Citation Nr: 20021836 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 18-06 403 DATE: March 27, 2020 REMANDED Entitlement to service connection for the cause of the Veteran’s death is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1969 to February 1971. The appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Service Connection for the Cause of the Veteran’s Death The Veteran died, in March 2017, of an anoxic brain injury due to sudden cardiac arrest, as shown in the Certificate of Death, and as stated in an undated letter from a private treating physician, B. Greenberg, M.D., and in an August 2017 letter by a family member who is also a physician. Records of the Veteran’s final hospitalization in March 2017 reflect findings of sudden cardiac arrest and anoxic brain injury. The appellant states that the Veteran’s service-connected diabetes mellitus, type II (diabetes), contributed substantially or materially to his death because it significantly increases the risk of sudden cardiac arrest. See January 2019 VA Form 9; see also 38 C.F.R. § 3.312. The appellant has submitted medical articles finding that diabetes is associated with an increased risk of sudden cardiac death. One article states that “[t]he independent role of diabetes mellitus in enhancing risk of sudden cardiac death has been investigated in a small number of studies . . . [which] have consistently identified diabetes as a strong predictor of sudden cardiac death.” Another article states that sudden cardiac arrest is “a major cause of mortality among patients with diabetes,” and that “there are some [sudden cardiac arrest] factors that may be specifically related to diabetes, such as microvascular disease and autonomic neuropathy.” There is also an article abstract finding that hypoglycemia caused by diabetic medication to regulate blood sugar levels can cause increased risk of ventricular fibrillation and sudden death. However, it notes that antihyperglycemic agents such as Metformin have only a low risk of causing severe hypoglycemia. An August 2017 letter by a physician who is also a family member states that “[t]hat there is a large array of scientific medical research linking the existence of diabetes mellitus to a significantly increased risk of sudden cardiac arrest,” and concludes that given these findings, the Veteran’s service-connected diabetes “was a major causal factor in his sudden cardiac arrest and death.” The physician notes that a few months before the Veteran’s death, his Metformin dosage was doubled, and that he complained of having more trouble keeping his arrhythmia under control. In this regard, she observes that the Veteran had been diagnosed with an arrhythmia around the same time he was diagnosed with diabetes, which had been kept under control with medication (Rhythmol). After the dosage of Metformin was increased, the Veteran was having episodes of arrythmia multiple times each week, according to the letter. The physician cites to the article mentioned above linking hypoglycemia to an increased risk of atrial fibrillation, ventricular tachycardia, and heart failure, and states that the increase in the Veteran’s Metformin dosage contributed to more frequent episodes of hypoglycemia, with more frequent episodes of atrial fibrillation and abnormal cardiac repolarization. The Board finds that the physician’s August 2017 letter is not sufficient to make an informed decision, as it does not account for the fact that the Veteran’s diabetes was evidently well-controlled prior to his death, and he was otherwise in good health. Specifically, the letter by Dr. Greenberg, the Veteran’s treating physician, states that the Veteran was diagnosed with diabetes in 2001, and that with diet and exercise his diabetes “basically resolved” or was completely controlled for many years. Dr. Greenberg stated that in later years it was treated with Metformin, but the diabetes remained under good control. The Veteran also had elevated cholesterol that was treated with medication, according to this letter. The physician further noted that the Veteran had intermittent atrial fibrillation. The physician stated that sudden cardiac arrest is a common cause of death, and that risk factors are being over age fifty, being male, diabetes, high cholesterol, and hypertension. Dr. Greenberg observed that the “usual scenario” was blockage of arteries due to cholesterol, resulting in a clot that causes loss of blood supply to the heart. The physician concluded that he believed that was what happened to the Veteran, noting that the physician knew healthy people with no significant risk factors who had a sudden cardiac arrest. Apart from the fact that the Veteran’s treating physician, according to his letter, did not think that the Veteran’s sudden cardiac arrest was due to his diabetes, which was under good control, the record indicates that the Veteran had a long-standing history of a heart condition. Specifically, VA treatment records reflect that he reported having heart dysthymia since he was seventeen. See September 2007 VA Treatment Record. A May 2003 private stress test report showed enlarged left and right ventricles. A small fixed apical effect on the vertical long axis was also noted. The “most significant finding” was the bi-ventricular enlargement with reduced [left ventricular] function.” It was noted that the finding may suggest cardiomyopathy. A May 2003 private treatment record reflects that the Veteran was seen in the emergency room for an irregular heartbeat. He stated he had been jogging, and experienced recurrent palpitations, fatigue, and light-headedness. It was noted that he had been diagnosed with an enlarged heart. An October 2003 private treatment record reflects that the Veteran reported palpitations and near-syncope that had their onset during exercise, and stated that such episodes had been occurring for years, but had worsened in the past few months. A December 2003 letter from his treating physician states that a few months earlier the Veteran was noted to have atrial fibrillation. A February 2005 letter from the Veteran’s treating physician referring the Veteran for a cardiology consultation states that the Veteran had intermittent problems with atrial fibrillation, and observes that the Veteran had a past history of diabetes which was well controlled and had “basically resolved” with diet and exercise. The physician notes that four or five nights in a row the Veteran would have atrial fibrillation for a couple of hours. A VA medical opinion was obtained in January 2018. The examiner found against a relationship between the Veteran’s death from cardiac arrest and his diabetes. The examiner explained that it was not uncommon for an individual with atrial fibrillation to develop cardiac arrest, quoting medical literature that states that atrial fibrillation is “the most common heart arrhythmia affecting up to 5 million Americans” and “is linked to an increased risk for sudden cardiac death.” The examiner also stated that there was no evidence-based medical literature he was aware of, and no evidence in the Veteran’s medical records, that his diabetes would have pre-disposed him to develop atrial fibrillation and sudden cardiac arrest so as to cause his death. The January 2018 VA medical opinion is not sufficient to make an informed decision, as there are numerous medical articles in the file showing that diabetes is a significant risk factor for sudden cardiac arrest. The examiner’s statement that there is no evidence-based medical literature that would support a link between the Veteran’s diabetes and his sudden cardiac death does not account for those articles. At the same time, as noted above, the Board is unable to rely on the August 2017 private physician’s letter, because it does not account for the Veteran’s history of a heart condition. As noted in the January 2018 VA medical opinion, atrial fibrillation is “the most common heart arrhythmia,” and “is linked to an increased risk for sudden cardiac death.” Accordingly, on remand, a new VA medical opinion must be obtained that considers the medical literature submitted by the appellant indicating that diabetes is a significant risk factor for sudden cardiac death and the August 2017 letter from the physician who is also a family friend that opines that the Veteran’s diabetes was a major causal factor in his sudden cardiac arrest and death. The examiner must also consider the fact that, as noted in that letter, VA treatment records show that in October 2016, the Veteran’s dosage of Metformin was more than doubled: he previously was prescribed 500mg a day; in October 2016, an additional 750mg per day was prescribed and he was advised to monitor for signs of hypoglycemia during and after exercise. The August 2017 letter states that after the increase in dosage, the Veteran complained of increased episodes of arrythmia. In this regard, according to that letter and a medical article abstract enclosed with it, hypoglycemia is associated with an increased risk of ventricular fibrillation and sudden death, although the article also states that antihyperglycemic agents such as Metformin have only a low risk of causing severe hypoglycemia. This opportunity should also be taken to make appropriate efforts to obtain outstanding private treatment records that may provide relevant evidence on the claim. Specifically, a September 2007 VA treatment record notes that the Veteran was treated by a Dr. Stafford for his heart condition. A February 2005 cardiology referral is addressed to a Dr. Stafford Warren, which the Board assumes is the same person. A December 2003 cardiology referral is addressed to a Dr. D. Nguyen. Finally, March 2017 private hospitalization records note that the Veteran had been treated by a Dr. Gharib for his atrial fibrillation. The treatment records from these physicians have not been obtained. On remand, the appellant should be asked to authorize their release, and be invited to submit them herself. The matters are REMANDED for the following action: 1. Request the appellant to authorize the release of the Veteran’s private treatment records from the following physicians: Stafford Warren.; D. Nguyen; and Dr. Gharib. Appropriate efforts must be made to obtain these records if the appellant fills out and returns the proper release forms. She should also be invited to submit the records herself. 2. Obtain a VA medical opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s diabetes contributed substantially or materially to his death by sudden cardiac arrest. The opinion should not be delayed for the above records development. However, if any records subsequently added to the file warrant additional comment or a new opinion, then a supplemental medical opinion should be obtained. In the opinion, the examiner must generally consider the medical articles submitted by the appellant finding that diabetes is a significant risk factor for sudden cardiac death. The examiner need not discuss or mention any article in particular, except as deemed necessary by the examiner for purposes of rendering the opinion. That said, the examiner must address the finding in one of the article abstracts stating that hypoglycemia associated with diabetic medication can cause an increased risk of ventricular fibrillation and sudden death. In this regard, the examiner must consider the August 2017 letter by a family friend who is also a physician, in which she notes in reference to that article that the Veteran’s Metformin was doubled a few months before his death (in October 2016), and that subsequently he complained of increased episodes of arrhythmia. The examiner should note that according to the aforementioned article abstract, antihyperglycemic agents such as Metformin have only a low risk of causing severe hypoglycemia. The examiner must also consider the Veteran’s history of a heart dysthymia, which VA treatment records state had reportedly been present since he was seventeen. Beginning around April 2003, after his initial diagnosis of diabetes, in December 2001, he complained of tachycardia and palpitations. In an October 2003 record, he reported that his palpitations and near-syncope had been present for years, but were worse in the past few months. A May 2003 stress test showed bi-ventricular enlargement with reduced left ventricular systolic function, which “may suggest a cardiomyopathy.” While his increased episodes of arrythmia occurred after his diabetes diagnosis, the diabetes was well-controlled according to his treating physician. A February 2005 cardiology referral notes Veteran’s problems with intermittent atrial fibrillation, and a past history of diabetes that he had controlled and “basically resolved” with diet and exercise. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rutkin, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.