Citation Nr: 1815233 Decision Date: 03/09/18 Archive Date: 03/19/18 DOCKET NO. 13-01 652 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to service connection for coronary artery disease (CAD), claimed as heart attack, to include as secondary to service-connected anxiety and depression disorder. REPRESENTATION Veteran represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran and his Spouse ATTORNEY FOR THE BOARD S. Ferguson, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1989 to May 1992. This appeal to the Board of Veterans' Appeals (Board/BVA) is from an October 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Veteran testified in a video conference hearing before the undersigned Veterans Law Judge (VLJ) in June 2013. A transcript of the hearing is of record. The Board previously remanded this matter in January 2015, December 2015, and June 2017 for further evidentiary development. The case has now returned to the Board for additional appellate action. FINDING OF FACT A heart disorder, diagnosed as coronary artery disease (CAD), did not have onset during service, was not caused by service, did not manifest within one year of separation from service, and was not caused or worsened by service-connected anxiety and depression disorder. CONCLUSION OF LAW The criteria for service connection for CAD have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist. With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has also complied with the remand orders of the Board. In response to the Board's multiple remands, updated copies of VA medical records were obtained and added to the claims file along with private treatment records and records from the Social Security Administration (SSA). VA examinations and medical opinions addressing the claimed disability were also obtained throughout the claims period, most recently in January 2016. Therefore, VA has complied with the remand orders of the Board and the duties to notify and assist. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical or, in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303; see also Hickson v. West, 12 Vet. App. 247, 253(1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Service connection may also be granted for chronic disabilities, to include cardiovascular disease, if such are shown to have been manifested to a compensable degree within one year after the veteran was separated from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition to the requirements of service connection as detailed above, regulations also provide that service connection is warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Further, any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When determining service connection, all theories of entitlement, direct and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). As such the Board will address the Veteran's claim for service connection for CAD on both direct (to include presumptive) and secondary bases. The Veteran contends that he is entitled to service connection for CAD, including as secondary to his service-connected anxiety and depression disorder. The in-service treatment records are absent of complaint, treatment, or diagnosis of any heart condition. The record indicates that the Veteran was diagnosed with CAD in 2003 and had myocardial infarctions in 2003 and 2009; however, there is no evidence within his VA or private treatment records of an etiological opinion linking his heart condition to military service or a service-connected disability. Conversely, the available opinions indicate that other factors such as hypertension and a history of smoking led to his CAD. A November 2003 private cardiology record noted the Veteran had an acute myocardial infarction in October 2003 and listed hypertension, smoking history, and family history as cardiac risk factors. The treating physician also noted that he was diagnosed with anxiety and depression disorder, but did not indicate that the conditions had any relation to the Veteran's heart condition. A March 2005 private treatment record noted cardiovascular risk factors including hypertension and recent chest pain, likely secondary to underlying cardiovascular disease; a history of myocardial infarction; and a history of coronary artery disease. The physician indicated that the Veteran would also benefit by discontinuing smoking and getting a primary care follow up for reducing cardiovascular risk factors. The physician did note that given his history of anxiety and depression, he should obtain psychiatric counseling, but did not indicate these conditions affected his CAD. A June 2010 VA primary care note indicated that the Veteran's weight contributes to his CAD risk. In a September 2015 VA examination, the examiner indicated the Veteran's CAD was less likely than not incurred or caused by an in-service injury, event, or illness. The examiner further stated that his CAD was less likely than not aggravated by his service-connected psychiatric disorders, with the primary risk factor for his heart disease being cigarette smoking. A January 2016 VA medical opinion also indicated that it was less likely than not that the Veteran's CAD was caused by or aggravated by his service-connected anxiety and depression disorder. The physician opined that there appeared to be genetic, inflammatory, and metabolic etiologies for CAD, and noted that available literature did not support evidence that anxiety and depression causes or aggravates CAD. The physician further noted that anxiety and depression alone are not primary causes of CAD in the literature. At his June 2013 Board hearing, the Veteran testified that he began to experience panic attacks while stationed in South Korea during active duty service. He testified that he continued to experience panic attacks after leaving the military, and that they became more frequent in 2003. He stated that he felt like he was having a heart attack during these panic attacks, and did experience a heart attack in 2003. He further testified that it was his belief that his heart attacks were secondary to his anxiety issues, but was not sure if there was a medical opinion confirming such. Although the record reflects that the Veteran received treatment for anxiety and panic attacks on numerous occasions, including emergency room reports, there is no indication that his service-connected anxiety or depression disorder caused or aggravated his CAD. The Veteran frequently reported experiencing symptoms such as elevated heart rate, tightness in his chest, and heart palpitations, but there is no indication that these symptoms were associated with or affected his CAD. While the Veteran is competent to report (1) symptoms observable to a layperson (e.g., elbow pain); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, a lay veteran is not competent to render opinions regarding the etiology of a medically complex conditions and the Board is not required to assign any probative weight to bald assertions by a lay veteran regarding such subjects. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). Accordingly, the Veteran, who lacks medical training, is not competent to opine on the etiology or proper diagnosis of his CAD. See, e.g., Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The competent medical evidence of record indicates that the Veteran was diagnosed with CAD more than one year after his discharge from active duty service and that it was not caused by or aggravated by his service-connected anxiety and depression disorder. Therefore, the Board finds that the preponderance of the evidence is against the Veteran's claim and he is not entitled to service connection for CAD on either a primary or secondary basis. ORDER Entitlement to service connection for coronary artery disease (CAD), claimed as heart attack, to include as secondary to service-connected anxiety and depression disorder, is denied. ____________________________________________ M. H. Hawley Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs