Citation Nr: 1806208 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 09-01 428 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to service connection for coronary artery disease, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Chisholm, Chisholm, and Kilpatrick ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran had active duty service from April 1973 to May 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Board previously remanded this case for additional development in June 2012, June 2014, and July 2015. In June 2012, the case was remanded to obtain Social Security records and afford the Veteran a VA examination. In June 2014, the Board found that the July 2012 examination did not comply with the June 2012 remand directives. The case was remanded to obtain a new examination in compliance with the June 2012 remand instructions. In July 2015, the Board again found that the August 2014 examination did not comply with the June 2014 remand instructions and remanded to obtain a new opinion in compliance with the June 2014 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). A June 2016 Board decision denied service connection for coronary artery disease, including secondary to service-connected PTSD. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). In June 2017, the Court issued an order that granted a Joint Motion for Remand (Joint Motion) filed by counsel for both parties, vacated the Board's June 2016 decision, and remanded the matter on appeal to the Board for action in compliance with the Joint Motion. FINDING OF FACT Resolving all reasonable doubt in favor of the Veteran, the probative evidence of record shows that the Veteran's coronary artery disease was due to his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for coronary artery disease have been met. 38 U.S.C. §§ 1101, 1131 (2012); 38 C.F.R. § 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that his coronary artery disease was caused or aggravated by his service-connected PTSD. Service connection may be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310 (a) (2017). Service connection is also possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the decision of the Court in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310 (b). The evidence of record establishes that the Veteran has a current diagnosis of coronary artery disease. Therefore, the issue on which the case turns is whether the coronary artery disease was caused or aggravated by the Veteran's PTSD. The Board notes that there are several VA opinions of record finding that the Veteran's coronary artery disease was not caused or aggravated by his PTSD, including in October 2007, July 2012, and September 2015. However, the October 2007 examiner did not provide any rationale for the opinion that it was less likely as not that PTSD caused the Veteran's heart disease when depression and anxiety have been associated with coronary artery disease in some studies. The July 2012 examiner's rationale for her opinion was insufficient, as she did not consider the impact that the Veteran's PTSD-related depression and anxiety had on his coronary artery disease. Finally, the September 2015 examiner used the incorrect aggravation standard for a secondary service connection claim of "permanent worsening" when opining that the Veteran's coronary artery disease is less likely than not caused or aggravated (permanently worsened) by his service-connected PTSD. Therefore, the Board assigns low probative weight to the October 2007, July 2012, and September 2015 VA opinions. The Veteran submitted a November 2017 private medical opinion from a cardiologist in support of his claim. The cardiologist reviewed the Veteran's entire claims file, noting that the Veteran underwent three vessel coronary artery bypass grafting in February 1991 at the age of 36. He cited the findings of several articles in the medical literature supporting an association that was more likely than not causal between PTSD and coronary heart disease outcomes. The studies showed a strong link with subclinical outcomes, a dose relationship, and evidence for mechanistic associations suggesting that the relation was real and certainly clinically important. Based on the medical literature and the fact that the Veteran developed significant ischemic heart disease at a very young age with a paucity of cardiac risk factors, the cardiologist opined that it was more likely than not that the Veteran's service-connected PTSD contributed substantially to his development of coronary artery disease in that it aggravated his heart condition and ultimately contributed to coronary artery bypass grafting at a young age. The Board assigns high probative weight to this opinion, as the cardiologist reviewed the Veteran's claims file, provided adequate rationale for the opinion, and cited medical literature in his findings. Therefore, the benefit of the doubt is resolved in favor of the Veteran, and service connection for coronary artery disease, as secondary to service-connected PTSD, is warranted. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for coronary artery disease, as secondary to service-connected PTSD, is granted. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs