and opinion. In January 2013, a VA physician's assistant (PA) did not note a review of the file or the 2006 VA opinions. The PA noted that both coronary artery disease and hypertension are caused by plaque buildup in the vascular system. However, the PA concluded that hypertension does not cause or aggravate coronary or peripheral vascular disease and that the Veteran's diseases were caused by genetic factors and hyperlipedemia. The PA also noted that the Veteran current kidney dysfunction was caused by renal artery stenosis and a subsequent stent placement. The PA did not address the use of steroids in 1957, the relevance of the heart murmur, or the contrary opinions of the VA physicians in 2006. In May 2013, the Board concluded that the medical evidence of record was not sufficient and requested an additional medical review of the entire file and an advisory opinion to determine whether the Veteran's coronary artery disease and peripheral artery disease are at least as likely as not (50 percent probability or greater) caused or aggravated beyond the normal progress of the disorder by a) Reiter's Syndrome; b) treatment for Reiter's Syndrome in 1957 with prednisone; c) the heart murmur first identified in 1961, (d) nephritis or other episodes of renal dysfunction, and/or (e) hypertension. In June 2013, a VA internal medicine physician and assistant professor of medicine and quality officer at a university medical school noted a detailed review of the entire claims file, listed several published references, and tabulated selected clinical measurements or observations from the medical history associated with heart murmur, urinalysis, and blood pressure. The physician also noted a review of the previous medical opinions. The physician provided answers and explanation to the Board's questions as follows. The physician concluded that the Veteran's coronary artery and peripheral vascular diseases were not caused or aggravated by service connected Reiter's Disease or its treatment with prednisone in 1957. The physician explained that, although the medical literature suggests a link between Reiter's Disease and some cardiovascular conditions such as myocarditis, pericarditis, and aoritis, the Veteran was not diagnosed with these forms of heart disease but rather with aortic sclerosis and stenosis and a murmur associated with stenosis. Regarding the treatment with prednisone, the course of treatment was short, tapered, and not associated with high blood pressure or any other symptoms of ischemia at the time. Regarding the heart murmur, the physician noted that an extra heart sound may be harmless unless it is caused by turbulent flow over a diseased heart valve. In this Veteran's case, his murmur was most consistently described in the records as aortic stenosis. Although aortic stenosis does not cause coronary artery disease, the physician concluded that it did aggravate coronary artery disease beyond the normal progression by requiring the heart to pump harder against a stiff valve. The physician did not make clear whether the murmur noted in 1961 between the periods of active service was just a harmless noise or an early manifestation of aortic stenosis. Regarding causation or aggravation by service-connected nephritis, the physician noted that this is a non-specific condition that may be caused by many diseases. In this Veteran's case, during his hospitalization in 1957, clinicians intermittently noted red blood cells in the urine. Subsequently for decades, there was no evidence of on-going or current nephritis. Rather, the Veteran developed renal artery disease with stenosis and chronic kidney disease. Although the latter is a risk factor for coronary artery disease, the onset of kidney disease was over ten years later than coronary artery disease. Therefore, the physician concluded that neither coronary artery disease nor peripheral vascular disease was caused or aggravated by nephritis or the later onset chronic kidney disease. Regarding service-connected hypertension, the physician noted that hypertension is a risk factor for both coronary artery disease and peripheral vascular disease, referencing research by two national medical associations. The physician concluded that the Veteran's coronary artery disease was likely caused or aggravated by genetic factors, hypercholesterolemia, dyslipidemia, and tobacco use that are independent risk factors and present in this Veteran for decades. Nevertheless, the physician concluded that although the diagnosis of coronary artery disease preceded the diagnosis of hypertension, it was likely aggravated by hypertension. As peripheral vascular disease was diagnosed after hypertension, it was likely caused or aggravated by hypertension. The physician noted agreement or disagreement with the earlier opinions consistent with her conclusions. A copy of the opinion was provided to the Veteran and his representative. In September 2013, the Veteran provided a response and submitted two medical treatises with a waiver of consideration by the RO. The Veteran did not submit an evaluation by a medical professional to address the applicability of the treatises to his particular case. The Veteran cited one treatise for the proposition that aortic stenosis causes coronary artery disease. The authors of one treatise determined that their research of 69 patients suggested that patients with aortic stenosis without angina have only a small chance of developing coronary artery disease compared to those patients who do experience angina. The data suggested a difference of 10.3 and 32.5 percent respectively. The authors of another treatise reported a case study of one patient who experienced reactive arthritis (Reiter's Disease) and later developed aortic insufficiency. The authors referred to another study of 93 patients with aortic stenosis of which 18 had markers for a previous episode of reactive arthritis. The authors of the study suggested that there was a genetic component to explain why certain patients with reactive arthritis later develop aortic stenosis. Although, in general, information contained within medical articles and treatise evidence is too abstract to prove the nexus element of a service-connection claim, treatises "can provide important support when combined with an opinion of a medical professional." Sacks v. West, 11 Vet. App. 314, 316-17 (1998). Furthermore, a medical article or treatise, standing alone, may provide sufficient evidence of a causal connection when it "discusses generic relationships with a degree of certainty" so that the causal connection is "based upon objective facts rather than on an unsubstantiated lay medical opinion." Id. at 317. The Board concludes that service connection for coronary artery and peripheral vascular disease on a direct basis is not warranted because neither disease manifested during or within one year of active service. There is no credible lay or medical evidence of a continuity of symptoms of a cardiovascular or peripheral vascular disease for many years after active service. The Board concludes that service connection for coronary artery disease and peripheral vascular disease is warranted on a secondary basis because the diseases were found by competent and credible medical examiners to have been aggravated beyond the normal progression by service-connected hypertension. The Board places some probative weight on the opinions of the VA physicians in June and July 2006 who both concluded that hypertension was a cause for coronary artery disease. Neither physician explained the conclusion when hypertension was diagnosed many years after coronary artery disease. Neither addressed peripheral vascular disease or the other factors raised by the Veteran including Reiter's Disease and its treatment, heart murmur, or nephritis. The Board places less probative weight on the opinion of the PA in January 2013 who also did not address the other factors and found no relationship to hypertension contrary to the opinions of all other physicians. The PA explained why the diseases were caused by other factors but did not fully explain why hypertension was not an aggravating factor. The Board places greatest probative weight on the detailed and well supported opinion by the internal medicine physician and professor in June 2013 who addressed the dispositive issue of aggravation with a clear explanation. Resolving all doubt in favor of the Veteran, the Board will grant service connection for coronary artery disease and peripheral vascular disease secondary to hypertension. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the Board is granting service connection for coronary artery disease and peripheral vascular disease secondary to service-connected hypertension, the Board need not address the relevance and weight of evidence regarding causation and aggravation by Reiter's Disease, treatment with prednisone, nephritis, heart murmur and aortic stenosis. ORDER Service connection for coronary artery disease secondary to the service-connected hypertension is granted. Service connection for bilateral peripheral vascular disease secondary to the service-connected hypertension is granted. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs