Citation Nr: 21007661 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 12-27 485 DATE: February 10, 2021 ORDER Entitlement to service connection for residuals of triple bypass surgery (including CAD), as secondary to hypertension, is denied. FINDING OF FACT The Veteran’s residuals of triple bypass surgery, including coronary artery disease, were not caused or aggravated by his service-connected hypertension. CONCLUSION OF LAW The criteria for entitlement to service connection for residuals of triple bypass surgery, including coronary artery disease, claimed as secondary to hypertension, are not met. 38 U.S.C. § 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from January 1967 to December 1970 and from September 1985 to October 1997 with additional periods of active duty for training. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision (RD) of a Regional Office (RO) of the Department of Veterans Affairs (VA) in New York. The Veteran timely filed his October 2012 Form 9 appeal and the Board issued a March 2015 and June 2017 remand for additional development and in January 2019 issued a decision denying the claim for residuals of triple bypass surgery, including coronary artery disease, as secondary to his service-connected hypertension. In October 2019, the U.S. Court of Appeals for Veteran’s Claims (CAVC) granted a joint motion for remand (JMR) stating the Board relied upon an inadequate VA examination in support of its decision because the examiner applied the wrong standard for secondary service connection. The Board remanded the case in April 2020 for an addendum medical opinion, the RO issued a September 2020 supplemental statement of case (SSOC) and the case was returned to the Board for adjudication. 1. Entitlement to service connection for residuals of triple bypass surgery, including CAD, as secondary to hypertension The Veteran contends that his residuals of triple bypass surgery, including his diagnosis of coronary artery disease (CAD) is due to his service-connected hypertension. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progression by, a service-connected disability. The Veteran was diagnosed with coronary artery disease (CAD) in September 2003 and underwent triple bypass surgery in December 2003. See August 2017 VA Examination. The Board finds that the Veteran has a current disability of residuals of triple bypass surgery, including CAD. However, while the Board finds that the Veteran has a current disability, the preponderance of the evidence is against finding that the Veteran’s residuals of triple bypass surgery, including CAD, is proximately due to, the result of, or aggravated beyond its natural progression by, his service-connected hypertension. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The August 2017 VA examiner opined that the Veteran’s residuals of bypass surgery, including his CAD, was less likely than not caused or aggravated by his hypertension. See August 2017 VA Examination. The examiner explained that coronary artery disease is multifactorial and often develops over decades. There are many risk factors including, but not limited to aging, family history of heart disease, smoking, hypertension, hyperlipidemia, diabetes mellitus, sedentary lifestyle, and obesity. Further, he stated he could not determine the extent the Veteran’s hypertension played a role in developing his CAD; however, as the Veteran reported he was taking hypertension medication and his blood pressure was controlled it would have no significant effect on his CAD. Id. The June 2020 VA examiner indicated that the Veteran’s CAD was caused by plaque build up in the coronary arteries. See June 2020 VA Examination. He opined that the Veteran’s residuals of bypass surgery, including his CAD, was less likely than not proximately due to, or the result of his hypertension. See June 2020 VA Examination. In support of his opinion he stated that current medical literature identifies multiple factors contribute to the pathogenesis of atherosclerosis, including endothelial dysfunction, dyslipidemia, inflammatory, and immunologic factors, plaque rupture, and smoking. While hypertension is listed as one risk factor for development of CAD, there is no credible medical evidence to support causation and therefore a nexus could not be established. Id. In addition, the VA examiner opined that the Veteran’s residuals of bypass surgery, including his CAD, was not aggravated beyond its natural progression by his hypertension. In support of his opinion, the examiner explained that current medical literature does not support the suggestion that the Veteran’s claimed condition CAD is subject to possible aggravation, beyond the natural progression, by his hypertension. The Veteran’s medical treatment records indicated that the Veteran’s hypertension had been well controlled with medications and therefore there is no mechanism for aggravation. Id. The examiner also provided medical citations in support of his opinions. Id. Arteriosclerotic heart disease (coronary artery disease) is rated as a disease of the heart in accordance with 38 C.F.R. § 4.104, diagnostic code 7005. The Veteran’s service-connected hypertensive vascular disease (hypertension) is rated as a disease of the arteries and veins. 38 C.F.R. § 4.104, DC 7101. Under DC 7101, note 3 instructs that hypertension must be evaluated separately from hypertensive heart disease and other types of heart disease. The rating schedule considers Veteran’s hypertension a different type of heart disease then his CAD and related to different anatomical systems. Although hypertension may be a risk factor for CAD, the evidence of record indicates that the Veteran’s hypertension was under control with medication. While the Veteran believes his residuals of bypass surgery, including CAD is proximately due to, or aggravated by, his service-connected hypertension, the preponderance of the evidence weighs against finding his CAD is secondary to his hypertension. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body, pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Although the Veteran contends that his private physician told him that his CAD was caused by his years of high blood pressure, the medical evidence of record does not support this contention. See October 2012 Form 9 Appeal, June 2009, August 2009 Private Medical Treatment Records. Consequently, the Board gives more probative weight to the August 2017 and June 2020 VA examinations. The Board finds that the Veteran’s CAD was not proximately due to, or aggravated by, his service-connected hypertension. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim of entitlement to service connection for residuals of bypass surgery, including CAD, as secondary to hypertension, must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Aubee, 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.