Citation Nr: 21061557 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 15-27 393A DATE: October 4, 2021 ORDER Service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died in December 2013, with the underlying cause of death stated as "acute myocardial infraction." 2. At the time of the Veteran's death, service connection was in effect for posttraumatic stress disorder (PTSD) with depression, chronic fatigue syndrome, and healed scar of the right hand. 3. The cause of the Veteran's death is not related to service or a service-connected disability. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C. § 1310, 5107; 38 C.F.R. §§ 3.102, 3.303,3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Navy from August 1975 to July 1978 and from January 1991 to July 1991. He also had reserve service. He passed away in December 2013. The Appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter in July 2018. The Board finds that the remand directives have been substantially complied with and therefore will proceed with the appeal. Stegall v. West, 11 Vet. App. 268. Legal Criteria Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Dependency and Indemnity Compensation (DIC) benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. § 3.5. The death of a veteran will be considered to have been due to a service-connected disability where the evidence establishes that the disability was either the principal or contributory cause of death. 38 C.F.R. § 3.312(a). The issue involved will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran. 38 C.F.R. § 3.312(a). A principal cause of death is one which, 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 one which contributed substantially or materially to cause death or aided or lent assistance to the production of death. See 38 C.F.R. § 3.312(c). A contributory cause of death is inherently one not related to the principal cause. In determining whether the 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)(1). In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Contentions The Appellant asserts that the Veteran's death should be service connected. See January 2015 VA 21-4138 Statement in Support of Claim. In the May 2021 Appellate Brief, the Appellant's representative argued that there are associations between the Veteran's service-connected PTSD and cardiovascular disease. Additionally, the representative argued that the Veteran's exposure to environmental hazards during his service in Desert Storm/Desert Shield may be linked to his cardiovascular disease. Evidence At the time of the Veteran's death service connection was in effect for posttraumatic stress disorder (PTSD), chronic fatigue syndrome, and healed scar of the right hand. Neither the enlistment examination for the Veteran's first tour of duty, nor his second tour of duty are part of the file. As such, the Veteran is presumed to have been healthy upon entrance. Additionally, the June 1990 enlistment examination for Naval reserve service shows that he denied heart trouble and high blood pressure. A private clinical summary report shows that the Veteran was admitted from October 2004 to November 2004. He was known to be hypertensive for more than 5 years, and a "smoker for 12 pack years." An October 2004 interpretation of a chest radiograph from a private provider shows a diagnosis of atheromatous aorta. A November 2004 VA medical record illustrates a diagnosis of hypertension. A February 2005 VA treatment record reflects the Veteran was diagnosed with hypertension 10 years prior and he was noted to be a current smoker, smoking at least a pack a day. It was noted that his father had coronary artery disease (CAD). A June 2005 VA record illustrates increased smoking and worsened hypertension. During a November 2010 VA PTSD evaluation the Veteran was diagnosed with hypertensive heart disease. A December 2010 VA record reflects that the Veteran still smoked a pack a day. An August 2011 VA record shows that the Veteran was diagnosed with hypertension in 1994. A July 2012 VA test results letter describes a diagnosis of atherosclerotic aorta. A June 2013 VA primary care physician outpatient note shows an active prescription to treat hypertension. Upon review of systems (respiratory) intermittent cough with phlegm was indicated and it was noted that the Veteran was still a smoker consuming 15 to 20 sticks a day. A letter authored by a private psychiatrist dated December 2014 was submitted in January 2015. The psychiatrist noted that the Veteran was diagnosed with depression in 1991. The psychiatrist opined, "I believe that his illness which caused his demise at age 58 years is service connected." A VA examiner provided opinions in March 2020. The examiner opined that it is less likely than not that that the Veteran's principal cause of death (acute myocardial infarction) was incurred or in or caused by a specific in-service illness, event, or injury. "STRs were all reviewed searching for any in-service illness, event, or injury, which could cause or lead to any condition related to acute myocardial infarction and no such illness, event, or injury was found. Rather, medical records support that illnesses and conditions unrelated to service were more likely than not the cause of his acute myocardial infarction. Medical records documented that his father had coronary artery disease (see medical note 2/11/05 for example) and this indicates a strong genetic predisposition for acute MI unrelated to service. Medical records document a long history of smoking (primarily in civilian life) and this is known to cause CAD which would predispose to acute myocardial infarction (see medical notes 12/6/10, 10/23/04, and 6/3/13 for example). Medical records also document development and treatment of hypertension and hyperlipidemia in civilian life and these conditions would predispose toward development and treatment of acute myocardial infarction (see 6/3/13 note for example). The medical literature supports that the vast majority of acute myocardial infarctions are due to underlying coronary artery disease but in performing this review I also searched for evidence of any non-CAD cause of acute myocardial infarction which might be related to service but no such evidence was found. I searched for any medical records of symptoms in service which might conceivably be linked to service and again no such evidence was found. Rather, the first symptoms in the medical records which could be linked to his later death due to acute myocardial infarction were found many years after leaving service (see medical notes regarding chest pain 2/11/05 and 9/8/05)." The examiner listed medical references. The examiner also opined that it is less likely than not that the Veteran's cause of death was proximately due to or the result of his service-connected PTSD. "There is some suggestive evidence in the medical literature that cardiac disorders such as acute myocardial infarction can be caused or aggravated by psychological stress. But this evidence is relatively weak compared to the strong and well-established evidence of other causes such as family history, smoking, hypertension, and hyperlipidemia. In this particular case the medical records document that the Veteran had PTSD with depression, but no evidence was found that this was causing or aggravating any myocardial infarction related condition. For example, I searched for evidence of the veteran having chest pain or other cardiac symptoms triggered by PTSD/depression and no such evidence was found. Rather, the records document that he had multiple risk factors known to predispose to myocardial infarction and unrelated PTSD/depression (see notes document family history of CAD, smoking, hyperlipidemia and hypertension including 6/3/13 and 2/11/05). Symptoms of chest pain indicative of possible CAD which could possibly relate to his later myocardial infarction were linked in the medical records to hypertension rather than PTSD/depression (see 9/8/05 note). The examiner listed medical references. The examiner also opined that it is less likely than not that the Veteran's cause of death was proximately due to or the result of or aggravated by his service-connected chronic fatigue syndrome. "The medical literature supports that a lack of physical exercise can by [sic] a factor in developing CAD which could lead to myocardial infarction. However, in this particular case the medical records document that the veteran had other strong and well established conditions unrelated to his chronic fatigue syndrome which would be far more likely to cause his myocardial infarction. These including family history of CAD (see 2/11/05 note) and smoking and hypertension and hyperlipidemia (see 6/3/13 note). The medical literature support these factors (unrelated to service and chronic fatigue) as being far more likely to lead to myocardial infarction and record review simply does not provide evidence of chronic fatigue causing or aggravation any myocardial infarction related condition in this case." The examiner listed medical references. The examiner also opined that it is less likely than not that the Veteran's cause of death was proximately due to or the result of his service-connected healed scar of the right hand, residual of traumatic ray amputation at the second proximal metacarpal level with resection of the right index finger. "The medical literature does not support that healed scar right (dominant) hand, residual of traumatic ray amputation at the second proximal metacarpal level with resection of the right index finger would cause or aggravate any condition related to acute myocardial infarction. Review of the medical records for this case did not reveal any evidence of healed scar right (dominant) hand, residual of traumatic ray amputation at the second proximal metacarpal level with resection of the right index finger causing or aggravating any condition related to myocardial infarction. Rather, medical record review revealed that the veteran had other well established causes for myocardial infarction such as family history of CAD, hypertension, hyperlipidemia and smoking and these causes appear unrelated to healed scar right (dominant) hand, residual of traumatic ray amputation at the second proximal metacarpal level with resection of the right index finger." The examiner also provided rationale to explain why a baseline level of severity could not be determined. "In this case, the medical records reveal no evidence of acute myocardial infarction (or any condition related to acute myocardial infarction) being aggravated beyond expected natural progression. Rather the records document that he was born with a pre-disposition to develop CAD/MI (father had CAD). As an adult in civilian life he developed hypertension and required treatment. He also smoked for many years. These factors led to his death due to myocardial infarction in a manner entirely compatible with the known natural history for atherosclerotic cardiovascular disease which commonly presents with acute MI and death. This is an extremely common and well known pattern for this disorder which is not indicative of any aggravation beyond expected natural progression." The examiner listed medical references. The examiner also opined that it is less likely than not than any of the Veteran's service-connected disabilities (or a combination of them) substantially or materially contributed to his death, combined with each other or his myocardial infarction to cause his death, or aided or lent assistance to the production of his death. "Medical records provide clear and strong evidence that the Veteran died of an acute myocardial infarction (see death certificate) and that he had conditions which would be expected to cause myocardial infarction (see notes indicating family history of CAD, smoking, hypertension, and hyperlipidemia to include 2/11/05 and 6/3/13). No evidence was found to indicate that his SC conditions alone or in combination caused or aggravated any myocardial infarction related condition and/or aided or lent assistance in the production of his death. The Veteran's records and the medical literature support that the Veteran had multiple potent causes for his heart attack to include family history of CAD, smoking, hypertension, and hyperlipidemia." Analysis The Board has carefully considered whether the benefit of the doubt should be afforded to the Appellant as to whether the Veteran's acute myocardial infarction was related to service or his service-connected disabilities. However, the preponderance of the evidence is against such findings, and the appeal will be denied. The most probative evidence of record illustrates that there is no causal link between the Veteran's myocardial infraction and his military service. The death certificate lists the manner of death as acute myocardial infarction. The death certificate does not list any other disabilities, disease, or symptoms to indicate any other disease contributed to the death of the Veteran or to the development of his acute myocardial infarction. The Veteran was not service connected for acute myocardial infarction or residuals of acute myocardial infarction at the time of his death. Additionally, the Veteran did not file a claim at any time during his lifetime for service connection for acute myocardial infarction. Service treatment records are negative for complaints, treatments or diagnoses related to a myocardial infarction, heart attack, or any symptoms related to a blockage of the coronary arteries. The earliest dated record to illustrate a diagnosis involving the heart is dated October 2004over a decade post the Veteran's July 1991 separation. The probative evidence of record, to include the VA medical opinions all illustrate that there is no nexus between the Veteran's acute myocardial infarction and his time in service. The Board recognizes the December 2014 letter authored by the Veteran's private provider. However, as stated in the July 2018 Board remand no rationale was provided and this opinion is inadequate. As the December 2014 private medical opinion failed to provide rationale to support conclusion, the Board assigns the opinion no probative weight. Additionally, as the examiner stated, "I believe" when providing the opinion, this opinion is inadequate as the language used is very vague. See Polovick v. Shinseki, 23 Vet. App. 48 (2009) (a medical opinion is speculative when it uses equivocal language such as "may well be," "could," or "might"). The Board assigns significant probative value to the March 2020 VA medical opinions. The medical opinions are based on a comprehensive review of the Veteran's claims file, consideration of lay evidence of record, supporting medical literature and provided sufficient rationale to support the examiner's conclusions. The opinions provided adequate rationale in which the medical expert had fairly considered material evidence, to include the Veteran's medical history and lay statements. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). Accordingly, the VA opinions far outweigh the December 2014 statement. Therefore, the Board finds that service connection for acute myocardial infarction on a direct theory of entitlement is not warranted. The Board recognizes that the VA examiner stated hypertension may be more of a factor in the development of acute myocardial infarction and that the record illustrates a 1994 diagnosis of hypertension, three years post the Veteran's July 1991 separation from his second tour of duty. However, during the Veteran's lifetime the RO adjudicated the matter and found that his hypertension was not related to service. Additionally, being hypertensive as early as 1994 does not illustrate that the Veteran had heart disease or any heart disorders at that time that ultimately led to his death. Also, being considered hypertensive three years post separation, alone does not equate to a showing that the Veteran's hypertension was related to service. The Board has considered the argument advanced by the Appellant. Specifically, in the April 2021 Brief the Appellant's representative referred to two separate studies, suggesting that the Veteran's service-connected PTSD was related to the cardiovascular disease, hypertension, that caused his death. As detailed above, there are competent, thorough medical opinions of record where the VA examiner concluded that the myocardial infarction that caused the death of the Veteran was not due to his service-connected PTSD. Additionally, there is no indication that the Appellant or her representative have had any medical training. As such, their statements are considered lay evidence. She is competent to report as to symptoms she observed but is not competent to independently opine as to the specific etiology or render a medical nexus of a disability, as such requires medical expertise and the ability to interpret diagnostic medical testing. Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Thus, the Appellant's assertions and argument presented by her representative are not considered to be competent nexus evidence and the Board assigns more weight to the VA opinions provided by the medical professional. Regarding the argument relating the Veteran's PTSD and hypertension, there is no probative evidence of record to show a correlation between his PTSD and hypertension. Additionally, the Veteran is not service connected for hypertension. The Board has also reviewed the articles linked to the April 2021 Brief. The articles describe a general correlation between PTSD and cardiovascular disease/hypertension. The articles do not provide information specific to the Veteran and do not serve as medical opinions for the Veteran's specific medical history and pathology. Therefore, the Board finds that the articles do not meet the "more likely than not" threshold that would establish service connection for the Veteran's cause of death. The most probative evidence as to the cause of the Veteran's death are the March 2020 VA opinions. The opinions are based on a thorough review of all the evidence of record. The March 2020 VA examiner offered detailed rationale, and plausible explanation for concluding that the service-connected disabilities did not cause or contribute to the Veteran's death. The VA examiner indicated that medical evidence does not support a link to any of the Veteran's service-connected disabilities to his acute myocardial infarction. There is no probative evidence of record that shows the Veteran's death was related, in any fashion, to his service-connected disabilities. Notably, the examiner concluded that the Veteran's history of smoking, hypertension, and predisposition to the development of CAD more likely than not caused his acute myocardial infarction, and it eventually led to his death. The most probative evidence of record clearly indicates that the Veteran's death was a result of acute myocardial infarction, a non-service-connected disability. Not only does the death certificate list acute myocardial infarction as the cause of death, but notably the record shows, as the VA examiner stated, that there were other long term risk factors such as hypertension and smoking. Accordingly, the Board finds that the preponderance of the evidence is against a finding that the Veteran's acute myocardial infraction, the singular cause of his death, was caused by or aggravated by his service-connected disabilities or is otherwise related to his active duty service. A service-connected disability did not cause the Veteran's death or contribute substantially or materially to his death. Consequently, service connection for cause of death is denied. Although the Board is sympathetic to the Appellant's claim and acknowledges the years of honorable service the Veteran provided, taking into account all the relevant evidence of record and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Appellant's claim that the Veteran's cause of death is related to active duty service. In reaching this decision the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Appellant's claim, the doctrine is not for application. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). T. TALAMANTES Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Dixon, Associate 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.