Citation Nr: 21004514 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 12-34 009 DATE: January 27, 2021 ORDER Service connection for coronary artery disease (CAD)/heart disease as secondary to service-connected psychiatric disability is denied.   FINDING OF FACT The Veteran’s heart disease, including CAD, is not secondary to a service-connected psychiatric disorder. CONCLUSION OF LAW The criteria for service connection for CAD/heart disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1973 to June 1976. The case is on appeal from a May 2008 rating decision. In August 2017, the Veteran testified at a Board hearing. Most recently, in May 2020, the Board remanded the claim for further development. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service connection for CAD/heart disease. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. See 38 C.F.R. § 3.310. Analysis Treatment records document the Veteran’s current diagnosis of CAD. Service connection is in effect for major depressive disorder (MDD) with specific phobia and posttraumatic stress disorder (PTSD). The Veteran contends that his heart disease is secondary to his service-connected psychiatric disability. As noted in a prior remand, the record includes a March 2008 opinion from a private physician stating his impression that there is a more than 60 percent chance that the Veteran’s chronic stress, sleep disorder, and PTSD more likely than not contributed to the Veteran’s heart disease. The private physician did not review the Veteran’s claims folder prior to rendering his opinion and does not provide a basis for his conclusion. A conclusion by a competent medical professional without supporting documentation does not provide the necessary proof to establish a link to the claimed disability and service. Bloom v. West, 12 Vet. App. 185, 187 (1999). Therefore, the Board accords the opinion little evidentiary weight and it is insufficient to establish a connection between the Veteran’s heart disease and his service-connected psychiatric disability. In June 2018, the Veteran underwent a VA examination. The VA nurse practitioner confirmed the Veteran’s CAD. The VA nurse practitioner explained the etiology of the Veteran’s CAD is the build up of plaque in the arteries, which narrows the arteries and leads to decreased blood flow. The VA nurse practitioner noted the Veteran takes cholesterol and blood pressure medication daily to address his heart condition, has received a total of five stents between 2004 and 2008, and underwent coronary artery bypass surgery in March 2017. She also noted that the patient is diabetic. With respect to the private cardiologist’s March 2008 opinion that the Veteran’s stress, sleep disorder, and PTSD led to the Veteran’s heart condition, the VA nurse practitioner stated more research is necessary to determine how stress contributes to heart disease. She indicated stress may affect behaviors and factors that contribute to heart disease risk, such as: high blood pressure and cholesterol levels, smoking, physical inactivity, and eating. Although no medical literature connecting CAD and the psychiatric disorder was noted, the VA nurse practitioner cited to a medical article in 2007 reflecting that a higher level of PTSD may increase the risk of CAD in older men and a 1993 medical article stating that psychological trauma and subsequent repeated reminders of traumatic events may trigger a cascade of neuronal, hormonal, and immunologic effects that damage the body. In April 2019, the VA nurse practitioner provided an addendum opinion. She indicated the Veteran’s CAD is less likely than not caused by or aggravated by the Veteran’s PTSD. She noted the lack of scholarly articles that connect CAD and MDD/PTSD. She again stated more research is needed to determine how stress contributes to heart disease. The VA nurse practitioner indicated the long-standing risk factors for the development of CAD typically include age, cholesterol, blood pressure, cigarette use, diabetes, and left ventricle hypertrophy on electrocardiography. The VA nurse practitioner stated the Veteran’s CAD is more likely than not related to the Veteran’s diabetes and smoking history. Pursuant to the Board’s May 2020 remand, another medical opinion was obtained. In September 2020, a VA physician reviewed the Veteran’s records. The VA examiner noted the Veteran’s initial date of diagnosis for CAD was 1999 and documented the Veteran’s cardiac catherization reports and treatment procedures, including the Veteran’s coronary artery bypass surgery in March 2017. The VA examiner explained CAD involves the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis. The VA examiner stated that atherosclerosis, sometimes referred to as the hardening or clogging of the arteries, is the buildup of cholesterol and fatty deposits, called plaques, on the inner wall of the arteries. The VA examiner also addressed the March 2008 private physician’s opinion supporting the Veteran’s claim. The VA examiner indicated that although the private physician opined that the Veteran’s chronic stress, sleep disorder, and PTSD more likely than not led to the Veteran’s heart condition, the Veteran’s December 2007 discharge summary noted a diagnosis of hypertension and type 2 diabetes mellitus, which are medically known risk factors in the development of coronary artery disease. She acknowledged that MDD with specific phobia and PTSD are not known to cause a buildup of cholesterol and plaques resulting in atherosclerosis and leading to CAD. The VA examiner gave the opinion that the Veteran’s CAD was less likely than not proximately due to or the result of the Veteran’s service-connected MDD with specific phobia or PTSD. The VA examiner also stated the Veteran’s CAD was less likely than not aggravated beyond its natural progression by the Veteran’s service-connected MDD with specific phobia or PTSD. In consideration of this evidence, the Board finds that the Veteran’s CAD/heart disease was not caused or aggravated by his service-connected psychiatric disability. The Board finds the September 2020 VA examination report to be the most persuasive evidence of record. The VA examiner thoroughly reviewed the Veteran’s record and the private physician’s contrary opinion. The private physician’s opinion is outweighed by the findings of the VA examiner because the September 2020 VA examiner provided a more thorough rationale in support of the conclusions reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Based on the VA examiner’s review and medical knowledge, she opined that the Veteran’s CAD/heart disease is not related to service. She supported her conclusions with well-reasoned analysis considering the relevant facts. Her opinion is afforded significant weight because it is factually accurate, fully articulated, and based on sound reasoning. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). The Board acknowledges the Veteran’s contention that his CAD/heart disease is linked to his PTSD. However, as a lay person, he has not shown that he has specialized training sufficient to render such an etiology opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In this regard, the etiology of coronary artery disease/heart disease is a matter not capable of lay observation and requires medical expertise to determine. Specifically, the question of the causation or onset of such disorder involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Therefore, the Veteran’s opinion as to the etiology of his CAD/heart disease is afforded less probative weight than the September 2020 VA examiner’s report. In sum, the preponderance of the evidence shows that the Veteran’s CAD/heart disease is not secondary to the Veteran’s service-connected psychiatric disability. Therefore, the benefit-of-the-doubt doctrine is not applicable and service connection for CAD/heart disease is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.L. Thomas 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.