Citation Nr: 18118399 Decision Date: 07/13/18 Archive Date: 07/13/18 DOCKET NO. 14-02 110 DATE: July 13, 2018 ORDER Entitlement to service connection for heart disease, to include as due to asbestos exposure, and as secondary to service connected posttraumatic stress disorder (PTSD) with alcohol abuse disability is denied. Entitlement to service connection for hypertension, to include as due to asbestos exposure, and as secondary to service connected PTSD with alcohol abuse disability is denied. Entitlement to service connection for hepatitis C, to include as secondary to service connected PTSD with alcohol abuse disability is denied. FINDINGS OF FACT 1. The Veteran’s heart disease does not relate to service or to his service-connected PTSD with alcohol abuse disability. 2. The Veteran’s hypertension does not relate to service or to his service-connected PTSD with alcohol abuse disability. 3. The Veteran’s hepatitis C does not relate to service or to his service-connected PTSD with alcohol abuse disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for heart disease, to include as due to asbestos exposure, and as secondary to service connected PTSD with alcohol abuse disability, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for hypertension, to include as due to asbestos exposure, and as secondary to service connected PTSD with alcohol abuse disability, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for hepatitis C, to include as secondary to service connected PTSD with alcohol abuse disability, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from February 1977 to February 1980. In July 2015, the Veteran testified at a Board hearing before a Veterans Law Judge. The transcript is of record. The VLJ who chaired the July 2015 hearing is no longer with the Board; the Veteran has twice been offered the option of having a new hearing, but he has not responded to either inquiry. These issues, along with others, have been before the Board twice in the past. Notably, as a result of the Board’s prior actions, the Veteran is now in receipt of a 100 percent disability rating for the entirety of the appellate period. Service Connection In order to establish service connection for the claimed disability, 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 Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). “Aggravation” of a nonservice-connected condition by a service-connected condition means a chronic worsening of the nonservice-connected condition by the service-connected condition, not merely temporary or intermittent flare-ups. See Hunt v. Derwinski, 1 Vet. App. 292 (1991); Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002). The Board has reviewed the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the service connection claim. 1. Entitlement to service connection for heart disease, to include as due to asbestos exposure, and as secondary to service connected PTSD with alcohol abuse disability The Veteran contends that his heart disease is due to his active military service. Specifically, the Veteran asserts that his heart disease is due to fume and asbestos exposure during service. The Veteran indicated that he was exposed to asbestos in 1977 during an overhaul of a destroyer. Alternatively, the Veteran asserts that his heart disease is secondary to his service-connected PTSD with alcohol abuse. Regarding direct service connection and concerning the first element, the existence of a current disability, the Board finds that the Veteran has a current diagnosis of coronary artery disease (CAD). As to the second element, the in-service incurrence, VA has conceded that the Veteran had in-service asbestos exposure as the Veteran’s MOS was highly probable for asbestos exposure. Notwithstanding the conceded in-service exposure to asbestos, the third element, a causal connection between fumes and asbestos exposure and the Veteran’s CAD must be established. The Veteran was afforded a VA opinion in January 2018. The examiner opined that the Veteran’s heart disease was less likely than not related to service, had its onset during military service, or is otherwise related to service, to include as due to exposure to fumes from a ship fire and asbestos exposure. The examiner expressed that the Veteran was possibly exposed to asbestos, but the results would be a respiratory issue and not a cardiac issue. The examiner noted that there are no current scientific evidence linking asbestos and cardiac issues. In addition, the examiner stated that the Veteran had an extensive history of cocaine abuse and that cocaine is associated with important cardiac complications. The examiner expressed that significant and severe coronary atherosclerosis is common in young chronic cocaine users and there is a relationship between duration and frequency of cocaine use and the extent of coronary disease. Therefore, the examiner concluded that the Veteran’s cocaine use was the most likely cause of the Veteran’s heart disease. Regarding the Veteran’s contention that CAD is secondary to his service-connected PTSD, the Board notes that service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In support of his claim, the Veteran submitted an article from VA Research Currents, entitled “Heart-mind mystery, unraveling the link between PTSD and heart disease.” The article revealed that there is large body of evidence that unequivocally links trauma exposure to poor physical health. The article noted that a 2013 article by VA and UCSD researchers posed the provocative question of whether PTSD is a “fast track to premature cardiovascular disease.” However, the article indicated that there is not the scientific equivalent of a smoking gun establishing a direct causal link between PTSD and heart disease, but the research seems to be moving in that direction. The article reported that “it’s not clear how exactly PTSD leads to heart disease. Most experts believe it’s a combination of factors: biological (for example, stress hormones and inflammation), behavioral (lack of activity, poor diet, smoking, social isolation), and psychological (accompanying conditions such as depression and hostility, which themselves are linked to heart disease).” The article also pointed out that “there may be underlying genetic risk factors that increase the risk of both PTSD and heart disease.” Regarding whether the Veteran’s CAD was secondary to his service-connected PTSD, the Veteran was afforded a VA examination in March 2017. The examiner opined that the Veteran’s heart disease was less likely than not caused by his service-connected PTSD with alcohol abuse disability due to the lack of medical science indicating a convincing link between the two. The examiner also indicated that alcohol is a depressant and not a stimulant and there is no proven link between alcohol abuse and CAD. The examiner did note that there was a definite link between cocaine and CAD in medical literature. The examiner was unable to provide an opinion as to if the Veteran’s CAD was aggravated by the Veteran’s service connected PTSD without resorting to speculation given the Veteran’s chronic, long-term polysubstance abuse disorder. Regarding whether the Veteran’s drug abuse is at least as likely as not proximately due to or the result of PTSD with alcohol abuse, the Veteran was afforded a VA medical opinion in January 2017. The examiner opined that the Veteran’s drug abuse was less likely than not proximately due to or the result of the Veteran’s PTSD. The examiner noted that the Veteran reported that he began using cocaine in the 1980s and that he started using cocaine as a product of his environment, with people around him using while drinking. The examiner reported that the Veteran did not attribute his history of cocaine use to PTSD symptoms. Further, the examiner expressed that in “51 VA inpatient psychiatric admissions from 1992 to 2014 related to alcohol and cocaine use, PTSD is only documented as a diagnosis in discharge summaries on 5 occasions, without any documentation suggesting that cocaine use was thought to be caused by PTSD symptoms.” Taken together, the examiner concluded that the Veteran’s stimulant use disorder was less likely as not secondary to PTSD. Upon review of the evidence, the Board finds that service connection for CAD is not warranted on either a direct or secondary basis. In so finding, the Board acknowledges the Veteran’s statements, in which he relates his current disability to service. As a lay witness, the Veteran is certainly competent to attest to his symptoms. However, the Board finds that the Veteran is not competent to provide a diagnosis and/or etiology for his CAD. Such an opinion requires medical knowledge and training of an internal disease process, which the Veteran is not shown to possess. Regarding direct service connection, the most probative evidence of record is the January 2018 VA opinion. The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The January 2018 VA opinion used both the facts of the case and objective medical principles to support the negative nexus opinion. This clinician considered the conceded exposure to asbestos and explained why asbestos did not cause the current disability. The Board finds that this nexus opinion is highly probative as to the issue of etiology. Regarding service connection for CAD on a secondary basis, the Board finds the most probative evidence of record are the January 2017 and March 2017 VA examiners’ opinions. Both VA opinions used the facts of the case and objective medical principles to support the negative nexus opinions. The examiners rendered an opinion after thoroughly reviewing the claims file and relevant medical records. The Board notes that, while the article submitted by the Veteran discussed the relationship between both heart disease and PTSD, it contained no information specific to this Veteran’s CAD and, hence, is not dispositive of his claim. See Wallin v. West, 11 Vet. App. 509, 514 (1998) (treatise evidence cannot simply provide speculative generic statements not relevant to the Veteran’s claim, but, “standing alone,” must include “generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion” (citing Sacks v. West, 11 Vet. App. 314, 317 (1998))); see also Stadin v. Brown, 8 Vet. App. 280, 284 (1995). In addition, the article indicated that there is not the scientific equivalent of a smoking gun establishing a direct causal link between PTSD and heart disease. Furthermore, while the March 2017 examiner indicated that there was a definite link between cocaine and CAD, the Board notes that drug abuse is not service connected so therefore service connection on a secondary basis is not warranted. Finally, though the examiner noted that he could not provide an opinion as to aggravation without resort to speculation, the examiner explained the reason why he could not offer such an opinion. To date, neither the Veteran nor his attorney have submitted a competent opinion regarding any possible aggravation of his CAD by his service-connected disabilities. In the absence of any such evidence, the Board finds that there is no evidence of aggravation to support that theory of secondary service connection. In sum, the Board finds that the most probative evidence of record is against the claim. Service connection for heart disease is not warranted on either a direct or secondary basis. The benefit-of-the-doubt rule is not applicable because the evidence is not in relative equipoise. 2. Entitlement to service connection for a hypertension, to include as due to asbestos exposure, and as secondary to service connected PTSD with alcohol abuse disability The Veteran contends that his hypertension is due to his active military service. Specifically, the Veteran asserts that his hypertension is due to fume and asbestos exposure during service. The Veteran indicated that he was exposed to asbestos in 1977 during an overhaul of a destroyer. Alternatively, the Veteran asserts that his hypertension is secondary to his service-connected PTSD with alcohol abuse. The Board finds that the Veteran has a current diagnosis of hypertension and that VA has conceded that the Veteran had in-service asbestos exposure. Notwithstanding the conceded in-service exposure to asbestos, the third element, a causal connection between fumes and asbestos exposure and the Veteran’s hypertension must be established. The Veteran was afforded a VA opinion in January 2018. The examiner opined that the Veteran’s hypertension was less likely than not related to service, had its onset during military service, or is otherwise related to service, to include as due to exposure to fumes from a ship fire and asbestos exposure. The examiner noted that the Veteran was possibly exposed to asbestos, but the results would be a respiratory issue and not a hypertension issue. The examiner noted that there are no current scientific evidence linking asbestos and hypertension. The examiner concluded that the Veteran’s hypertension is at least as likely as not caused by smoking, excessive salt intake, obesity, and sedentary life style. The examiner reported that smoking is a definite risk factor for hypertension due to its acute effect on the sympathetic nervous system and arterial stiffness. The examiner expressed that hypertensive smokers are more likely to develop severe forms of hypertension. Regarding the Veteran’s contention that hypertension is secondary to his service-connected PTSD, as noted above, the Veteran submitted a VA Research Currents article, entitled “Heart-mind mystery, unraveling the link between PTSD and heart disease.” Regarding whether the Veteran’s hypertension was secondary to his service-connected PTSD, the Veteran was afforded a VA examination in March 2017. The examiner opined that the Veteran’s hypertension was less likely than not caused by his service-connected PTSD with alcohol abuse disability due to the lack of medical science indicating a convincing link between the two. The examiner also indicated that alcohol is a depressant and not a stimulant and there is no proven link between alcohol abuse and hypertension. The examiner was unable to provide an opinion as to if the Veteran’s hypertension was permanently worsened by the Veteran’s service connected PTSD without resorting to speculation given the Veteran’s chronic, long-term polysubstance abuse disorder. Upon review of the evidence, the Board finds that service connection for hypertension is not warranted on either a direct or secondary basis. In so finding, the Board acknowledges the Veteran’s statements, in which he relates his current disability to service. As a lay witness, the Veteran is certainly competent to attest to his symptoms. However, the Board finds that the Veteran is not competent to provide a diagnosis and/or etiology for his hypertension. Such an opinion requires medical knowledge and training of an internal disease process, which the Veteran is not shown to possess. Regarding direct service connection, the most probative evidence of record is the January 2018 VA opinion. The January 2018 VA opinion used both the facts of the case and objective medical principles to support the negative nexus opinion. This clinician considered the conceded exposure to asbestos and explained why asbestos did not cause the current disability. The Board finds that this nexus opinion is highly probative as to the issue of etiology. Regarding service connection for hypertension on a secondary basis, the Board finds the most probative evidence of record is the March 2017 VA examiner’s opinion. The VA opinion used both the facts of the case and objective medical principles to support the negative nexus opinion. This examiner rendered an opinion after thoroughly reviewing the claims file and relevant medical records. The Board notes that the article submitted by the Veteran did not contain information specific to this Veteran’s hypertension and, hence, is not dispositive of his claim. See Wallin v. West, 11 Vet. App. 509, 514 (1998). Finally, though the examiner noted that he could not provide an opinion as to aggravation without resort to speculation, the examiner explained the reason why he could not offer such an opinion. To date, neither the Veteran nor his attorney have submitted a competent opinion regarding any possible aggravation of his hypertension by his service-connected disabilities. In the absence of any such evidence, the Board finds that there is no evidence of aggravation to support that theory of secondary service connection. In sum, the Board finds that the most probative evidence of record is against the claim. Service connection for hypertension is not warranted on either a direct or secondary basis. The benefit-of-the-doubt rule is not applicable because the evidence is not in relative equipoise. 3. Entitlement to service connection for a hepatitis C, to include as secondary to service connected PTSD with alcohol abuse disability The Veteran contends that his hepatitis C is due to his active military service to include as due to drug abuse associated with PTSD. The Board finds that the Veteran has a current diagnosis of hepatitis C. The Veteran’s service treatment records are absent of treatment or a diagnosis for hepatitis C. VAMC treatment notes show that the Veteran was diagnosed with hepatitis C in November of 2006, 26 years after discharge from service. Nevertheless, the Veteran was afforded a VA opinion in January 2018. The examiner opined that it is less likely than not that the Veteran’s hepatitis C was caused by or incurred in service. The examiner expressed that hepatitis C is transmitted through the blood and can be transmitted by needles, unprotected sexual contact, and tattoos. The examiner indicated that there is no record of the Veteran having incurred hepatitis C in service and that the Veteran’s hepatitis C incurred sometime between 2001 to 2011, secondary to the Veteran’s IV drug use. The examiner reported that the Veteran denied blood transfusions, tattoos, and high risk sexual behaviors. The examiner also stated that hepatitis C in the United States is mostly related to illicit injection of drugs. Regarding whether the Veteran’s drug abuse is at least as likely as not proximately due to or the result of PTSD with alcohol abuse, the Veteran was afforded a VA medical opinion in January 2017. The examiner opined that the Veteran’s drug abuse was less likely than not proximately due to or the result of the Veteran’s PTSD. The examiner noted that the Veteran reported that he began using cocaine in the 1980s and that he started using cocaine as a product of his environment, with people around him using while drinking. The examiner reported that the Veteran did not attribute his history of cocaine use to PTSD symptoms. Further, the examiner expressed that in “51 VA inpatient psychiatric admissions from 1992 to 2014 related to alcohol and cocaine use, PTSD is only documented as a diagnosis in discharge summaries on 5 occasions, without any documentation suggesting that cocaine use was thought to be caused by PTSD symptoms.” Taken together, the examiner concluded that the Veteran’s stimulant use disorder was less likely as not secondary to PTSD. Upon review of the evidence, the Board finds that service connection for hepatitis C is not warranted on either a direct or secondary basis. In so finding, the Board acknowledges the Veteran’s statements, in which he relates his current disability to service. As a lay witness, the Veteran is certainly competent to attest to his symptoms. However, the Board finds that the Veteran is not competent to provide a diagnosis and/or etiology for his hepatitis C. Such an opinion requires medical knowledge and training of an internal disease process, which the Veteran is not shown to possess. The Board finds the January 2017 and January 2018 VA examiners’ opinions to be the most probative evidence of record regarding the relationship between the Veteran’s hepatitis C and service. The examiners expressed familiarity with the record and provided a clear explanation of rationale. The examiners’ opinions fully articulated with clear conclusions based on an accurate factual foundation and supported by sound reasoning. The Board finds no reason to question the January 2017 and January 2018 VA examiner’s expertise or the rationale given. There is no competent medical opinion to the contrary. In addition, since drug abuse, is not service connected, service connection on a secondary basis is not warranted. In sum, the Board finds that the most probative evidence of record is against the claim. Service connection for hepatitis C is not warranted on either a direct or secondary basis. The benefit-of-the-doubt rule is not applicable because the evidence is not in relative equipoise. Evan M. Deichert Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Monica Dermarkar, Associate Counsel