Citation Nr: 21004748 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 14-35 221A DATE: January 28, 2021 ORDER Entitlement to service connection for coronary artery disease (CAD), claimed as a heart condition, is denied. FINDING OF FACT The most probative evidence of record does not show that the Veteran’s CAD was incurred in or aggravated by active duty service or active duty training (ADT). CONCLUSION OF LAW The criteria for service connection for CAD have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1961 to November 1964. He also served periods of active duty training (ADT), inactive duty training (IDT), and active duty for special work (ADSW) while serving with the United States Army Reserves from September 1968 to February 1998. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran provided testimony at a videoconference hearing before the undersigned Veteran’s Law Judge. A transcript of the hearing has been associated with the claims file. The Board remanded this matter in October 2019 and September 2020 for additional development, which has been substantially completed. See Stegall v. West, 11 Vet. App. 268, 272 (1998). Entitlement to service connection for CAD, claimed as a heart condition. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Active military, naval, or air service includes any period of active duty for training (ADT) during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty for training (IDT) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101(21), (24); 38 C.F.R. § 3.6(a), (d); Biggins v. Derwinski, 1 Vet. App. 474 (1991). ADT is full-time duty in the Armed Forces performed by reserves for training purposes. 38 C.F.R. § 3.6(c)(1). Certain chronic diseases, including CAD, will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. This presumption only applies to periods of active duty and not to the appellant’s ADT or IDT because, by definition, the presumption of service connection applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. With regard to a claimant whose claim is based solely on a period of ADT or IDT, there must be some evidence that the condition was incurred or aggravated during the relevant period of service. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). The Veteran seeks service connection for CAD. He argues that his heart condition, to include a January 1992 heart attack, is due to or was aggravated by stress from rotating between ADT and civilian employment for an extended period. Service treatment records do not show complaints, treatments, or diagnosis for any cardiovascular condition. On reports of medical examination dated June 1974 and January 1976, the Veteran denied heart trouble, pain or pressure in chest, palpitation or pounding heart, shortness of breath. A September 1987 Army Reserve commission examination shows no significant findings related to heart disease. An April 1990 examination report documents family history of heart disease and tobacco use. Based on the laboratory results, diet information was given, and the Veteran was urged to quit smoking (one packet a day for 30 years). The Veteran again denied heart trouble, pain or pressure in chest, palpitation or pounding heart, shortness of breath. (He denied these symptoms again in September 1991). However, at this time, hyperlipidemia was noted based on laboratory results and diet was discussed again. The medical evidence of record shows that the Veteran had a myocardial infarction (MI) and three-vessel coronary artery bypass graft (CABG) surgery in January 1992. Based on the evidence of record, the Board finds that service connection for CAD is not warranted. The Veteran’s active duty service treatment records does not show any complaints, treatments, and diagnosis for a cardiovascular condition. There were no complaints, treatments or diagnosis for a heart condition. The first medical evidence of the disability was in 1992 which was over 28 years after his discharge from active duty service and approximately 28 years after discharge from the reserves. The fact that there were no records of any complaints or treatment involving the Veteran’s CAD for many years after active duty service weighs against the claim. As such, the Board finds that elements two and three under Shedden have not been met. Therefore, service connection is not warranted on a direct-incurrence basis. Furthermore, the most probative medical evidence of record does not establish that the Veteran’s CAD was incurred in or permanently aggravated by, his active duty or ADT service. Concerning this, an April 2020 VA examiner found that the Veteran’s need for a three vessel bypass suggests he had significant atherosclerotic build up in all three of the bypassed coronary vessels, which indicates that he had had asymptomatic slowly progressive CAD for quite some time, and likely years before his heart attack. The examiner conceded there is a large body of evidence linking stress to cardiovascular disease, but she was unable to determine the degree that stress may have contributed to the Veteran’s CAD compared to the combined contribution of his long standing hyperlipidemia, smoking history, and family history. In September 2020, the Board remanded this matter to obtain a supplemental medical opinion as to whether the Veteran’s reported stress during ADT aggravated his CAD. An addendum opinion was obtained in September 2020. The VA examiner stated that the Veteran is found to have a diagnosis of CAD status post myocardial infarction (MI) and three vessel CABG in January 1992. The examiner noted that prior to his diagnosis of acute MI and CABG, the Veteran had documented traditional cardiac risk factors of elevated cholesterol, a 30-pack year history of smoking and a family history of coronary artery disease all documented in a note dated 4/16/1990. However, no cardiac related symptoms were reported, and an examination note dated September 26, 1991 again discussed his elevated cholesterol but did not document any cardiac related symptoms. Additionally, in multiple statements, the Veteran wrote that he was in good health and good physical condition, able to participate in PT exercises without any difficulty, or any pain or significant shortness of breath in November 1991, just two months before his acute MI and CABG. The examiner concluded that the Veteran’s disease process then was insidious and asymptomatic with a super-imposed acute event resulting in plaque rupture and myocardial infarction; diffuse 3 vessel disease could not have developed in a matter of months or even in a year, because atherosclerosis, the disease process underlying coronary artery disease is a slow progressive, chronic inflammatory condition in which lipids and fibrous material are gradually deposited between layers of the vessel walls either diffusely or in focal segments (plaque), resulting in areas of thickening arterial walls narrowing of the lumen of the arteries and restriction of blood flow. It was noted that this process generally occurred over years or decades and atherosclerosis is usually asymptomatic until plaque stenosis worsens beyond 70 to 80 percent of the luminal diameter of the blood vessel, at which point angina may begin to occur. However, plaque can occasionally rupture, triggering the body to form a blood clot in the area, thereby inadvertently completely occluding the artery and causing an acute MI. The Veteran has reported that during the period of August 1990 and June 1991, he was under extreme work-related stress due to alternating two weeks of active duty as battalion executive officer and acting battalion commander and his civilian job of a course director teaching logistics management to soldiers and such. The examiner reasoned that the Veteran’s work-related stress then was not the cause of his acute MI, as he noted the period of extreme work stress as having ended in June 1991, 6 months prior to his acute MI. In terms of chronic work-stress, the examiner acknowledged that stress has been shown to contribute to the long-term development of CAD, although causation has not been established. The examiner explained that CAD is a complicated, multifactorial disease process involving numerous risk factors or contributors all combining over years to result in progressive atherosclerosis of the coronary arteries. Generally, these cardiovascular risk factors or contributors are additive such that having multiple risk factors increases the likelihood of developing CAD. The examiner opined that given the pre-existing presence of several risk factors (specifically gender, family history, nearly 30 years of smoking, with ongoing smoking, and high cholesterol), it would not be possible to delineate the relative contributions of each of these risk factors to the development of his coronary artery disease as compared to work related stress. The examiner added that in particular, it would not be possible to determine the effect of 10 months of a stressful work situation as compared to the additive effect of nearly 30 years of smoking, a genetic predisposition and years of elevated lipid levels. As the issue of aggravation, the examiner provided an opinion that “it is less likely than not that the Veteran’s CAD was aggravated or permanently worsened, due to [the Veteran’s] reported stress while serving on active duty for training and/or active duty for special work. In support of this opinion, the examiner offered the following rationale: Although the reported work related stress may have contributed to the progression of the underlying, pre-existing coronary artery disease, the contribution of 10 months of increased stress, which is not quantifiable, is likely to be small as compared to the years of impact on disease development of the other risk factors, especially in the face of ongoing smoking. Therefore, while the reported work related stress likely contributed somewhat to the worsening of his coronary artery disease, the contribution would have been far less that the total contribution of his multiple other risk factors, and it is unlikely to have resulted in a permanent increase in disability related to coronary artery disease beyond the natural progression of the ongoing disease process itself. The Board finds the March and September 2020 VA examiner’s opinion to be highly probative on the issue of etiology of the Veteran’s CAD in light of the detailed explanation and reasoning provided by the examiner and her expertise in this matter. The opinion is based on a very thorough review of the entire evidence of record, carefully considering the Veteran’s lay assertions and the medical opinions from Dr. J.H. The Board has also considered the private opinion letters submitted by Veteran. In a July 2012 opinion letter, his private cardiologist, Dr. J.H. states that the Veteran was under “an extreme amount of stress and in terms of relationship between stress and heart disease I think this is well established I do think that the extreme stress that he was in one and a half to two years before his heart attack contributed to development of heart disease and the need for subsequent bypass operation.” Dr. H. indicated that the Veteran had high cholesterol in 1991 but was working on diet and passed an Army physician at that time. In a second letter dated July 2018, Dr. H. stated that the stress was as likely as not to contribute to his heart attack and subsequent heart surgery.” In September 2018, the Veteran also submitted two articles addressing the relationship between stress and heart disease. Notably, the article submitted by the Veteran is not specific to him and was not accompanied by a positive nexus opinion. See Mattern v. West, 12 Vet. App. 222, 228 (1999) (providing that a medical article or treatise “can provide important support when combined with an opinion of a medical professional” if the medical article or treatise evidence discusses 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). As regards the private opinions, Dr. H. does not specifically note that the Veteran’s CAD was permanently aggravated beyond the natural progression of the disease due to the reported extreme stress during his periods of ADT. Additionally, there is no indication that Dr. H. reviewed the Veteran’s claims file prior to rendering the opinion regarding the etiology of the Veteran’s CAD. This is not, however, by itself detrimental to the probative value of the opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (failure by an examiner to review a claims file will render an examination inadequate if there is information in the claims file that is important and necessary for a doctor to make an informed medical opinion). Indeed, the September 2020 VA examiner pointed out that Dr. H. failed to mention the Veteran’s 30-year history of smoking. As the September 2020 VA examiner explained the reasons for her conclusions based on an accurate characterization of the evidence, her opinion is entitled to more probative weight than Dr. H.’s opinion. The Board has considered the Veteran’s statements regarding the etiology of his CAD. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, a nexus between the Veteran’s CAD and service, is outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Based on the foregoing, the preponderance of the evidence is against the Veteran’s claim. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. J. In, 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.