Citation Nr: 1623982 Decision Date: 06/15/16 Archive Date: 06/29/16 DOCKET NO. 09-10 192 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for coronary artery disease (CAD), to include as secondary to service-connected posttraumatic stress disorder (PTSD) with major depressive disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Martha R. Luboch, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1968 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran testified at a Video Conference hearing before the undersigned Veterans Law Judge in September 2011. A transcript of that proceeding has been associated with the claims file. A November 2012 RO rating decision granted service connection for PTSD with major depressive disorder, and assigned initial ratings and effective dates of awards. That decision terminated the Board's jurisdiction in the Veteran's appeal seeking service connection for posttraumatic stress disorder. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Therefore, the remaining issue on appeal is entitlement to service connection for coronary artery disease ("CAD"). This appeal previously before the Board in July 2014 at which time it was remanded for additional development. Additionally, in April 2016, the Board sought an outside medical opinion with regard to the Veteran's CAD. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. FINDINGS OF FACT Resolving all doubt in favor of the Veteran, coronary artery disease is proximately due to her service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for coronary artery disease as secondary to the service-connected PTSD have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2006), (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist As the Board's decision to grant service connection for coronary artery disease (also referred to as "CAD") herein constitutes a complete grant of the benefit sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 and the implementing regulations. The Board notes that an outside medical opinion was obtained in April 2016. The Board finds that although the Veteran did not receive a 60-day notice letter with a copy of the medical opinion, this was harmless error as the Board's decision constitutes a complete grant of the benefits sought on appeal. Service Connection 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, to include arteriosclerosis, cardiovascular-renal disease, and myocarditis 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, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). 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 be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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). 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). Facts The Veteran was granted service connection for PTSD with major depressive disorder in November 2012. The Veteran has asserted that her PSTD is a result of her work as a physical therapist technician with returning Vietnam soldiers who were badly burned, required limb amputation, and were otherwise wounded. The Veteran contends that she has had nightmares for years about her burn victims and amputees and this ultimately caused her to have a massive coronary which ended up with her needing a triple heart bypass. See February 2008 Veteran Statement. The Veteran has stated that while in service, she worked with burn patients and helped to debride their dead skin. The Veteran's service treatment records show that her blood pressure was within normal limits, and her heart and vascular system were considered to have been normal, both upon entrance into service and discharge from service. Her remaining service records reflect no complaints or findings indicative of any cardiovascular problem. The Veteran had coronary bypass surgery and was diagnosed with Ischemic Heart Disease, Chronic in July 2007. Private treatment records dated October 2007 show that the Veteran had met with a mental health counselor on six occasions, prior to being diagnosed - specifically, once in April, once in May, three times in June and once in July 2007. The Veteran's mental health counselor indicated that the Veteran had been diagnosed with symptoms of depression, anxiety, and chronic posttraumatic stress disorder. The counselor opined that some of the Veteran's anxiety and PTSD was related to the time she spent in the Army as a physical therapy technician. In May 2008, the Veteran's treating psychiatrist submitted a letter stating that the Veteran suffers with PTSD, with symptoms including hypervigilance, hyperstartle response, and re-experiences traumatic events with the minimum of triggers, more frequently triggering full blown panic episodes, all of which have debilitating effects on her cardiovascular status. On examination in August 2012, the examiner noted that the Veteran had chronic congestive heart failure. The examiner opined that the Veteran's CAD was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The examiner noted that the Veteran smoked tobacco for many years, had diabetes for over 10 years, and had a family history of coronary artery disease, which make it not surprising that the Veteran had significant coronary disease by the age of 57. The examiner found that the Veteran's coronary artery disease resulted in ischemic heart disease and indicated that the medical literature does not indicate that PTSD causes coronary artery disease or ischemic heart disease. The Veteran, through her representative, has submitted medical literature that correlates Coronary Artery Disease and PSTD. Specifically, the Veteran points to a 2011 article published in The Open Cardiovascular Medicine Journal and a 2007 article published in the Journal of the American Medical Association (JAMA) which found that Veterans with PTSD are more likely to develop coronary heart disease. In a September 2014 addendum opinion, the examiner opined that the Veteran's CAD was less likely than not aggravated by her service-connected PTSD. The examiner opined that the Veteran has had no additional procedures on her heart and recent medical records indicate that she does not have exertional chest pain, all of which speaks against any aggravation of her known coronary disease. The examiner further stated that an echo done in July 2014 showed normal wall motion with ejection fraction of 50-60%, therefore there has been no deterioration in her cardia function. The examiner stated that the Veteran's report of aggravation of her CAD and private opinion that her PTSD symptoms have debilitating effect on her cardiovascular status are not supported by objective information in the clinical records. In an April 2016 outside medical opinion (OMO), the cardiology specialist found that the Veteran's (coronary heart disease) CHD/IHD is more likely than not due to her service-connected psychiatric disorder. The specialist also found that the Veteran's CHD/IHD is more likely than not aggravated by her service-connected psychiatric disorder. The specialist cited an article from the Journal of the American College of Cardiology from September 2013 which states that "[a]mong Vietnam-era Veterans, PTSD is associated with an increased risk of CHD, confirmed with quantitative measures of coronary perfusion and myocardial blood flow. This increased risk is not due to a higher rate of established risk factors for CHD. It is also not explained by adverse health behaviors such as smoking and alcohol consumption or by familial risk factors shared by PTSD and CHD." The examiner quoted additional literature, ultimately noting that "overall, there are considerable data supporting an association that is likely causal between PTSD and CHD outcomes. Although the studies often use self-reported data with risk factor measurement and self-reported outcomes without validation, the strong associations with subclinical outcomes, the studies that show a dose relationship and the evidence for plausible mechanistic associations suggest that the relation is real and clinically important." Analysis At the outset, the Board notes that the Veteran has a diagnosis of IHD/CAD, as evidenced in private treatment records as well as her August 2012 VA examination. There are no medical records reflecting the Veteran's physical condition between her discharge in 1969 and private treatment records from October 2003. Because the Veteran's heart and vascular system were deemed to have been normal upon clinical examination at discharge from service, the Board is precluded from finding incurrence during service. In addition, as there is no evidence of a heart condition within the year following the Veteran's discharge from service, and she has not alleged a continuity of symptomatology, the Veteran's subsequently-diagnosed IHD/CAD cannot be presumed under the law to have had its inception during service. In other words, absent evidence of heart problems during service, or within one year or service, governing law dictates that the disability did not have its inception during service and cannot be presumed under law to have had its inception during service. 38 U.S.C.A. §§ 1101, 1112, 38 C.F.R. §§ 3.307, 3.309. The Board therefore holds that direct and/or presumptive service connection is not warranted. Turning to secondary service connection, the Veteran asserts that her CAD is caused or aggravated by her service-connected PTSD. Private treatment records indicate that the Veteran was initially diagnosed with CAD in July 2007, at age 57. The Board notes that the Veteran is currently service-connected for PTSD at 30 percent. In May 2008, the Veteran's treating physician submitted a letter stating that the Veteran suffers with PTSD, with symptoms including hypervigilance, hyperstartle response, and re-experiences traumatic events with the minimum of triggers, more frequently triggering full blown panic episodes, all of which have debilitating effects on her cardiovascular status. The Veteran was afforded a VA examination in August 2012. After reviewing the medical records and examining the Veteran, the VA examiner opined that the Veteran's CAD was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As rationale for her conclusions, the examiner indicated that the Veteran smoked tobacco for many years, had diabetes for over 10 years, and had a family history of coronary artery disease, which in the examiner's opinion made it not surprising that the Veteran had significant coronary disease by the age of 57. The examiner found that the Veteran's coronary artery disease resulted in ischemic heart disease and indicated that the medical literature does not indicate that PTSD causes coronary artery disease or ischemic heart disease. In a September 2014 addendum opinion, the August 2012 examiner opined that the Veteran's CAD is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition. The examiner rationed that the Veteran has had no additional procedures on her heart and recent medical records indicate that she does not have exertional chest pain, all of which speaks against any aggravation of her known CAD. The examiner further stated that an echo done in July 2014 showed normal wall motion with ejection fraction of 50-60%, therefore there has been no deterioration in her cardia function. The examiner then disagreed with the Veteran's report of aggravation of her CAD and the private opinion which states that the Veteran's PSTD symptoms have debilitating effect on her cardiovascular status. The examiner concluded that these statements are not supported by objective information in the clinical records. In an April 2016 outside medical opinion (OMO), a cardiology specialist found that the Veteran's CAH/IHD is more likely than not due to her service-connected psychiatric disorder. The specialist also found that the Veteran's CAD/IHD is more likely than not aggravated by her service-connected psychiatric disorder. The specialist cited an article from the Journal of the American College of Cardiology from September 2013 which states that "[a]mong Vietnam-era Veterans, PTSD is associated with an increased risk of CHD, confirmed with quantitative measures of coronary perfusion and myocardial blood flow. This increased risk is not due to a higher rate of established risk factors for CHD. It is also not explained by adverse health behaviors such as smoking and alcohol consumption or by familial risk factors shared by PTSD and CHD." The examiner quoted additional literature, ultimately noting that "overall, there are considerable data supporting an association that is likely causal between PTSD and CHD outcomes. Although the studies often use self-reported data with risk factor measurement and self-reported outcomes without validation, the strong associations with subclinical outcomes, the studies that show a dose relationship and the evidence for plausible mechanistic associations suggest that the relation is real and clinically important." Although the above opinions reach different conclusions, the Board finds that both opinions provide clear conclusions with supporting data, and a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Additionally, both addressed the issues of secondary service-connection and aggravation of the Veteran's service-connected PTSD. Therefore, the Board finds that the August 2012 examination with September 2014 addendum opinion should be afforded the same probative weight as the April 2016 OMO. The Board observes that, in the letter provided in May 2008, the Veteran's private psychiatrist stated that the Veteran's PTSD has had debilitating effects on the Veteran's cardiovascular status. The Board notes that this opinion was provided by the Veteran's psychiatrist and not a cardiologist and does not further explain the Veteran's cardiovascular status and what exactly her PTSD is doing to her heart, nor did it indicate that the opinion was rendered after speaking to the Veteran about her medical history or after the Veteran's medical records were reviewed. However, because this opinion was rendered by her treating psychiatrist who likely has some knowledge of the Veteran's medical history, the Board affords this letter some probative weight, but less weight than the August 2012 VA examination and April 2016 outside medical opinion. The Board acknowledges the Veteran's lay assertions that after years of dreams about her burn victims and amputees as well as burning arms and severed legs chasing her, she had a massive coronary which required her to get a triple heart bypass. The Veteran has also testified that in her dreams, she would see men on fire and she didn't have the ability to put them out, which would cause her to wake up screaming. See September 2011 BVA Hearing Transcript at pg.8. In this regard, while the Veteran can competently report symptoms she experienced, however any opinion regarding the nature and etiology of the Veteran's CAD requires medical expertise that she has not demonstrated. The Board recognizes that the Veteran was assigned to the hospital physical therapy department in-service; however, she has not demonstrated that she has the medical knowledge to determine the etiology of her CAD. See Jandreu v. Nicholson, 492 F.3d 1372, 1376 (2007). As such, the Board assigns the Veteran's statements relating her CAD to her PTSD little probative weight. Additionally, the Veteran testified that her VA surgeon told her a lot of the heart problems she experienced can be attributed to PTSD, and that because she already had PTSD, then it's more than likely her PTSD caused or helped cause the heart attack she experienced. See September 2011 BVA Hearing Transcript at pg. 20. The Board notes that the Veteran is competent to testify as to statements made to her and as there is no reason to question her credibility, the Board finds these statements to be credible. After considering the totality of the evidence, the Board finds that, when resolving all doubt in favor of the Veteran, service connection for CAD is warranted as secondary to her PTSD. Initially, the Board notes that, although the Veteran was diagnosed with CAD prior to PTSD, the lay and medical evidence clearly shows that the Veteran was diagnosed with CAD after she began receiving mental health counseling for symptoms consistent with PTSD. Moreover, the outside medical opinion determined that there was a high likelihood that the Veteran's CAD was triggered by his PTSD and offered a rationale for this conclusion. Accordingly, when resolving all doubt in favor of the Veteran, service connection is warranted for CAD as secondary to the service-connected PTSD. In reaching this conclusion, the Board finds that the evidence is in at least a state of equipoise. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for coronary artery disease is granted. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs