Citation Nr: 20022592 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 16-35 286 DATE: April 1, 2020 ORDER Entitlement to service connection for the cause of the Veteran’s death is granted. FINDING OF FACT 1. The Veteran died in March 2004; the death certificate lists the immediate cause of death as cardiopulmonary arrest. 2. The Veteran was service-connected for gouty arthritis of the joints at the time of his death. 3. The Veteran’s service-connected gouty arthritis of the joints combined with other risk factors to cause his death. CONCLUSION OF LAW The criteria to establish entitlement to service connection for the cause of the Veteran's death have been met. 38 U.S.C. §§ 1110, 1131, 1310, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Army from February 1976 to February 1996. The Veteran died in March 2004, and the appellant his surviving spouse. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision. The claim listed above was initially denied by the Board in a November 2018 decision. The appellant appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2019 Order, the Court vacated the Board's decision and remanded the matter to the Board for development consistent with the parties' Joint Motion for Remand (Joint Motion). 1. Entitlement to service connection for the cause of the Veteran’s death. DIC is awarded to a veteran's surviving spouse for death resulting from a service-connected disability. 38 U.S.C. § 1310. To establish service connection for the cause of the veteran's death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. A service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one not related to the principal cause. In determining whether a service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). The Veteran's death certificate identifies the immediate cause of death as cardiopulmonary arrest. No underlying cause of death was noted. At the time of his death in March 2004, the Veteran was service-connected for gouty arthritis of the joints; tinnitus; residual scars, excised, thrombosed hemorrhoids; hallux valgus with osteoarthritis of the left great toe; and residuals of a mild wedge compression at D7-D8. In May 2017, Dr. S. provided a medical opinion related to the appellant’s claim. Dr. S. noted that he had reviewed the Veteran's entire claims file. Dr. S. stated that he was aware that the Veteran died in March 2004 from cardiopulmonary arrest, and that the Veteran had been service-connected for gouty arthritis of the joints at that time. Dr. S. observed that the findings from a November 1996 VA examination revealed that the Veteran's medical history included gout, a disorder for which the Veteran had treated with medication intermittently since his separation from service. The examination noted that the Veteran experienced flare ups of gout that occurred in various joints, including the feet, knees, hips, and elbows. Pain from gout restricted the Veteran's activities, and his elbow and knee stayed sore most of the time. The Veteran generally experienced one to two flare ups over a three month period. An asssociated joint examination showed that the Veteran did not have complaints of joint disorders or restrictions of motion. His only complaint was gout. The Board notes that Dr. S.’ summary of these examination findings is consistent with the examination reports. Dr. S. explained that gout is a metabolic disease associated with hyperuricemia, and it led to acute joint inflammation as part of a response to precipitation or urate crystals in the joint that commonly manifested as acute gout. Dr. S. indicated that the disorder is also associated with chronic inflammation around micro tophi. Hyperuricemia is a cardinal feature of gout, and it is associated with endothelial dysfunction; an issue that may contribute to the risk of heart disease in patients with gout. In addition, uric acid likely contributed to the risk of heart disease in patients with gout. Dr. S. stated that it is also likely that uric acid contributed to the oxidation of lipoproteins within atherosclerotic plaque, thereby contributing to the progression of lesions in coronary arteries. Gout is also associated with systemic inflammation, and studies had linked systemic inflammation to the risk of heart disease and other similar chronic systemic inflammatory conditions. Research further showed that gout was linked to a higher risk of death from all causes and cardiovascular disease. Dr. S. highlighted the findings from one study that cardiovascular mortality rates were highest in the gout group, and Dr. S. noted that more cardiovascular deaths (20 percent) were found among subjects with gout. In addition, hyperuricemia induced endothelial dysfunction, renal arteriopathy, and tubulointerstitial disease. The inflammation associated with gout also contributed to cardiovascular events, and other studies had established the role of inflammation in accelerated atherosclerosis. Dr. S. acknowledged that the Veteran's treatment records also noted a medical history of tobacco use, mixed hyperlipidemia, and a past history of heavy alcohol use. See August 2008 Private treatment record; December 2012 VA treatment record. However, Dr. S. found that it was impossible to determine whether gout or one of these other risk factors was the primary cause of the Veteran's cardiopulmonary arrest. Dr. S. concluded that gout and the Veteran's other risk factors each contributed equally to the development of his cardiopulmonary arrest. Consequently, Dr. S. opined that it was at least as likely as not that the Veteran's gout contributed substantially and materially to the development of his cardiopulmonary arrest, and ultimately his death. Rather than concluding that the Veteran’s gout casually shared in producing death, Dr. S.’ opinion reflects a determination that the Veteran’s gout combined with his other risk factors to cause his death. Dr. S.’ discussion of his inability to determine which risk factor was the primary cause of the Veteran’s cardiopulmonary arrest indicates that it was Dr. S.’ opinion that each of the identified risk factors, including gout, had a causal connection with the Veteran’s immediate cause of death. The Board finds that Dr. S.' opinion is highly probative as he considered the Veteran's medical history, cited to relevant medical literature, and provided a detailed rationale for his conclusion. The Board also notes that there is no negative medical opinion to weigh against this conclusion. Based on the foregoing, the Board finds that weight of the evidence is in favor of finding that the Veteran’s service-connected gouty arthritis of the joints was a contributory cause of the Veteran’s death. Entitlement to service connection for the cause of the Veteran’s death is therefore granted. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.C. Spragins, 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.