Citation Nr: 21063254 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-54 302 DATE: October 13, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is granted, subject to the regulations governing payment of monetary awards. FINDING OF FACT 1. The Veteran died in April 2016; the immediate cause of his death was coronary artery disease (CAD); hypertension and hypercholesteremia have been identified as significant contributing conditions. 2. The Veteran had established service connection for sleep apnea, bilateral knee osteoarthritis, right ankle strain, allergic rhinitis, GERD, and dermatomyositis with residual erythroderma of the face and mild lower extremity muscle weakness. 3. Competent medical evidence relates the Veteran's CAD to his calcified aortic value and aortic stenosis noted in service and supports that his service-connected dermatomyositis materially and substantially contributed to his death. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is warranted. 38 U.S.C. §§ 1110, 1131, 1310, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is the surviving spouse of a Veteran who served on active duty from October 1983 to September 2008, and died in April 2016. This matter is before the Board of Veterans' Appeals (Board) on appeal of an April 2017 Department of Veterans Affairs (VA) rating decision. In May 2021, a virtual hearing was held before the undersigned; a transcript is in the record. To establish service connection for the cause of a Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(a). To constitute the principal cause of death, the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b). For a service-connected disability to constitute a contributory cause of death, it must be shown to have contributed substantially and materially to the veteran's death; combined to cause death; aided or lent assistance to the production of death. It is not sufficient to show that a service-connected disability casually shared in the producing death; rather, it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1). Generally, minor service-connected disabilities, particularly those of a static nature or not materially affecting a vital organ, would not be held to have contributed to death primarily due to unrelated disability. In the same category there would be included service-connected disease or injuries of any evaluation (even though evaluated as 100 percent disabling) but of a quiescent or static nature involving muscular or skeletal functions and not materially affecting other vital body functions. 38 C.F.R. § 3.312(c)(2). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. 38 C.F.R. § 3.312(c)(3). There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. It would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(4). In determining whether the disorder that resulted in the death of the Veteran was the result of active service, the laws and regulations pertaining to service connection apply. 38 U.S.C. § 1310. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for a disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: (1) a current claimed disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury in service. See Shedden v. Principi, 281 F.3d 1163, 1166-67 (Fed. Cir. 2004). The determination as to whether these requirements are met is based on an analysis of all evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Before he died, the Veteran had established service connection for sleep apnea (rated 50 percent), right knee osteoarthritis (rated 10 percent), left knee osteoarthritis (rated 10 percent), allergic rhinitis (rated 0 percent), GERD (rated 0 percent), and dermatomyositis with residual erythroderma of the face and mild lower extremity muscle weakness (rated 0 percent). While he sought service connection for atrioventricular block prior to his death, a November 2015 statement of the case (SOC) continued to deny the claim and a substantive appeal was not received. The appellant contends that the Veteran's cause of death was etiologically/causally linked to the first-degree atrioventricular (AV) block diagnosed in service, or in the alternative, service-connected dermatomyositis contributed substantially and materially to the cause of his coronary artery disease. Service treatment records (STRs) document that, in late 2004, the Veteran started seeking treatment for what ultimately found to be dermatomyositis without apparent myositis. His STRs also note numerous cardiac findings beginning in June 2005. A June 2005 echocardiogram (ECG) found a bicuspid aortic valve calcified, mild eccentric aortic insufficiency, and mild to moderate mitral regurgitation. A June 2006 CT scan report found an aortic valve calcification, which was noted to be evidence for aortic stenosis. A July 2006 ECG found a mild calcified, bicuspid AV block and no significant change in this ECG was found as compared to the June 2005 ECG. Clinical records note he had been prescribed Plaquenil from 2006 to 2008 to treat his dermatomyositis. On November 6, 2009 (approximately 14 months following separation from service), the Veteran was hospitalized for bradycardia; a pacemaker was implanted. In a November 11, 2009 narrative summary and patient discharge report, 3rd decree AV block post permanent dual chamber pacemaker; moderately obstructive atherosclerotic coronary artery disease, left circumflex artery, obtuse marginal artery 2; dyslipidemia with low HDL, dermatomyositis; aortic insufficiency (AI)/aortic valve stenosis (AS); and bicuspid aortic valve were diagnosed. Treatment records notes he was referred for further evaluation of bradycardia in the setting of first degree AV block the day prior. On arrival to the cardiology clinic, the EKG revealed a high degree AV block and he was hospitalized. During his hospitalization, the Veteran underwent multiple consultations to determine the etiology of his heart block with questionable condition abnormality, specifically whether it was related to his bicuspid aortic valve vs subacute bacterial endocarditis (SBE) vs Lyme disease. A November 10, 2009 private dermatology consultation notes the Veteran had no findings consistent with dermatomyositis at the time of consultation. The provider reviewed medical literature and reported that several case reports of heart block in association with dermatomyositis were found. The provider noted there were several reports of patients who developed cardiac symptoms, including a heart block, while in clinical remission or while receiving prednisone independent signs of active disease in skeletal muscle activity (CK levels). The provider opined that it did not appear from the article that steroid treatment for conduction disorders would be helpful and noted one longitudinal study mentioned reported that conduction abnormalities progressed, and new disturbances developed despite corticosteroid treatment. The provider reported another study in the review showed that myositis appeared to be independent of steroid therapy. The provider opined that despite the lack of findings for dermatomyositis on clinical examination or active CK levels, the Veteran could have had subclinical inflammation that could have led to his 3rd degree heart block, noting that it would be unlikely that this would not be a progressive condition if so. A November 10, 2009 private infectious disease consultation found there was no evidence to support a diagnosis of Lyme disease or SBE. A November 2009 private rheumatology consultation opined that he did not suspect that the Veteran's complete heart block is due to dermatomyositis. The provider stated that the history of the Veteran's disease included only an episode of muscle symptoms on initial presentation which was mild and immediately responsive to a short course of oral steroids. The rheumatologist noted a single study addressed the development of conduction ABNLs to include complete heart block independent of active muscle disease. The provider opined that the Veteran's calcific aortic value and annulus were the more likely etiology but either etiology would be impossible to prove as cardiac MRI or BX were not tenable. The provider did not address the 3-year course of treatment of dermatomyositis in service or a 1st degree AV block which manifested in service, following the symptoms and treatment for dermatomyositis in service. On July 2013 VA heart examination (while seeking service connection for his AV block), the provider opined there were no chronic cardiac conditions that are related to the mitral regurgitation found in service. The examiner does not address the other cardiac findings documented in service, to include the calcified aortic valve, aortic stenosis and 1st degree AV block. In September 2014, the Veteran submitted medical treatise indicating an association between dermatomyositis with frequent subclinical manifestations predominated by conduction abnormalities and congestive heart failure that may lead to complete heart block. The medical treatise also indicated that conduction abnormalities are the most common asymptomatic cardiac manifestations (observed in 32% to 72% of patients) of those with dermatomyositis and in some cases required a pacemaker placement. In a June 2015 addendum opinion, the July 2013 examiner opined the Veteran's then 3rd degree AV block (complete heart block) is not related to service, noting (without explaining rationale) that the complete heart block is not the same as the 1st degree AV block found in service. The examiner opined that the Veteran did not have active dermatomyositis, noting only very mild muscle involvement at presentation and none since, and that he never required immunosuppressive treatment except for a very short course of steroids. The examiner reported medical literature shows that there have only been 4 cases of complete heart block associated with dermatomyositis and those patients had extensive muscular involvement. The examiner does not address the other heart conditions diagnosed during service, to include a calcified aortic value and aortic stenosis. The Veteran died on April [REDACTED], 2016. The Veteran's death certificate lists the immediate cause of death as coronary artery disease (CAD) with contributing conditions of hypertension and hypercholesteremia. In September 2017, a VA physician opined that the service-connected dermatomyositis and the medications used to treat the condition were less likely than not caused or substantially contributed to the Veteran's death. The examiner noted that the Veteran's death certificate lists the cause of death as CAD and this is a condition but not a cause of producing death. The examiner speculated that the cause of death listed on the death certificate could indicate a myocardial infarction (MI) but there could be other causative factors such as arrhythmia, complications of aneurysm, ect. Assuming that the Veteran's cause of death was a MI while also acknowledging that it had not been determined at that point, the examiner stated that some studies do indicate an increased risk of MI in association with dermatomyositis. However, the examiner opined that the cumulative non-service- connected risk factors (of hypertension, hyperlipidemia, and early family history of CAD in a first degree relative) were greater than the risk from dermatomyositis. The examiner noted his dermatomyositis was mild and occurred greater than 10 years prior to the Veteran's death. While the examiner also opined that the Veteran's STRs did not reveal a diagnosis which would have at least as likely as not contributed to the Veteran's death, the examiner does not address the medical treatise of record indicating a symptom of dermatomyositis may include conduction abnormalities and the findings of heart abnormalities in service (to include 1st degree AV block and a calcified aortic value). At the May 2021 hearing, the appellant testified that the Veteran's heavily calcified bicuspid aortic valve began during service. She alleged that the VA opinions were too narrow and failed to answer whether his heart condition began in service, noting there is no evidence that the 1st degree AV block could not eventually become a 3rd degree AV block. She testified that she is a retired surgical assistant and reviewed medical literature on dermatomyositis. She stated that based on her review of medical literature, dermatomyositis affects every muscle of the body, which includes the heart, and he became weak. The Board finds that the November 2009 dermatology private medical opinion places the probative value of the evidence supporting the appellant's claim at least in equipoise with the opinions against the claim. Multiple private consulting providers assessed the Veteran in 2009 (when coronary artery disease and 3rd decree AV block were assessed, and a pacemaker was placed). They are probative evidence supporting the claim, and the Board finds them (cumulatively) persuasive. While the consulting rheumatologist disagreed with dermatology's assessment that the Veteran could have a subclinical inflammation of dermatomyositis that could have led to his heart block, the rheumatologist opined that the Veteran's condition is more likely due to calcific aortic valve and annulus and an aortic valve calcification were noted in service. The 2009 providers expressed familiarity with the Veteran's record and the providers included citations to several specific medical records in support of their opinions. The Board finds the 2009 opinions to be more probative than the one offered by the two VA examiners who failed to consider the role the Veteran's dermatomyositis played as a causative factor in the development of the 1st degree AV block or the findings of a calcified aortic valve in service. Upon review of the record, the Board finds that the competent evidence of record is at least in equipoise as to whether the Veteran's service-connected dermatomyositis and heart conditions, which manifested in service, were proximate causes of his fatal coronary artery disease. Resolving reasonable doubt in the appellant's favor (as required in such circumstances), the Board concludes that service connection for the cause of the Veteran's death is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.