Citation Nr: 1415185 Decision Date: 04/07/14 Archive Date: 04/15/14 DOCKET NO. 09-24 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION 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). The Veteran served on active duty from November 1950 to April 1952, including combat service in Korea for which he received the Purple Heart. He died in March 2008, and the appellant is his surviving spouse. This matter initially came before the Board of Veterans' Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In that decision, the RO, among other things, denied the appellant's claim for entitlement to service connection for the cause of the Veteran's death. The Board denied the claim in January 2013. In October 2013, the United States Court of Appeals for Veterans Claims granted a Joint Motion to vacate the Board's decision and remand the claim to the Board. FINDINGS OF FACT 1. At the time of his death, the Veteran was in receipt of service connection for, among other things, posttraumatic stress disorder (PTSD). 2. The evidence is at least evenly balanced as to whether the Veteran's PTSD contributed substantially and materially to the heart disorders that caused his death. CONCLUSION OF LAW With reasonable doubt resolved in favor of the appellant, service connected PTSD was a contributory cause of the Veteran's death. 38 U.S.C.A. §§ 1110, 1310, 5107 (West 2002); 38 C.F.R. §§ 3.5, 3.102, 3.312 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION DIC benefits are payable to the surviving spouse of a Veteran if the Veteran died from a service-connected disability. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.5(a)(1). In order to establish service connection for the cause of a Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312(a). In order to constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently not one related to the principal cause. In order to constitute the contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). The death certificate indicates that the cause of death was cardiac arrest due to myocardial infarction due to diabetes due to hypertension. At the time of death, the Veteran was in receipt of service connection for PTSD, rated 50 percent effective January 13, 1999. The appellant claims that the Veteran's service connected PTSD was a contributory cause of death. For the following reasons, the Board agrees. The Veteran's treating physician, Dr. Rasool, submitted June 2008 and May 2009 letters in support of the appellant's theory. He indicated that he treated the Veteran for almost two years immediately preceding his death for PTSD, hypertension, and hyperlipidemia. He concluded that the Veteran's long history of severe PTSD caused him to develop coronary artery disease and related disorders. He cited several medical studies indicating that patients with PTSD are more likely to develop coronary artery disease and that PTSD significantly increases the risk of death from this disease. He therefore concluded that the Veteran's PTSD symptoms were a cause of and directly aggravated his coronary artery disease and a major contributing factor to the myocardial infarction that caused his death. The appellant contends that VA has acknowledged a link between PTSD and heart disease. It is noted that VA has found that the presumption of service connection was warranted for hypertensive vascular disease for prisoners of war (POW). This determination was based on several medical studies indicating that veterans who had a long-term history of PTSD had a high risk of developing cardiovascular disease and myocardial infraction, and since POWs have a relatively high rate of PTSD incurrence, they would presumably be at greater risk of cardiovascular disease to include hypertension. See Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated With Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). See also VA National Center for PTSD, Kay Jankowski, PTSD and Physical Health ("A number of studies have found an association between PTSD and poor cardiovascular health"). In an April 2009 medical opinion, a VA physician indicated that he had extensively reviewed the Veteran's claims file and that, while there was clear documentation of longstanding psychiatric disease, the medical literature did not support that PTSD causes coronary artery disease. The physician reasoned that the note from the Veteran's treating physician that the Veteran's PTSD caused or was a contributing factor to his coronary artery disease was a personal opinion only and not substantiated by the medical literature. The Veteran's multiple risk factors, including hypertension, diabetes and hyperlipidemia, likely were the principal causes of his death or contributed substantially or materially to his death. In an April 2011 follow-up opinion, the VA physician indicated that it could not be determined based on the evidence that the Veteran's PTSD caused the cardiovascular disease. The multiple risk factors of hypertension, diabetes, and hyperlipidemia were established risk factors for coronary artery disease and were sufficient to account for the Veteran's clinical course. Consequently, he found no basis for finding that the PTSD caused or aggravated the Veteran's heart disease. The VA physician challenged the studies cited by Dr. Rasool and found that the Veteran's cardiovascular problems that caused death were less likely than not (less than a 50% probability) caused by, or a result of, his PTSD symptoms. He indicated that the Veteran's other cardiac risk factors more likely than not accounted for his coronary artery disease. He also indicated that the impact of the Veteran's PTSD symptoms in causing any aggravation of the cardiovascular problems that caused death could not be determined without resort to mere speculation. Pursuant to a request for an independent medical opinion from a specialist in cardiology, in November 2012. This independent medical expert (IME) reviewed the claims folder, summarizing that the Veteran had been diagnosed with PTSD, which was believed to have been undiagnosed for nearly 50 years, dating to his combat service during the Korean War and suffered from severe anxiety and moderate to severe psychiatric symptoms. The IME indicated that one of the studies cited by Dr. Rasool did not consider patients who were diabetic and concluded that "the effects of PTSD symptoms on the risk of CHD appear to be somewhat modest." The IME also cited a weakness in another study, i.e., an inability to evaluate factors related to the PTSD and heart disease such as ongoing substance use, changing psychosocial status, or other cardiovascular risk factors. Further, the study did not include diabetic patients. Based on the above, the IME concluded that with significant risk factors such as hyperlipidemia, male gender, age, and hypertension, as well as coronary artery disease equivalent of Type II diabetes mellitus, it could not be said that PTSD caused or contributed materially to the Veteran's cardiac arrest following myocardial infarction. Thus, the Board is confronted with conflicting medical opinions as to whether the Veteran's PTSD contributed substantially and materially to his death from heart disease. All of the physicians explained the reasons for their conclusions and their opinions are thus entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). There was disagreement as to the probative value of medical studies indicating a relationship between PTSD and heart disease. VA has determined there is at least some validity to similar studies and this reasonably supports Dr. Rasool's opinion. The evidence is thus at least evenly balanced as to whether the Veteran's PTSD contributed substantially and materially to his death from heart related disease. VA law and regulations require that the reasonable doubt created by this approximate balance of the evidence must be resolved in favor of the appellant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for the cause of the Veteran's death is therefore warranted. ORDER Entitlement to service connection for the cause of the Veteran's death is granted. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs