Citation Nr: 1510336 Decision Date: 03/12/15 Archive Date: 03/24/15 DOCKET NO. 13-00 410A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for coronary artery disease, including as secondary to major depressive disorder with anxiety disorder and alcohol abuse. REPRESENTATION Appellant represented by: Pennsylvania Department of Military and Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Nye, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1970 to October 1972. This case comes to the Board of Veterans Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In August 2014, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is part of the Veteran's electronic claims file. Since the hearing, the Board has received records of private medical treatment which were unavailable to the RO at the time it issued its rating decision and subsequent statements of the case denying the Veteran's compensation claim for coronary artery disease. According to the hearing transcript, the Veteran's representative waived initial consideration of this evidence by the RO. The new evidence will therefore be considered by the Board in deciding this appeal. See 38 C.F.R. § 20.1304(c) (2014). FINDING OF FACT The evidence is approximately evenly balanced as to whether the Veteran's coronary artery disease is the result of or was aggravated by his major depressive disorder with anxiety disorder and alcohol abuse. CONCLUSION OF LAW With reasonable doubt resolved in the Veteran's favor, coronary artery disease is proximately due to or was aggravated by a separate service connected disease or injury. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.104, 3.303, 3.159, 3.310 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. § 5103, 5103A, 38 C.F.R. § 3.159. As the Board is granting the only claim now being decided, further discussion of the VCAA is unnecessary. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in active military service or was aggravated by an injury or disease incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "nexus" between the current disability and an in-service precipitating disease, injury or event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is warranted for a disease first diagnosed after the claimant's discharge from service 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). Depending on the facts of the individual case, service connection may be proven directly "by affirmatively showing inception or aggravation during service or through the application of statutory presumptions . . ." 38 C.F.R. § 3.303(a), or on a "secondary" basis if the claimed disability is proximately due to, the result of, or aggravated by, a disease or injury which is service-connected. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 449 (1995). In June 2011, after the Veteran appealed the denial of service-connected compensation for coronary artery disease, the RO reopened the Veteran's previously denied claim for an acquired psychiatric disorder, and granted service connection for "major depressive disorder with anxiety disorder and alcohol abuse." In written statements submitted in support of his claim, the Veteran contends that his coronary artery disease claim should be granted because that condition is the secondary result of his service-connected depression and anxiety. According to the Veteran's post-service VA and private medical records, he has a diagnosis of coronary artery disease. This diagnosis satisfies the "current disability" element of his claim for service connection. See Fagan, 573 F.3d at 1287. There is no similar diagnosis in the Veteran's service treatment records. There is evidence of psychiatric treatment in service in March of 1972 for "drunkenness" and in May of the same year due to "depression" and a self-inflicted injury caused by ingesting "8 downers" together with an undetermined amount alcohol. His post-service records describe a psychiatric hospitalization in Georgia in March and April of 1980. But there is no evidence of heart trouble until a myocardial infarction and angioplasty in July 1994. He had a second myocardial infarction and a coronary bypass operation in 1996, and a third myocardial infarction in 2004. The Veteran submitted no medical or lay evidence suggesting that he developed coronary artery disease in service or that his coronary artery disease was the direct result of any particular disease, injury or event in service. Rather, the chief focus of the Veteran's claim is secondary service connection under 38 C.F.R. § 3.310. To help VA determine the nature of the relationship, if any, between the Veteran's coronary artery disease and his service-connected major depressive disorder, the RO arranged for the Veteran to be examined by a physician assistant in August 2012. After examining the Veteran and reviewing his claims file, the physician assistant concluded that the Veteran's heart condition was not the result of military service. The examiner found: "No direct or conclusive evidence that [mental health] conditions contribute directly to current heart condition. Preliminary evidence of alcohol abuse and life stressors indicate potential adverse cardiac influence. Current occupation as a long distance truck driver (patient reports multiple trucks with several million miles driving distance) has been a significant stressor. Review of BH/MH C&P's not supportive of military stressors as a direct exclusive cause of current heart condition in light of (+) history and evidence of obesity, smoking (d/c's approx. 5-6 years ago) hyperlipidemia and inactivity." The Veteran provided a letter from his private cardiologist dated April 2014. This letter includes the summary of a more recent physical examination of the Veteran and a medical opinion that there is a connection between the Veteran's anxiety disorder and his coronary artery disease: "[The Veteran] suffered through a lot of stress during the Vietnam War. He served as a photographer and began smoking back then to deal with the stress, and I think coronary artery disease has clearly become an issue for him through the years as a result." Having reviewed the evidence, the Board perceives certain weaknesses in the August 2012 VA examiner's report, particularly with respect to the nexus issue. First, the examiner emphasized the lack of "direct conclusive evidence" that the Veteran's mental health symptoms contributed to his current heart condition. Evidence does not need to be "conclusive" to establish a fact for the purpose of a claim for VA benefits. See Hood v. Nicholson, No. 04-1125, 2006 WL 1522947 (Vet. App. May 10, 2006) (vacating Board decision which relied on an examiner's opinion that "there was no conclusive evidence" of an element which the claimant was required to prove). "Under section 5107(b), a claimant will prevail when the evidence is in 'relative equipoise,' and the claim will be denied only if 'a fair preponderance of the evidence is against the claim.' . . . There is no requirement that there be conclusive proof of causation." Id. at *2 (quoting Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990)). The examiner also indicated that "military stressors" were not the "direct and exclusive" cause of the Veteran's heart condition. Proof that a service-connected disease or injury aggravated the claimed disability may establish entitlement to secondary service connection, even if the service-connected disability was not the exclusive cause of the claimed disability. See Allen, 7 Vet. App. at 448-49. Moreover, the examination report form includes boxes next to pre-printed text indicating that the Veteran's heart condition either was or was not the result of a separate service-connected disability and a second set of boxes indicating that the heart condition either was or was not aggravated by a separate service-connected disability. The August 2012 VA examiner left all these boxes blank. Moreover, the examiner's suggestion that "military stressors" were not as important to the development of the Veteran's heart condition as "alcohol abuse and life stressors" potentially conflicts with VA's prior determination that the Veteran's major depressive disorder with anxiety disorder and alcohol abuse is related to service. This does not discount any relationship in its entirety. As for the contrary opinion of the Veteran's private cardiologist, the statement attributing his stress to "the Vietnam War" is the subject of conflicting evidence. In his original application for compensation benefits for coronary artery disease, the Veteran denied serving in Vietnam. According to his personnel records, his military occupation specialty was photo lab specialist and he was stationed overseas with the United States Strategic Communications Command Signal Brigade in Seoul, Korea between September 1971 and October 1972. At his videoconference hearing, the Veteran testified that he took occasional trips to Vietnam from Korea. But his record of assignments only mentions service in Korea and in the continental United States. According to his DD-214 Form, the Veteran served in Korea, but not in Vietnam. A medical opinion is of limited value if it is based on an inaccurate factual premise. Cf. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Nevertheless, the Board finds that the cardiologist's statement about Vietnam does not undermine the grounds for his opinion. In the first place, the cardiologist's letter does not claim that the Veteran actually set foot in Vietnam, only that his service took place during "the Vietnam War", which is true, see 38 U.S.C.A. § 101(29), and the Veteran reported that the specific claimed stressors that he described to VA in support of his claim for service connection for a mental health disorder took place in Korea. Reading his report as a whole, the Board is not convinced that service in Vietnam was an essential premise of the private cardiologist's conclusion attributing the Veteran's coronary artery disease to stress-related smoking. Though the opinions differed in their ultimate conclusions, the VA examiner's description of the causes of the Veteran's coronary artery disease is perfectly consistent with the private cardiologist's suggestion coronary artery disease was result of stress-related smoking, which began in the military. And both etiology opinions are consistent with the Veteran's own testimony at a September 2012 hearing at the RO before a Decision Review Officer, in which he described excessive smoking and drinking to cope with the symptoms of his mental illness. Finally, VA recognizes a relationship between stress and cardiovascular disease. 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). Presumption of service connection was warranted for hypertensive vascular disease for prisoners of war (POW). The reasoning behind the presumption includes several medical studies, indicating that veterans with a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction, and since POWs have a relatively high rate of PTSD incurrence, they are presumably be at risk for cardiovascular disease. 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"). Resolving the conflicting evidence in the Veteran's favor, see 38 U.S.C.A. § 5107(b), the Board finds that the Veteran's coronary artery disease is the secondary result of or was aggravated by his service-connected major depressive disorder with anxiety disorder and alcohol abuse. See 38 C.F.R. § 3.310. ORDER Entitlement to service connection for coronary artery disease is granted. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs