Citation Nr: 21062171 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 13-20 946 DATE: October 6, 2021 REMANDED Entitlement to service connection for coronary artery disease (CAD) and cardiac arrhythmia as secondary to posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for hypertension as secondary to PTSD is remanded. Entitlement to service connection for a central nervous system (CNS) disability as secondary to CAD and cardiac arrhythmia is remanded. Entitlement to a total disability based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from October 1962 to October 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2013 and March 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2020, the Board last remanded these issues to the RO for further development. Although the Board sincerely regrets the additional delay, a remand is warranted to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 1. Entitlement to service connection for CAD and cardiac arrhythmia as secondary to PTSD and entitlement to service connection for hypertension as secondary to PTSD Unfortunately, a remand is warranted because the last VA opinions of record, in July 2021, regarding secondary service connection are again inadequate and do not substantially comply with the prior Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). In this regard, although the October 2020 Board remand directives instructed the VA examiner to consider and comment upon the articles concerning PTSD and cardiovascular disease associated with the claims file as well as the Veteran's statements, the July 2021 VA examiner did not address these articles or the Veteran's statements in providing negative nexus opinions. Moreover, the July 2021 VA examiner did not provide adequate rationale in concluding that the Veteran's service-connected PTSD did not cause nor aggravate his hypertension. In this regard, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the VA examiner noted, without further rationale, that the records are silent for a nexus between hypertension and PTSD or an unhealthy lifestyle. Regarding aggravation, the examiner noted that while the Veteran presented with may risk factors associated with hypertension, there was no evidence suggesting that this condition was aggravated due to the Veteran's PTSD or unhealthy lifestyle measures. These opinions are inadequate because the VA examiner did not provide a reasoned medical explanation connecting her conclusions. The VA examiner also did not address the Veteran's claim that stress associated with his PTSD aggravates his hypertension. Finally, as the July 2021 VA examiner indicated that the Veteran's body mass index (BMI) reflects he has been overweight/obese and found that the most likely cause of the Veteran's CAD is family history, obesity, diabetes, and smoking, the Board finds that on remand a VA examiner must address whether the Veteran's weight/obesity is an intermittent step between a service-connected disability and his claimed conditions. Specifically, although obesity is not a disease for service connection purposes, it nonetheless may be an intermittent step between a service-connected disability and a current disability that may be service connected on a secondary basis. VAOPGCPREC 1-2017 (Jan 6, 2017). As such, the VA examiner should address whether symptoms related to the Veteran's service-connected PTSD and/or sleep apnea, resulted in the development of obesity as an intermediary step in the manifestation of his CAD, cardiac arrhythmia, and/or hypertension. 2. Entitlement to service connection for a CNS disability as secondary to CAD and cardiac arrhythmia and entitlement to a TDIU due to service-connected disabilities As the outcome of the Veteran's remanded service connection claims for hypertension and CAD and cardiac arrhythmia bears weight on the Veteran's claims for service connection for a CNS disability and TDIU, such are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, adjudication of these issues is deferred pending development of the Veteran's hypertension and heart claims. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment of record is dated December 2020. 2. Then, obtain an addendum medical opinion from an appropriate medical professional who has not previously provided an opinion in this case to address the Veteran's claim for service connection for CAD and cardiac arrhythmia as secondary to his service-connected PTSD. The claims file, to include a copy of this Remand, should be made available to and be thoroughly reviewed by the examiner. The examiner should respond to the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's CAD and cardiac arrhythmia is caused by the Veteran's service-connected PTSD, to include any unhealthy lifestyle habits and/or stress due to his PTSD? (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's CAD and cardiac arrhythmia is aggravated by the Veteran's service-connected PTSD, to include any unhealthy lifestyle habits and/or stress due to his PTSD? If aggravation is found, the examiner should quantify the degree of aggravation, if possible, and state whether there was a medically ascertainable increase in disability regardless of permanence. In providing the above causation and aggravation opinions, the VA examiner MUST CONSIDER AND ADDRESS: (i) the Veteran's PTSD symptoms reflected in the VA examinations of record including angry outbursts, anxiety, hypervigilance, and difficulty in adapting to stressful circumstances; (ii) the articles associated with the claims file regarding a relationship between PTSD and cardiovascular disease and how such relate to the Veteran's claim, see e.g., article submitted by the Veteran in October 2012 entitled PTSD Linked to Increased Risk of Death, Cardiovascular Disease ("PTSD . . . can lead to not only risk markers of their own but also unhealthy lifestyle habits"), website article entitled Unraveling the link between PTSD and heart disease dated February 2014 (citing research noting that after researchers adjusted for clinical and demographic factors known to influence heart disease such as age, obesity, alcohol use, etc., PTSD was associated with more than double the risk for ischemia), website article entitled Posttraumatic Stress Ups Heart Disease submitted by the Veteran in January 2017 (citing to researchers indicating data suggesting that prolonged stress and significant levels of PTSD symptoms may increase the risk for coronary heart disease in older male veterans); AND (iii) the Veteran's statements that the stress from his service-connected PTSD as well as PTSD symptoms of anger, depression, and a lack of control of eating and drinking habits causes/aggravates his CAD and cardiac arrhythmia. (c) Additionally, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's service-connected PTSD and/or sleep apnea caused or aggravated the Veteran's obesity? (d) If so, (1) is the Veteran's obesity a substantial factor in causing or aggravating his CAD and cardiac arrhythmia; and (2) would the Veteran's CAD and cardiac arrhythmia not have occurred or worsened but for the obesity caused by his service-connected disability? The examiner should comment on all questions above and set forth a complete rationale for all opinions. A detailed discussion of the relevant facts and medical principles involved, including citations to supporting clinical data/medical literature, would be of considerable assistance to the Board. If the examiner cannot provide a requested opinion without resorting to mere speculation, it must be stated, and the examiner must provide the reasons why an opinion would require speculation. 3. Obtain an addendum medical opinion from an appropriate medical professional who has not previously provided an opinion in this case to address the Veteran's claim for service connection for hypertension as secondary to his service-connected PTSD. The claims file, to include a copy of this Remand, should be made available to and be thoroughly reviewed by the examiner. The examiner should respond to the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran hypertension is caused by his service-connected PTSD, to include any unhealthy lifestyle habits and/or stress due to his PTSD? (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's hypertension is aggravated by his service-connected PTSD, to include any unhealthy lifestyle habits and/or stress due to his PTSD? If aggravation is found, the examiner should quantify the degree of aggravation, if possible, and state whether there was a medically ascertainable increase in disability regardless of permanence. In providing the above causation and aggravation opinions, the VA examiner MUST CONSIDER AND ADDRESS: (i) the Veteran's PTSD symptoms reflected in the VA examinations of record including angry outbursts, anxiety, hypervigilance, and difficulty in adapting to stressful circumstances; (ii) the articles associated with the claims file regarding a relationship between PTSD and cardiovascular disease and how such relate to the Veteran's claim, see e.g., article submitted by the Veteran in October 2012 entitled PTSD Linked to Increased Risk of Death, Cardiovascular Disease ("PTSD . . . can lead to not only risk markers of their own but also unhealthy lifestyle habits"), website article entitled Unraveling the link between PTSD and heart disease dated February 2014 (citing research noting that after researchers adjusted for clinical and demographic factors known to influence heart disease such as age, obesity, alcohol use, etc., PTSD was associated with more than double the risk for ischemia), website article entitled Posttraumatic Stress Ups Heart Disease submitted by the Veteran in January 2017 (citing to researchers indicating data suggesting that prolonged stress and significant levels of PTSD symptoms may increase the risk for coronary heart disease in older male veterans); AND (iii) the Veteran's statements that the stress from his service-connected PTSD as well as PTSD symptoms of anger, depression, and a lack of control of eating and drinking habits causes/aggravates his hypertension. (c) Additionally, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's service-connected PTSD and/or sleep apnea caused or aggravated the Veteran's obesity? (d) If so, (1) is the Veteran's obesity a substantial factor in causing or aggravating his hypertension; and (2) would the Veteran's hypertension not have occurred or worsened but for the obesity caused by his service-connected disability? The examiner should comment on all questions above and set forth a complete rationale for all opinions. A detailed discussion of the relevant facts and medical principles involved, including citations to supporting clinical data/medical literature, would be of considerable assistance to the Board. (Continued on the next page) If the examiner cannot provide a requested opinion without resorting to mere speculation, it must be stated, and the examiner must provide the reasons why an opinion would require speculation. 4. Following the development and adjudication of the claims for service connection for CAD and hypertension as requested above, develop as necessary and readjudicate the claims for a CNS disability and TDIU. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Amanda Purcell, 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.