Citation Nr: 1806791 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-24 815A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and her daughter ATTORNEY FOR THE BOARD K. Hughes, Counsel INTRODUCTION The Veteran served on active duty from June 1943 to January 1946, from May 1952 to April 1954, and from September 1956 to August 1959. His decorations include the Combat Infantry Badge. He died in April 2012 and the Appellant is his surviving spouse. This matter is before the Board of Veterans' Appeals (Board) on appeal of an April 2013 rating decision of the Department of Veterans Affairs (VA) Milwaukee Pension Management Center in Milwaukee, Wisconsin. Jurisdiction of the Appellant's claims file rests with the Regional Office (RO) in Detroit, Michigan. The Appellant testified before the undersigned Veterans Law Judge in November 2016. A transcript of the hearing is of record. This case was before the Board in February 2017 when it was remanded for additional development. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. The Veteran's certificate of death indicates that he died in April 2012; his immediate cause of death was cardiac arrest due to or as a consequence of congestive heart failure, metastatic prostate cancer was another significant condition which contributed to his death. 2. During the Veteran's lifetime, service connection was in effect for posttraumatic stress disorder (PTSD). 3. The weight of the competent and probative medical evidence of record is in favor a finding that the Veteran's service-connected PTSD, as likely as not, contributed substantially to his death. CONCLUSION OF LAW Resolving all doubt in favor of the Appellant, service connection for the cause of the Veteran's death is warranted. 38 U.S.C. § 1310 (2012); 38 C.F.R. §§ 3.307, 3.309, 3.310, 3.312 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Appellant seeks service connection for the cause of the Veteran's death. She asserts that her husband's PTSD contributed to his congestive heart failure and cardiac arrest, and therefore believes that the PTSD was a contributory cause of his death. The Board agrees. VA death benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. §§ 3.5, 3.312. In order to establish service connection for the cause of a veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributing cause of death. 38 C.F.R. § 3.312. For a service-connected disability to be a contributing cause, it must have substantially or materially contributed to a veteran's death; it is not sufficient to show that it casually shared in producing death, but rather there must be a causal connection. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(b),(c). The Board must assess the credibility and weight of evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). An appellant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102. When an appellant seeks benefits and the evidence is in relative equipoise, the appellant prevails. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). In this case, the Veteran's death certificate indicates that he died at home in April 2012. His immediate cause of death is listed as cardiac arrest due to or as a consequence of congestive heart failure. In addition, metastatic prostate cancer is listed as another significant condition which contributed to his death. During the Veteran's lifetime, service connection was in effect for PTSD. In support of her claim, the Appellant has submitted medical articles which suggest a connection between PTSD and cardiovascular problems. Specifically, these articles suggest a link between PTSD symptoms and future heart disease. See "PTSD May Raise Heart Risk," January 2, 2007, Military.com; "Prospective Study of Posttraumatic Stress Disorder Symptoms and Coronary Heart Disease in the Normative Aging Study," January 2007, Vol. 64, No.1, Jamanetwork.com; and "Post-traumatic Stress Disorder and Cardiovascular Disease," The Open Cardiovascular Medicine Journal, 2011, 5, 164-170. In support of her claim, the Appellant also submitted statements from the Veteran's counselor and cardiologist. Specifically, in a July 2009 statement, the counselor notes that the Veteran "has physiological reactivity to the traumatic cues, occurring approximately one to two times a night" and he reported "'I sweat when I have nightmares' and 'my heart races after the nightmares and this also scares me, because I have heart problems.'" In a May 2012 statement, the Veteran's cardiologist, A. Gupta, M.D., opined that PTSD "may have been a contributing factor to [the Veteran's] underlying coronary artery disease." In a December 2016 statement, Dr. Gupta noted he had treated the Veteran from 2004 until 2012; referred to a medical article regarding the incidence of heart disease, noting that it "was more than double" in patients with PTSD; and opined that it "is a[t] least as likely as not that [the Veteran's] PTSD caused his coronary artery disease (his primary cause of death)." Dr. Gupta explained that "[c]oronary artery disease lead[s] to ischemic cardiomyopathy causing Congestive Heart Failure, ultimately causing patients demise." In contrast, the evidence against the Appellant's claim consists of a February 2013 VA medical advisory opinion by a VA staff physician which found that the "Veteran's service-connected PTSD is less than likely as not contributed to his death from cardiac arrest due to CHG (congestive heart failure) and metastatic prostate cancer substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death." The explanation of rationale was that the examiner had reviewed "standard, current medical literature" and the Veteran's claims file. Pursuant to the February 2017 Board remand, which found the February 2013 opinion inconsistent with (and not reflecting consideration of) the medical articles and literature submitted by the Appellant in support of her claim, a second supplemental medical advisory opinion was obtained in May 2017 from the same staff physician who provided the February 2013 opinion. The physician opined "THAT THIS VETERAN'S PTSD LESS LIKELY THAN NOT CAUSED OR contributed substantially or materially to cause the Veteran's death. AS the Veteran's service-connected PTSD DID NOT involve an active process affecting vital organs such that there was NOT a resulting general impairment of health to an extent that DID NOT rendered the Veteran materially less capable of resisting the effects of other disease or injury primarily causing death." [Emphasis in original] The examiner questioned the validity of one study, noting that the study found the men had different levels of PTSD, "very few had enough symptoms for a true diagnosis" of PTSD and the study needed to be repeated to see if the findings hold true for PTSD-diagnosed veterans and women. The examiner also noted that the study did not track how frequently the men exercised. The rationale for this opinion was also "extensive review of medical records and literature;" however, the examiner did not provide a discussion of all of the articles submitted by the Appellant in support of her claim. Notably, the third of these articles includes the conclusion that "persons with PTSD have been reported to have an increased risk of hypertension, hyperlipidemia, obesity, and cardiovascular disease. Such persons have been observed to have an increased risk of coronary heart disease and possibly thromboembolic stroke. The reported link between PTSD and hypertension and other cardiovascular risk factors may partly account for the observed associations between PTSD and heart disease." In summary, the Board finds that the most probative evidence for and against the grant of service connection for the cause of the Veteran's death is in equipoise; that is, the private medical evidence demonstrating that the Veteran's PTSD substantially contributed to his death by aggravating his cardiac conditions is equally weighted against the VA medical evidence which suggested no link between any service-connected disability and his death. Accordingly, the Board finds that the evidence before it is adequate to resolve reasonable doubt in the Appellant's favor without remanding the claim to obtain an additional medical opinion. 38 C.F.R. § 3.159(c)(4); cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Essentially, the evidence in support of the Appellant's claim include the opinion of the Veteran's cardiologist, Dr. Gupta, addressing the effects of PTSD on the Veteran's death and providing a brief rationale; weighing against the claim are the February 2013 and May 2017 opinions of the VA staff physician which addressed the link between PTSD and heart disease and found no association but did not adequately address the medical literature which supported the claim. Thus, resolving all reasonable doubt in the Appellant's favor, the Board finds that it is at least as likely as not that the Veteran's service-connected PTSD was a contributory cause of his death, one which contributed substantially and materially to cause death, and/or aided or lent assistance to the production of death. Therefore, the Board finds that service connection for the cause of the Veteran's death is warranted. ORDER Service connection for the cause of the Veteran's death is granted. ____________________________________________ M.C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs