Citation Nr: 21071979 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 19-02 910A DATE: December 1, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died in August 1979 at age 33. The death certificate reflects that the immediate cause of death was cardiac arrest. 2. At the time of the Veteran's death, he had no service-connected disability. 3. No ischemic heart disease, or any other heart disease, is shown. 4. A disability incurred in or aggravated by service did not cause or contribute substantially or materially to the Veteran's death. CONCLUSION OF LAW The criteria for entitlement to service connection for the cause of the Veteran's death have not been met; service connection may not be presumed. 38 U.S.C. §§ 1110, 1116, 1310, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.307, 3.309, 3.312 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty as a commissioned officer in the U.S. Army from August 1969 to June 1971, including service in the Republic of Vietnam. He died in August 1979. The appellant claims as the Veteran's surviving spouse. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a March 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2021, the Board remanded the claim for further development. Such development has been completed and associated with the claims file, and the claim is ready for decision. Entitlement to service connection for the cause of the Veteran's death The appellant claims entitlement to service connection for the cause of the Veteran's death. The Veteran died in August 1979. The death certificate lists the immediate cause of death as cardiac arrest. The appellant claims as his surviving spouse. The appellant essentially asserts that the Veteran's "cardiac arrest" noted on the death certificate merely means stoppage of the heart, and that the actual underlying cause of death was a myocardial infarction ("heart attack") due to cardiovascular disease caused by the Veteran's active service. See Lay statement, received October 2018 at p.3 of 3; Correspondence, received December 2020 at p.3 and 74. The appellant has also asserted more specifically that the cause of death was ischemic heart disease due to Agent Orange exposure. See Correspondence, received December 2020 at p.74-75. To establish entitlement to service connection for the cause of a veteran's death, the evidence of record must show that a disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. 38 U.S.C. § 1310 (2012); 38 C.F.R. § 3.312 (2020). The service-connected disability will be considered as the principal cause of death when such disability, singly or jointly with another condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b) (2020). To be considered a contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. It is not sufficient to show that the service-connected disability casually shared in producing death; rather, a causal connection must be shown. 38 C.F.R. § 3.312(c) (1) (2020). The Veteran served in the Republic of Vietnam from August 1970 to June 1971. See DD Form 214. Therefore, exposure to the designated herbicide agents is conceded. See 38 C.F.R. § 3.307(a)(6). Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction, and atherosclerotic cardiovascular disease) is among those diseases listed for which service connection may be presumed in the case of certain herbicide agent-exposed veterans. See 38 C.F.R. § 3.309(e). In this case, however, as explained in greater detail below, there is no medical evidence to support any diagnosed ischemic heart disease. As such, the presumptive service connection provisions of 38 U.S.C. § 1116 and 38 C.F.R. § 3.309(e) are not for application. The Veteran's service treatment records show no cardiovascular complaints or diagnosis. His March 1971 separation examination report shows examination of his heart was normal. See STR at p.43 of 46. The Board acknowledges other complaints in the service treatment records of indigestion in 1969, with a negative barium study, and headaches in 1970. See STR at p.1, 23-25, and 42 of 46. As noted above, the Veteran was discharged from active service in June 1971, and he died eight years later in August 1979. The appellant has not identified any post-service treatment records for VA to obtain. An October 2018 DRO informal conference report shows she reported his records of treatment were unavailable. A search for VA outpatient (CAPRI) records was negative. The October 2018 DRO informal conference report shows the appellant reported a post-service history of the Veteran having lost interest and drive in his interests, as well as symptoms of swelling in his neck, arms, and legs, and night sweats. She reported that due to fatigue and difficulty climbing stairs, they purchased a rambler. She reported that records of treatment were unavailable. She also reported that on the night of the Veteran's death, they had travelled to Montana, and she woke in the night to an ugly sound and the Veteran had wet the bed in distress. She reported she performed cardiopulmonary resuscitation (CPR), he regained consciousness, and an ambulance took him to the hospital where he died two hours later. In a separate October 2018 lay statement, the appellant reported that two months prior to his death on one night the Veteran was fatigued, lightheaded, and vomiting, and had loss of breath. She also reported he struggled with mental health issues after returning from service, and on the night the Veteran died, he was exhausted after driving to Montana and watching his wife's musical performance. She also reported that no autopsy was performed after he died. In December 2020, the appellant testified at the Board hearing that post service, the Veteran experienced swelling in his neck requiring him to buy different shirts, and swelling in his legs and feet, and that the Veteran would take his socks off due to the swelling. See Transcript at p.5. She also testified that he suffered from severe exhaustion. See Transcript at p.6-7. As noted above, the death certificate shows the cause of death was "cardiac arrest," which is not medically defined as a disease. Rather, it only constitutes an event or symptom. Specifically, "cardiac arrest" is defined in Dorland's Medical Dictionary as the "sudden cessation of the pumping function of the heart, with disappearance of arterial blood pressure, connoting either ventricular fibrillation or ventricular standstill; it usually leads to death unless corrected but may be temporary or paroxysmal." See Dorland's Medical Dictionary (30th Ed.) at p.132 (defining types of "arrest"). An October 2018 VA medical opinion shows that examiner opined he could not opine as to the cause of the Veteran's cardiac arrest without resorting to mere speculation. A June 2021 VA medical opinion shows the examiner opined it is not at least as likely as not that the Veteran's cause of death, cardiac arrest, was due to ischemic heart disease. The examiner reasoned, citing to medical literature, that the major risk factors for coronary artery disease include being a male over the age of 45, diabetes mellitus, and tobacco use, and additional risk factors for coronary artery disease include hypertension, dyslipidemia, obesity, sedentary lifestyle, family history of premature coronary artery disease, and stress/depression, and tobacco use. The examiner noted that the Veteran was age 33 and that young patients with myocardial infarction typically have several risk factors for coronary artery disease, but the Veteran had no known risk factors for development of coronary artery disease or myocardial infarction - no known history of elevated cholesterol, hypertension, or tobacco use, and no known family history. The examiner noted in the report that the Veteran's separation examination showed his heart was normal. The examiner further reasoned that "cardiac arrest" refers to the sudden cessation of cardiac activity with hemodynamic collapse. The examiner explained that etiologies of sudden cardiac arrest include: heart failure, left ventricular hypertrophy due to hypertension, myocarditis, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, congenital coronary artery anomalies, mitral valve prolapse, Brugada syndrome, idiopathic ventricular fibrillation, congenital or acquired long QT syndrome, familial polymorphic ventricular tachycardia, familial SCD of uncertain cause, Wolff-Parkinson-White Syndrome, Commotio cordis, electrolyte disturbance (hypokalemia and hypomagnesemia), proarrhythmic drugs, autonomic nervous system activation, psychosocial factors. The examiner noted that risk factors for sudden cardiac arrest include tobacco, exercise, family history, serum CRP, excess alcohol intake, caffeine, and fatty acids. The examiner noted a detailed review of the service treatment records, as well as the appellant's October 2018 statements and her hearing testimony, including but not limited to her report that the Veteran experienced symptoms of fatigue, and swelling of the neck, legs, and feet. The examiner opined that it is difficult to ascertain the cause of fatigue given the lack of medical documentation, and that it could have been due to a host of possible etiologies, including: congestive heart failure, COPD, sleep apnea, abnormal thyroid, chronic renal or hepatic disease, electrolyte abnormalities, anemia, malignancy, infectious disease, rheumatologic conditions, multiple sclerosis, depression, anxiety, somatization, medications, and substance use. Regarding depression or anxiety in particular, the examiner noted that in October 2018, the appellant reported possible PTSD or depression. Regarding the appellant's report of swelling, the examiner noted that typical symptoms associated with cardiac edema are abdominal and peripheral congestion, which is found in congestive heart failure. The examiner noted that edema more generally can be due to a number of etiologies, including: congestive heart failure, deep vein thrombosis, muscle strain or tear, lymph obstruction, complex regional pain syndrome, venous insufficiency, thrombophlebitis, cellulitis, baker's cyst, medication side effect, nephrotic syndrome, hepatic disease, neoplasm constrictive pericarditis, or malnutrition. The examiner noted, however, that the Veteran's medical records are silent for congestive heart failure diagnosis. Regarding the neck swelling in particular reported by the appellant, the examiner noted that although patients with cardiac edema may have elevated jugular venous distension, there is no indication that a cardiac condition can contribute to "neck swelling." Rather, the examiner noted that causes of neck swelling include: lymphadenopathy, brachial cleft cyst, thyroglossal duct cyst, vascular tumors or malformation, laryngocele, retention cyst, dermoid cyst, and carcinomas. Regarding the appellant's report that the Veteran had loss of bladder control ("urinated himself"), sweating, and unconsciousness, the examiner noted that typically with a myocardial infarction, there is no loss of bowel or bladder control. Rather, the examiner noted that loss of bowel or bladder control is typically seen in a neurologic condition including a cerebral vascular accident or seizure. The examiner noted that although it is unknown whether the Veteran had a neurologic cause to his death due to the lack of available medical records, a neurologic etiology was a possibility. In September 2021, the Board remanded the claim for an additional VA medical opinion to address whether the cause of the Veteran's death was a cardiovascular condition other than ischemic heart disease, and if so, whether it was attributable to his active service. A September 2021 VA medical opinion shows the examiner opined it is less likely than not that the Veteran had a cardiovascular disease other than ischemic heart that was caused by his active service. The examiner noted a review of the medical records, and reasoned that the Veteran had no documented cardiac history/diagnoses during service or post-service, and there was no indication that the Veteran had any underlying cardiac condition. The examiner further reasoned that the March 1971 separation examination was silent for any problems and showed a normal heart exam. Regarding the Veteran's complaint of indigestion in service, the September 2021 VA examiner noted that according to UpToDate, indigestion/abdominal pain could be due to a number of etiologies, including: abdominal aortic aneurysm, mesenteric ischemia, perforation of the gastrointestinal tract, acute bowel obstruction, volvulus, myocardial infarction, appendicitis, biliary disease, pancreatitis, diverticular disease, gastroenteritis, foodborne illness, inflammatory disease, hepatitis, irritable bowel syndrome, urinary tract infection, nephrolithiasis, testicular torsion, alcoholic ketoacidosis, pneumonia, pulmonary embolism, splenic rupture, medications, intoxication, sphincter relaxation, hypotensive lower esophageal sphincter, hiatal hernia, neoplasm, infectious mononucleosis, rocky mountain spotted fever, H. Pylori, spider bite, thoracic nerve root dysfunction, pheochromocytoma, obesity, dietary intake (chocolate, fat, peppermint, caffeine, alcohol). Although the examiner acknowledged that myocardial infarction is noted as a potential cause for gastrointestinal symptoms per UpToDate, the examiner noted the Veteran was never diagnosed with myocardial infarction at any time. Rather, the examiner noted that the Veteran had indigestion symptoms in 1970, the subsequent separation examination report was silent for complaint, including no notation of any medication for indigestion, and therefore his symptoms presumably resolved. The examiner added that the Veteran's death occurred nine years after his reported indigestion. Therefore, the examiner opined it is less likely than not that the complaints of indigestion in service were associated with a cardiac condition. Regarding the headaches in service, the September 2021 VA examiner noted the Veteran was diagnosed in 1970 with tension headaches, and that headaches do not equate with cardiac diagnoses. The examiner noted that tension headaches are the second most prevalent disorder in the world according to UpToDate. Regarding the symptoms of fatigue and swelling reported by the appellant, the examiner echoed the list of possible causes noted by the June 2021 VA examiner, and the opinion that it is difficult to ascertain the cause of the fatigue given the lack of medical documentation, and noting the appellant reported possible PTSD or depression and a lack of energy. Regarding the swelling, the examiner echoed the opinion of the June 2021 VA examiner that although cardiac edema can be caused by congestive heart failure, there was no evidence in this case of congestive heart failure. Regarding the neck swelling specifically, the examiner was in agreement with the prior examiner that neck swelling cannot be caused by a cardiac condition. The examiner added that additional causes of the preceding subjective symptoms include: brain tumor, cerebral hemorrhage, hepatitis, arteriovenous malformation, cerebral aneurysm, traumatic brain injury, sleep apnea, laryngocele, thyroglossal duct cyst, thyroid abnormalities, and lymphadenopathy, but noted that there was no known cardiac etiology/diagnosis per review of the available medical records. The examiner noted a detailed review of the records and ultimately opined that the potential list of etiologies for the Veteran's cause of death are numerous, but there is no indication that it was due to a cardiac cause, and therefore, the cause of the Veteran's death it is less likely than not due to cardiac etiology. In light of the above evidence of record, the Board finds that the weight of competent and credible evidence is against finding that any disability incurred in or aggravated by service, including any cardiovascular disease, caused or contributed substantially or materially to the Veteran's death. The Board finds the above noted June 2021 and September 2021 VA examiners' opinions to be the most probative opinions of record because they are supported by very detailed rationales and are consistent with the contemporaneous medical evidence of record. The Veteran's separation examination report shows no cardiovascular complaint, and examination of his heart was normal. There is no post-service record of treatment for any cardiovascular complaint or diagnosis. There is otherwise no medical opinion of record tending to link the cause of the Veteran's death to his active service. To the extent that the appellant, as a lay person, opines that the Veteran's death was caused by his active service, the Board ultimately finds the medical opinions of the VA examiners to be more probative based on the examiners' detailed rationale, and based on their medical training, expertise, and credentials. See King v. Shinseki, 700 F.3d 1339 (2012); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board has carefully reviewed all of the articles submitted by the appellant, but none of these articles relate specifically to the Veteran and serve to etiologically link his cause of death to his active service. While it may be so that "cardiac arrest" is more of a mechanism of death and should not be listed on death certificates as a cause of death, unfortunately, in this particular case, the cause of death was listed as cardiac arrest, and no further cause was noted on the death certificate. See Correspondence, December 2020. The Board is sympathetic to the appellant's loss. But unfortunately, there is no medical opinion of record, and no medical treatment records, that tend to etiologically link the Veteran's cause of death in 1979 to his active service. Therefore, in summary, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for the cause of the Veteran's death; the benefit of the doubt rule is not for application. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Juliano, 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.