Citation Nr: 1748675	
Decision Date: 10/30/17    Archive Date: 11/06/17

DOCKET NO.  13-34 037A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in San Diego, California



THE ISSUE

Entitlement to service connection for a heart disorder, claimed as secondary to posttraumatic stress disorder (PTSD).



REPRESENTATION

Appellant represented by:	The American Legion



ATTORNEY FOR THE BOARD

B. Kuczynski, Associate Counsel 



INTRODUCTION

The Veteran served on active duty from February 1988 to February 1992.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in San Diego, California.  

This appeal was processed using the Veterans Benefits Management System (VBMS).  Accordingly, any future consideration of this case should take into consideration the existence of these records.


FINDING OF FACT

The Veteran's heart disorder did not manifest in service or to a compensable degree within one year of separation and is not otherwise related to his military service or to his service-connected PTSD.


CONCLUSION OF LAW

The Veteran's heart disorder was not incurred in active service, may not be presumed to have been so incurred, and is not proximately due to, the result of, or aggravated by a service-connected disability.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2016).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).


Law and Analysis

The Veteran has contended that service connection is warranted for a heart disorder as secondary to PTSD.  See July 2009 claim; June 2014 Veteran statement.

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§1110, 1131 (West 2014).  That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease.  Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to 
 service, establishes that the disease or injury was incurred in service. 38 C.F.R. §3.303(d) (2016).

For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time.  Arteriosclerosis and cardiovascular-renal disease are considered to be a chronic disease for VA compensation purposes.  If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§3.303(b), 3.309(2016); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§3.307, 3.309 (2016).

Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448   (1995) (en banc); 38 C.F.R. § 3.310.

In this case, the Veteran's DD-214 indicates that he served in Southwest Asia in 1991.  Service connection for an undiagnosed illness or a medically unexplained chronic multi-symptom illness may be established under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317.  However, these provisions do not apply in this case because the Veteran has a clinical diagnosis for his heart disorder. See also June 2014 VA examination report.

In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a heart disorder.

The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of a heart disorder.  While he was reportedly in good health at his entrance examination in 1988, he admitted to a family history of heart disease.  See February 1988 dental health questionnaire.  The Veteran also reported that he engaged in regular tobacco use of one pack every two days and alcohol consumption of a six-pack weekly to every two weeks since 1983.  See Id. (one pack every two days since 1983; six-pack weekly); see also August 1989 dental health questionnaire; September 1991 dental health questionnaire.   A December 1991 examination found his heart to be normal, and in a September 1992 dental health questionnaire, the Veteran denied having a history of heart problems, angina, a heart murmur, heart surgery, mitral valve prolapse, congenital heart lesions, prosthetic heart valve, and a pacemaker.

There is no evidence showing that a heart disorder manifested in service or within one year thereafter.  The first documentation of any heart disorder was many decades after the Veteran's military service.  The February 2010 VA examiner noted that the Veteran reported having a heart attack in May 2007, and the May 2013 VA examiner indicated that the Veteran's coronary artery disease started in 2008.  Moreover, the Veteran has not alleged that his heart disorder began in service.  In this regard, he told the May 2012 VA examiner that his heart problems began around May 2008.  Indeed, the Veteran has instead asserted that his current disorder is secondary to his service-connected PTSD.

In addition to the lack of evidence showing that a heart disorder manifested during active service or within close proximity thereto, the weight of the evidence of record does not link any current disorder to the Veteran's military service.  As noted above, the record shows that there were no complaints, treatment, or diagnosis of the claimed disorder in service.  As such, there is no injury, disease, or event to which a current disorder could be related. See 38 C.F.R. § 3.159 (c)(4)(i); cf. Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003) (noting that a medical examination conducted in connection with claim development could not aid in substantiating a claim when the record does not already contain evidence of an in-service event, injury, or disease).  Therefore, the Board finds that a heart disorder has not been shown to be causally or etiologically to an event, disease, or injury in service.

As to the Veteran's claim that his current heart disorder is related to his service-connected PTSD, the Board finds that the most probative evidence of record does not support this contention.  Although the Veteran has a current diagnosis of a heart disorder and is service-connected for PTSD, the more probative evidence has not established a relationship between these disorders.

The July 2010 VA examiner diagnosed the Veteran with coronary artery disease requiring stent placement and noted that he is service-connected for PTSD.  He commented that patients with PTSD have increased stress hormones that will produce or aggravate coronary artery disease and hypertension.  However, the examiner did not provide an opinion regarding the facts of the Veteran's case or any further rationale.  

The May 2012 VA examiner diagnosed the Veteran with an acute, subacute, or old myocardial infarction; coronary artery disease; ischemic heart disease; and quiescent status post ventricular arrhythmia.  The examiner opined that the claimed condition was at least as likely as not incurred in or caused by he claimed in-service injury, event, or illness.  However, in so doing, he merely noted that the July 2010 VA examiner had indicated that he was diagnosed with PTSD, which would cause hormonal changes and predispose him to ischemic heart disease.  No further rationale was provided.  

On the other hand, the May 2013 VA examiner noted that the Veteran is service-connected for PTSD.  He indicated that PTSD is generally a disorder arising from a highly traumatic event and observed that, in this case, the Veteran's PTSD arose from his Gulf War experiences.  He explained that the pathogenesis of coronary artery disease is caused by the hardening of the arteries and has risk factors for its development like hyperlipidemia and hypertension, which the Veteran has as evidenced by the June 2009 treatment records.  The examiner opined that his PTSD cannot cause the Veteran to develop any aggravation of his coronary artery disease because the pathophysiology is due to arteriosclerosis of hardening of the arteries.

In addition, an October 2013 VA examiner stated that he reviewed the conflicting medical evidence and found that it is less likely than not that the Veteran's current coronary artery disease is proximately due to or the result of his PTSD.  He indicated that the confirmed risk factors for the development of coronary artery disease included hypercholesterolemia, smoking, hypertension, hyperglycemia, type A behavioral patterns, hemostatic factors, genetics, and high levels of lipoprotein.  The examiner stated that PTSD has not been clearly proven to be a causal etiology in the development of coronary artery disease, let alone identified as a risk factor.  He noted that the Veteran has medical documentation of hypertension, hyperlipidemia, and a 26-year smoking history, which are far more credible etiologies.  

The law is clear that it is the Board's duty to assess the credibility and probative value of evidence, and provided that it offers an adequate statement of reasons and bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wray v. Brown, 7 Vet. App. 488 (1995) (the Board may adopt a particular independent medical expert's opinion for its reasons and bases where the expert has fairly considered the material evidence of record).The Board, of course, is not free to reject medical evidence on the basis of its own unsubstantiated medical conclusions. Flash v. Brown, 8 Vet. App. 332 (1995).

The Board finds that, after weighing the evidence, the May 2013 and October 2013 VA examiners' opinions are the most probative evidence of record.  The May 2013 and October 2013 VA examiners provided a rationale supported by the record.  Indeed, the pathology and risks factors for the Veteran's current heart disorder, as evidenced by his treatment records.  On the other hand, the July 2010 VA examiner made a general statement and did not discuss the particular facts of the Veteran's case.  Indeed, he did not address any of the risk factors noted in the medical records.  Moreover, the May 2012 VA examiner merely reiterated the July 2010 VA examiner's statement without any further rationale or discussion of the facts. 

The value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999).  Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning); Knightly v. Brown, 6 Vet. App. 200 (1994); Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record and conclusions of medical professionals which are not accompanied by a factual predicate in the record are not probative medical opinions).  In this case, and based on the foregoing, the Board attaches the greatest probative weight to the opinions of the May 2013 and October 2013 VA examiners who provided a rationale supported by the record.

The Board further notes that the Veteran has submitted an article pertaining to PTSD and the risk for heart disease.  However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998).  A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than unsubstantiated lay opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999).  In this case, however, the article is general in nature, and no medical professional has related the information contained therein to the Veteran.  Indeed, the positive opinions do not cite or address that article.  Therefore, the Board concludes that such evidence is entitled to little probative weight.

The Board also acknowledges the Veteran's own statements that his heart disorder is secondary to his service-connected PTSD.  However, the Veteran is not competent to provide a nexus opinion regarding the nature and etiology of his heart disorder. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the diagnosis and etiology of his heart disorder, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4   (Fed. Cir. 2007) (lay persons not competent to diagnose cancer).  The question of etiology in this case goes beyond a simple and immediately observable cause-and-effect relationship. 

Moreover, even assuming the Veteran's lay assertions regarding etiology are competent, the Board nevertheless finds the May 2013 and October 2013 VA medical opinions to be more probative, as they are based on a review of the record and the examiners' own medical expertise, training, and knowledge.  The examiners supported their conclusions with a rationale that considered the risk factors for this particular Veteran and disease.

Based on the foregoing the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a heart disorder.  Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply.  Accordingly the Board concludes that service connection for a heart disorder is not warranted.


ORDER

Entitlement to service connection for a heart disorder is denied.




____________________________________________
J.W. ZISSIMOS
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs