Citation Nr: 1752823 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 09-10 943 ) DATE ) ) On appeal from the Department of Veterans Affairs St. Paul Pension Management Center THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant is represented by: The American Legion ATTORNEY FOR THE BOARD C. Banister, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1971 to December 1973 and from February 1975 to February 1993. The Veteran passed away in March 2011, and the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in February 2017, at which time it was remanded for further development. The requested development was completed, and the case has been returned to the Board for further appellate action. FINDING OF FACT The most probative evidence is against a finding that the Veteran's coronary artery disease was incurred in or caused by service or caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for the cause of the Veteran's death have not been met. 38 U.S.C. §§ 1110, 1131, 1310, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 312 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The appellant seeks dependency and indemnity compensation (DIC) benefits as the surviving spouse of the Veteran, who died of coronary artery disease. The appellant asserts that the Veteran's coronary artery disease was incurred during service, or alternatively, was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). DIC benefits are payable to the surviving spouse, children, and parents of a veteran who dies from a service-connected or compensable disability. 38 U.S.C. § 1310. In order to establish service connection for the cause of the 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. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be established for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection may also be presumed for certain diseases, including coronary artery disease, if a veteran was exposed to an herbicide agent, including Agent Orange, during service, and the disease manifested to a degree of ten percent or more any time after service. 38 C.F.R. § 3.307(a)(6), 3.309(e). A veteran who served in the Republic of Vietnam during a presumptive period or who served between April 1, 1968 and August 31, 1971 in a unit that, as determined by the Department of Defense, operated in or near the Korean demilitarized zone (DMZ) in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii)-(iv). Upon review of the record, the Board finds that the most probative evidence is against a finding that the Veteran's coronary artery disease was incurred in or caused by service or caused or aggravated by a service-connected disability. With respect to presumptive service connection, the record does not show that the Veteran served in the Republic of Vietnam. The Board has reviewed and considered an article regarding the use of Agent Orange along the Korean DMZ. However, the Veteran did not enter service until December 1971. Thus, he did not serve in Korea during the presumptive period for herbicide exposure. Furthermore, a December 2011 correspondence from the National Personnel Records Center indicates that there is no evidence that the Veteran was exposed to an herbicide agent during service. Accordingly, service connection for coronary artery disease is not warranted on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. With respect to direct service connection, service treatment records show no complaints of or treatment for heart problems during service. A November 1992 report of medical examination indicates that the Veteran's heart was normal. On an accompanying report of medical history, the Veteran denied any history of heart trouble, pain or pressure in the chest, palpitation or pounding sound, or dizziness. Thereafter, the record is silent as to complaints of or treatment for coronary artery disease until December 2010. As there is no probative evidence of record directly linking the Veteran's coronary artery disease to service, the Board finds that service connection is not warranted on a direct basis. With respect to secondary service connection, the record shows that the Veteran was service connected for PTSD since August 2001. The Veteran was diagnosed with coronary artery disease in December 2010. At the time of the diagnosis, the Veteran's VA treatment provider noted the Veteran's history of PTSD; however, it was not included among his listed "cardiac risk factors." In June 2017, a VA examiner reviewed the evidence of record and opined that the Veteran's coronary artery disease was less likely than not caused or aggravated by his service-connected PTSD. The Board finds the opinion of the VA examiner to be highly probative and persuasive, as it is based on a review of the evidence of record and is supported with a reasoned medical explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). The examiner acknowledged that some studies suggest that there may be an increased risk of coronary artery disease associated with PTSD, and that it has been theorized that the increased activity of the sympathoadrenal axis may contribute to cardiovascular disease through the effects of catecholamines on the heart and vasculature. However, the examiner explained that no direct link has ever been identified. The examiner further noted that atherosclerosis, which is a pathologic process that causes disease of the coronary, cerebral, and peripheral arteries, occurs with increasing frequency with aging and that multiple factors contribute to the pathogenesis of atherosclerosis, including endothelial dysfunction, dyslipidemia, inflammatory and immunologic factors, plaque rupture, lipid abnormalities, and smoking. The examiner concluded that that there is no significant evidence that a mental health condition, such as PTSD, has any significant effect on the development or worsening of coronary artery disease. The Board has reviewed and considered a an article published in the Open Cardiovascular Medical Journal indicating that "persons with PTSD have been reported to have an increased risk of hypertension, hyperlipidemia, obesity, and cardiovascular disease" and that "the reported link between PTSD and hypertension and other cardiovascular risk factors may partly account for the observed associations between PTSD and heart disease." Additionally, briefs submitted by the appellant's representative contain citations to medical publications and websites regarding a possible link between PTSD and coronary artery disease. However, the Board assigns significantly less probative value to this evidence, as it does not address the particular facts of the Veteran's case. See, e.g. Sacks v. West, 11 Vet. App. 314, 316-17 (1998) (holding that a general medical journal article that did not specifically opine as to the causal relationship between the veteran's condition and active service was too general to satisfy the nexus element of a service connection claim). Although the appellant believes that the Veteran's coronary artery disease was related to service or his service-connected PTSD, as a lay person, she has not shown that she has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this regard, the etiology of cardiovascular disease is a matter not capable of lay observation and requires medical expertise to determine. Thus, the opinion of the appellant regarding the etiology of the Veteran's coronary artery disease is not competent medical evidence. In sum, the preponderance of the competent, credible, and probative evidence is against the claim, and service connection for the cause of the Veteran's death is denied. See Gilbert, 1 Vet. App. at 56. ORDER Service connection for the cause of the Veteran's death is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs