Citation Nr: 21002724 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 16-15 452 DATE: January 14, 2021 ORDER Entitlement to service connection for heart disease (coronary artery disease), to include as secondary to as secondary to service-connected psoriasis is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s heart disease manifested in active service or within one year after service or is otherwise related to his military service. 2. The Veteran’s heart disease is not proximately due to, or aggravated by, any service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a heart disease (coronary artery disease) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a heart disease due to service-connected psoriasis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from August 1977 to May 1981 and August 1981 to March 1986. This matter comes to the Board of Veterans’ Appeals (Board) from a decision of the Agency of Original Jurisdiction (AOJ). In November 2011, The AOJ issued a rating decision that denied the Veteran’s claims for service connection for heart disease and diabetes mellitus. In addition, he sought entitlement to restoration of his service-connected degenerative arthritis of the lumbar spine as well as sciatica of the left and right lower extremities, secondary to degenerative arthritis of the lumbar spine. The Veteran timely disagreed in a November 2013 Notice of Disagreement (NOD) and perfected his appeal in a March 2016 VA Form 9. In April 2018, a Board hearing was conducted. The hearing transcript has been associated with the Veteran’s file. Then in November 2018, the Board issued a remand for the VA to provide new disability examinations for the Veteran’s heart disease and diabetes mellitus. The Board also denied the Veteran’s claims as to entitlement to restoration of service connection for degenerative arthritis of the lumbar spine and entitlement to service connection to sciatica of the left and right lower extremities, secondary to degenerative arthritis of the lumbar spine. In July 2020, the AOJ granted service-connection for diabetes mellitus associated with psoriasis. Thus, the only remaining issue on appeal is entitlement to service-connection for heart disease. In November 2020, the Veteran’s claim was returned to the Board. Entitlement to service connection for heart disease (coronary artery disease), to include as secondary to as secondary to service-connected psoriasis. The Veteran contends his diagnosed coronary artery disease (heart disease) is secondary to his service-connected psoriasis. See August 2012 Statement; June 2013 NOD at 2. Even though the Veteran has not alleged his heart disease is directly related to service, the questions for the Board are whether there is sufficient evidence to find it is related to his service in the Air Force or secondary to any other service-connected disability. For the reasons discussed below, the Board concludes that the evidence does not supports a grant of service connection on a direct or secondary basis. Entitlement to service connection requires a Veteran to provide evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Also, a Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Or for any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(b). Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected; (2) evidence of a service-connected disability; and, (3) evidence of nexus establishing a connection between the service-connected disability and the current disability. 38 C.F.R. § 3.310. Lay evidence, such as a claimant’s statement, can be competent and sufficient to establish a diagnosis of a condition when (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing the symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). A lay person’s statement is competent if he or she has personal knowledge which is gained through the senses, to include what is heard, felt, seen, smelled, and tasted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the “benefit of the doubt” when the evidence is approximately balanced. Id. at 53. Beginning with the Veteran’s service, his entrance examination is negative for complaints of any heart problems. And his service medical records do not contain any complaints or treatment for heart problems. And his separation exam is negative for heart problems. In 2011, the Veteran submitted four articles that assert there is a link between psoriasis and cardiovascular conditions. The first article, published in 2009 on Health.com, titled “Psoriasis Linked to Heart Disease, Stroke, and Early Death” reports on a study authored by a doctor who states that patients with psoriasis are nearly twice as likely to have been diagnosed with heart disease. The doctor opines it is most likely due to underlying inflammation similar to rheumatoid arthritis. The article also notes researchers are not sure if psoriasis came before the cardiovascular conditions or those conditions came before psoriasis. The article concludes that patients with psoriasis should be screened for cardiovascular risk factors annually. The second article reports on a 2007 medical study that was designed to determine whether there is an association between psoriasis and other conditions, to include heart failure, existed with psoriasis patients in Israel. When the study compared the age-adjusted proportion of diabetes and atherosclerosis between patients with psoriasis, the proportion of both medical conditions was higher in psoriasis patients as opposed to a control group. The authors of the study state, “it is important to emphasize that while our study showed an association between psoriasis [and atherosclerosis], we did not determine the cause of this association.” Psoriasis Linked to Diabetes and Serious Cardiovascular Condition, Science Daily, https://www.sciencedaily.com/releases/2007/04/070418100821.htm (last visited January 4, 2021). The third article reports on a 2008 medical paper that asserts patients with moderate to severe psoriasis have an increased risk of cardiovascular disease and heart attacks. Also, hypertension, elevated cholesterol, and obesity. It concludes that patients with psoriasis should be warned of their increased of blocked arteries and heart attacks. The article does not assert a causal link between psoriasis and any particular cardiovascular disease. Psoriasis Is Often Undiagnosed and Is Associated with An Increased Risk of Heart Attack and Coronary Artery Disease, Penn Medicine News, https://www.pennmedicine.org/news/news-releases/2008/december/psoriasis-is-often-undiagnosed (last visited January 4, 2021). The fourth article reports on a study that found patients with severe psoriasis appear to have a 50 percent increased risk of death compared with patients without the skin condition. The authors of the study noted, “[f]urther studies are necessary to determine the cause of excess mortality in patients with severe psoriasis.” It does not assert a causal connection between psoriasis and heart disease. Psoriasis Associated with Increased Risk of Death, Science Daily, https://www.sciencedaily.com/releases/2007/12/071217162525.htm (last visited January 4, 2021. In August 2011, the Veteran underwent a VA disability examination for his entitlement claim. In that examination, the examiner opined that the Veteran’s heart disease was not caused by his service-connected psoriasis. The examiner explained that she did extensive research on psoriasis and even though there is a link between it and heart disease, a causal connection has not been discovered. She concludes that there is no scientific proof that psoriasis causes heart disease. See August 2011 VA Compensation and Pension Exam Report at 16. In January 2013, a VA examiner, K.C.O., MD, provided a medical opinion wherein he asserts the Veteran’s chest pains associated with ischemic heart disease is not related to psoriasis. Also, that the Veteran’s heart disease is not related to psoriasis. See January 2013 VA Medical Opinion at 3 Later that year, in December, Dr. K.C.O. conducted a VA disability examination on the Veteran. The Veteran reported leg pains associated with left leg radiculopathy interfere with his ability to walk at a fast pace due or long distances. The Veteran did not report functional limitations due heart conditions. See December 2013 VA DBQ at 4. Dr. K.C.O. noted the Veteran has ischemic heart disease and the diagnosis of coronary artery disease, with the first diagnosis occurring in 1996. Dr. K.C.O. indicated the Veteran does not have congestive heart failure. Id. at 3. Dr. K.C.O. opined that the Veteran’s heart disease is as likely as not proximately due to his service-connected psoriasis. He indicated that medical literature supports an association between the two conditions. Then he noted “he had other risk factors such as he did admit that he smoked for 27 years (age 14-20 years ago) and I also noted his (BAD) LDL cholesterol was quite high at 187 mg/dl u 1999 and so these other factors must be taken into consideration when deciding about his [heart disease]. (I reviewed a large section on this in Up to Date, an on-line medical reference service provided by the VA).” That was the end of his opinion. Id. at 19. In April 2018, a Board hearing was conducted for the Veteran’s entitlement claim. The Veteran testified that problems associated with his heart disease began around 20 years before the Board hearing. See Transcript dated April 2018 at 12. The Veteran also confirmed a doctor had not told him his diagnosed heart disease is secondary to his service-connected psoriasis. He states the contention stems from medical literature he read. And when he raised the theories of a link between the two disabilities to medical professionals, the theories were dismissed. Id. at 10-12. The Veteran was asked if his heart condition and diabetes got worse when his service-connected psoriasis flares-up, he affirmed his diabetic symptoms worsened. He did not say anything about symptoms associated with his heart disease. Id. at 12. Then, in October 2019, Dr. K.C.O. provided a third medical opinion wherein he opined that there is no causal connection between the Veteran’s service-connected psoriasis and heart disease. In this October 2019 VA medical opinion, Dr. K.C.O. considered and weighed whether smoking, hypertension, psoriasis, poor diabetic control, and use of motrin caused his heart disease. He explained the other factors, to include smoking (that plugged up the Veteran’s arteries in his leg), and prolonged use of motrin outweigh the likelihood that psoriasis caused the Veteran’s heart disease. Dr. K.C.O. added that he consulted with a cardiologist who agrees with his conclusion. See October 2019 Medical Opinion by K.C.O., MD, at 2. In September 2020, a different VA examiner, M.P., MD, provided an opinion that the Veteran’s service-connected psoriasis did not aggravate his heart conditions, to include ischemic heart disease. The examiner explained that the Veteran’s CAD was successfully treated with percutaneous coronary intervention (PCI, also known as angioplasty with stent) without functional impact. Also, that the Veteran’s primary exercise limitations are secondary to another condition—back pain. The examiner indicated the Veteran’s heart conditions has progressed according to the projected natural history of the condition and does not represent aggravation beyond its natural progression. See September 2020 VA Medical Opinion by M.P., MD, at 3-4. Turning to the Veteran’s claim for disability compensation, the first question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303. The Board concludes he has not. To answer that question, the first issue is whether the Veteran has a current disease disability. The Veteran has been diagnosed with coronary artery disease (heart disease). Thus, the record reflects a diagnosed heart disease. See December 2013 VA DBQ for Ischemic Heart Disease at 3. The next issue is whether the Veteran’s heart disease began in service. The Board finds it did not. The Veteran alleges he began observing symptoms associated with heart disease after his active duty service. The Veteran is competent and credible to report observations gained through the senses. Layno, 6 Vet. App. at 469. He testified he started observing symptoms around “20 years” before his Board hearing, which is around 1998. This is consistent with the record, which does not reflect any allegations that his heart disease began in or within one year after service. And a search of his medical records does not show a diagnosis of a heart disease before the 1990s. So, the Board finds his testimony credible and assigned it significant weight towards finding his symptoms manifested around 1998. Because the Veteran has not alleged nor does the record reflect his heart disease began during service, the evidence is against finding an in-service injury or incurrence. Gilbert, 1 Vet. App. at 54. The next issue is whether there is a nexus between the Veteran’s heart disease and his active service. The Board finds there is not. The Veteran has not alleged his heart disease manifested in or within one year after service. And the medical evidence of record supports the Veteran’s assertions: the first diagnosis of heart disease referred to in the record was made in 1996, many years after service. See December 2013 VA DBQ at 3. As a result, the evidence weighs against finding there is a nexus. Gilbert, 1 Vet. App. at 54. So, the Board finds there is no nexus between the Veteran’s heart disease and his active service. Since the Veteran has not established a nexus between his heart disease and active service nor an in-service incurrence, he has not established entitlement to service connection under 38 C.F.R. § 3.303. The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.310(a) or (b). To answer that question, the first issue is whether the Veteran has a non-service-connected disability and at least one service-connected disability. The Veteran’s diagnosed heart disease is not service connected. And the record reflects he is service connected for psoriasis. The Board notes the Veteran has not claimed any other service-connected disability caused or aggravated his heart disease. Also, a search of the record did not raise the inference of a claim for service connection under 38 C.F.R. § 3.310 based on any other service-connected disability. The next issue is whether the Veteran’s heart disease was proximately caused by his service-connected psoriasis. The Veteran has not alleged to possess the medical qualifications to opine on the cause of his heart disease; therefore, his statements that his heart disease was caused by his service-connected psoriasis were not considered. This is because he is not competent to render an etiological link between his diagnosed heart disease and psoriasis. Jandreau, 492 F.3d at 1377. Although the articles submitted by the Veteran assert an association between psoriasis and heart disease, they do not weigh in favor of a finding of causation. Beginning with the article, “Psoriasis Linked to Heart Disease, Stroke, and Early Death,” the authors confirmed they have not established a causal link between the conditions. So, the Board assigned it no probative weight towards a finding of causation. Similarly, the researchers who conducted the studies discussed in “Psoriasis Linked to Diabetes and Serious Cardiovascular Condition” and “Psoriasis Associated with Increased Risk of Death,” confirmed their research does not establish a causal link between psoriasis and other conditions, to include heart disease. So, the Board assigned them no probative weight towards a finding of causation. Contrary to the articles above, the article “Psoriasis Is Often Undiagnosed and Is Associated with An Increased Risk of Heart Attack and Coronary Artery Disease” does not refer to specific studies. It discusses increased risk of heart disease in people diagnosed with severe psoriasis and refers to studies, generally. Since it is more general than the articles above, it was assigned no probative weight. The August 2011 VA medical opinion is medical evidence that weighed against a finding of causation. The examiner, E.M., FNP, also evaluated whether his service-connected psoriasis was linked to a back disability, diabetes, Crohn’s disease, and high cholesterol. And the record reflects she did an extensive review of the record to opine on those conditions. So, the Board finds the examiner was fully cognizant of the Veteran’s past medical history. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). Also, the examiner provided a reasoned explanation for her conclusion that psoriasis does not cause heart disease. She explained that there is no medical evidence that supports a causal connection and listed other factors that are believed to be the cause of heart disease. Even though she did not address the medical articles submitted by the Veteran, those articles emphasized they are not asserting a causal link between the psoriasis and heart disease; so, they do not constitute conflicting medical evidence that had the likelihood of affecting her opinion. Thus, the examiner’s rationale was sufficient for the Board to evaluate whether the data she relied on connects to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. And the Board assigned it significant weight against a finding of causation. Dr. K.C.O. provided three opinions: the first in January 2013, second in December of the same year, and the third in October 2019. His January 2013 opinion was conclusory and not supported by a rationale. See January 2013 VA Medical Opinion at 3. So, it was assigned no probative weight. In December 2013, Dr. K.C.O.’s medical opinion followed an examination for ischemic heart disease. In addition to his personal examination, he reviewed the Veteran’s file and considered the Veteran’s observations and statements. So, the Board finds Dr. K.C.O. was fully cognizant of the Veteran’s past medical history. Nievez-Rodriguez, 22 Vet. App. at 301. At that time, Dr. K.C.O. opined that the Veteran’s heart disease is proximately due to his service-connected psoriasis. Although he identified the data he relied on, he did not sufficiently connect it to his conclusion. That is, he noted factors that had to be weighed but did not indicate his weighing of those factors when rendering his conclusion. Also, he did not explain why he changed his opinion. Nor was it apparent in the Board’s review of the record. Thus, the probative weight assigned to his opinion is diminished because it is not clear to the Board how he came to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Thus, the Board assigned it some, but not significant, probative weight. Later, in October 2019, Dr. K.C.O. indicates he did additional research on this issue and opines that the Veteran’s heart disease is less likely than not caused by his service-connected psoriasis. See October 2019 VA Medical Opinion at 1-2. Since Dr. K.C.O. has examined the Veteran before and reviewed his file up to the date of the opinion, the Board finds Dr. K.C.O. was cognizant of the Veteran’s past medical history when rendering this opinion. Nievez-Rodriguez, 22 Vet. App. at 301. This time, Dr. K.C.O. indicates how he determined that the Veteran’s heart disease was not caused by his service-connected psoriasis. In his explanation he listed the factors associated with heart disease and determined that smoking, poor diabetic control, use of motrin, and hypertension played a larger role in the development of the Veteran’s heart disease. Dr. K.C.O. also indicated he considered some studies when rendering his conclusion and consulted with a cardiologist, which agrees with his conclusion. See October 2019 VA Medical Opinion at 1-2. So, the Board was able to evaluate whether the data he relied on connects to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Although Dr. K.C.O. did not explain why he changed his opinion, it is apparent to the Board that the change is due to additional research and consultation with a specialist. In this opinion, he provides additional data pertaining to each of the risk factors listed in his December 2013 (positive) opinion. And he indicates he discussed his weighing of those risk factors with a cardiologist, which is a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels. See October 2019 VA Medical Opinion at 1. So, the Board was able to evaluate the factors that led to a change in his opinion. As a result, the Board found determined it was the more reliable opinion and assigned it significant probative weight against a finding of causation. As to the issue of causation, the Board finds the evidence is not approximately balanced. The articles submitted by the Veteran did not assert a causal link between heart disease and psoriasis. Even though Dr K.C.O. initially opined there was a link (in hi December 2013 opinion) he is later, and more probative opinion, opined there is no causal link. Also, the August 2011 negative opinion weighed against a finding of causation. So, doubt cannot be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. Thus, the Veteran has not established entitlement to service connection under 38 C.F.R. § 3.310(a). The next issue is whether the Veteran’s heart disease is aggravated by his service-connected psoriasis. The Board finds it is not. The September 2020 VA Medical Opinion weighed against finding that the Veteran’s heart disease is aggravated by his service-connected psoriasis. Here, the examiner notes he reviewed all the available records. See September 2020 VA Medical Opinion at 2. So, the Board finds he was cognizant of the Veteran’s past medical history. Nievez, 22 Vet. App. at 301. In coming to his conclusion, the examiner reviewed the functional impairments associated with the Veteran’s heart disease and opined that they do not indicate aggravation beyond its natural progression. The examiner emphasized that the treatment provided for his heart disease is expected. Also, the physical limitations associated the Veteran observes are primarily due to backs pains. See September 2020 VA Medical Opinion at 4. So, the examiner provided a reasoned explanation for his conclusion. Nievez, 22 Vet. App. at 301. And the Board assigned it significant probative weight against a finding of aggravation. As to the issue of aggravation, the Board finds the evidence is not approximately balanced. The only medical evidence that addresses this issue weighed against the Veteran’s claim. So, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. As a result, he is not entitled to service connection under 38 C.F.R. § 3.310(b). In sum, the Veteran has not established entitlement to service connection for his heart disease under 38 C.F.R. §§ 3.303 or 3.310. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dean, Michael S. 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.