Citation Nr: 1514741 Decision Date: 04/06/15 Archive Date: 04/21/15 DOCKET NO. 09-03 985 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran had active service from November 1974 to March 1975, from May 1975 to May 1979, and from October 1979 to December 1994. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In that decision, the RO denied entitlement to service connection for the cause of the Veteran's death and entitlement to Dependency and Indemnity Compensation (DIC) under 38 U.S.C.A. § 1318 (West 2014). The appellant testified at a hearing before a Decision Review Officer (DRO) at the RO in Montgomery, Alabama in July 2011. A written transcript of this hearing has been prepared and associated with the evidence of record. The appellant previously requested a hearing before a Veterans Law Judge (VLJ) of the Board at her local RO in February 2009, but subsequently withdrew this request. In July 2012, the Board denied the claims. In June 2013, the United States Court of Appeals for Veterans Claims (the Court) granted a joint motion by counsel for the appellant and VA to vacate the Board's decision denying service connection for the cause of death. The parties specifically indicated that they did not wish to disturb the portion of the Board's decision denying DIC under 38 U.S.C.A. § 1318 and that issue is therefore no longer before the Board. The Board notes that the Veteran's attorney has requested additional time to submit arguments in support of the claim. As the Board is granting the claim in full, it finds that the request is moot. FINDINGS OF FACT 1. The Veteran died in June 2007, and the appellant claims as his surviving spouse. 2. The immediate cause of death was cardiac arrest due to a heart attack. 3. At the time of the Veteran's death, he was service connected for posttraumatic stress disorder (PTSD) and other disabilities. 4. The evidence is at least evenly balanced as to whether the Veteran's PTSD contributed substantially to 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 2014); 38 C.F.R. §§ 3.102, 3.303, 3.312 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection for the cause of the Veteran's death may be granted if a disability incurred in or aggravated by service was either the principle or a contributory cause of the Veteran's death. 38 C.F.R. § 3.312(a). For a service-connected disability to be a contributory cause of death it must have contributed substantially or materially to cause death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312(c)(1). The Veteran died in June 2007 of cardiac arrest due to a heart attack. The appellant, his surviving spouse, contends that the Veteran's PTSD contributed substantially and materially to his death. There are multiple medical opinions on this question. In November 2008, a VA nurse practitioner (NP), after a thorough review and discussion of the evidence of record, opined that it was not at least as likely as not that the Veteran's death due to a heart attack was related to his service-connected PTSD. The NP explained that there is no overwhelming evidence within the medical literature that relates heart disease, heart attacks or sudden death to PTSD, and that the Veteran's heart attack was likely due to his underlying history of arteriosclerotic cardiovascular disease (ASCVD) and hypertension. Similarly, in July 2014, a Veterans Health Administration (VHA) cardiologist noted that there was little or no data regarding heart attack as a result of PTSD. He also opined that the Veteran did not necessarily die of a heart attack, as most death certificates list cardiac arrest as the immediate cause of death, and he more likely died of longstanding coronary heart disease. He therefore concluded that service connected PTSD did not contribute substantially or materially to death. In contrast, a private cardiologist, Dr. "D.B." submitted November 2008 and November 2013 statements opining that the Veteran's service-connected PTSD likely contributed substantially to his cardiac-related death. After a thorough review of the claims file and medical literature, he concluded that, given the paucity of significant cardiac risk factors and the absence of documented coronary artery disease, along with medical literature indicating an association between PTSD and cardiovascular morbidity, it was at least as likely as not that the PTSD contributed substantially to the heart attack that caused the Veteran's death. Significantly, one of the articles cited by Dr. D.B. was from VA's own web site, indicating that a number of studies have found that PTSD has been consistently associated with a greater likelihood of cardiovascular morbidity. Moreover, VA's own statements in connection with its rulemaking authority support such an association. VA has found that a presumption of service connection is warranted for hypertensive vascular disease for prisoners of war (POWs). This presumption is based on several medical studies indicating that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction; thus, 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). Given that there are probative medical opinions both for and against the Veteran's service-connected PTSD contributing substantially to his death, and that the positive opinions are supported by VA's own studies and rulemaking statements, the evidence is at least evenly balanced on this point. As the reasonable doubt created by this relative equipoise must be resolved in favor of the appellant, entitlement to service connection for the cause of the Veteran's death is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for the cause of the Veteran's death is granted. ______________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs