Citation Nr: 21009338 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 13-08 196 DATE: February 22, 2021 ORDER Entitlement to service connection for residuals of a heart attack as secondary to a service-connected right shoulder disability is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s residuals of a heart attack were proximately due to or aggravated by his service-connected right shoulder disability. CONCLUSION OF LAW The criteria for service connection for residuals of a heart attack as secondary to a service-connected right shoulder disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1975 to February 1976. This case is before the Board of Veterans’ Appeals (Board) on appeal from August and September 2009 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded for additional development in January 2017 and December 2018 Board decisions. The Board finds that there has been substantial compliance with those remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand); see also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board’s remand directives is required under Stegall). The Board observes that additional VA treatment records were received following the last adjudication by the RO in the May 2020 supplemental statement of the case (SSOC). The Board has reviewed these records and find that they are not pertinent to the issue of service connection for residuals of a heart attack secondary to a service-connected right shoulder disability. Therefore, a waiver is not necessary, and the Board will proceed with adjudication of the issue on appeal. Entitlement to service connection for residuals of a heart attack as secondary to a service-connected right shoulder disability. A disability that is proximately due to, or results from, another disease or injury for which service connection has been granted, will be considered part of the original disorder. 38 C.F.R. § 3.310(a). Moreover, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b). To establish secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 511 (1998). With regards to aggravation, the Board notes that “any incremental increase in disability and additional impairment of earning capacity in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence” constitutes aggravation. Ward v. Wilkie, 31 Vet. App. 233 (2019). Therefore, in a secondary service connection claim aggravation does not need to be permanent in nature. The Veteran contends that his residuals of a heart attack are secondary to his service-connected right shoulder disability, to include the associated surgical residuals. Specifically, the Veteran claims that as a result of his January 2008 surgery on his right shoulder, he experienced stress associated with the severe pain, both mental and physical and that the heart attack he experienced in February 2009 was secondary to those residuals. See February 2010 Notice of Disagreement. The Veteran does not contend that his residuals of a heart attack began during service. Initially, the Board notes that the record reflects myocardial infarctions in 2004 and 2009, currently diagnosed coronary artery disease (CAD), as well as noting that the Veteran is status post intracoronary stent placements in 2009. See November 2017 VA examination. Therefore, the currently disability element of the claim is established. Further, the Veteran is currently service connected for a right shoulder disability. Historically, the record reflects that in January 2008, the Veteran underwent a right shoulder rotator cuff repair. Post operatively, medical records reflect a protruding suture and drainage from the incision site which abated for the most part although occasionally he had some burning in the skin in that area. See October 2008 VA treatment record. A November 2008 MRI showed a recurrent residual or new full thickness rotator cuff tear. The Veteran has reported chronic pain in his right shoulder since he first injured it in 2006 including both before and after his January 2008 rotator cuff repair surgery. See October 2008 VA treatment records. The remaining question is whether the Veteran’s residuals of a heart attack are proximately due to or aggravated beyond their natural progress by his service-connected right shoulder disability. In this regard, the Board finds that the preponderance of the evidence is against finding that the Veteran’s residuals of a heart attack are secondary to his right shoulder disability. The VA examiner, Dr. G., determined that the Veteran’s 2009 heart attack and subsequent residuals were less likely than not caused or aggravated beyond their natural progression by his right shoulder disability, to include any residuals associated with the January 2008 shoulder surgery, such as mental and physical stress and/or severe pain. See December 2017 and October 2019 VA opinions. Dr. G. explained that his right shoulder disability was tendonitis coupled with shoulder tears and stated that there was no nexus between this type of shoulder disability and a heart attack. Instead, Dr. G. opined that the Veteran’s CAD which was first diagnosed in 2004, was the “most likely” cause of his 2009 heart attack. The VA examiner noted that she consulted with a cardiologist who concurred that the Veteran’s 2009 heart attack was most likely due to the natural progression of his underlying coronary artery disease in the setting of his already known risk factors. Specifically, Dr. G. explained that when one has CAD, the blood vessels that supply blood to the heart itself become narrowed due to plaque deposition which interferes with adequate oxygenation and blood and nutrients being delivered to the heart which results in heart attacks due to the fact that the demand outweighs the supply. Dr. G. noted that the Veteran’s CAD resulted in insufficient oxygen and blood circulating to his coronary heart arteries resulting in his first heart attack in 2004 which was so severe that he had to undergo emergent intracoronary stenting. See December 2017 and October 2019 VA opinions by Dr. G. Additionally, Dr. G. reasoned that the Veteran clearly had the cardiovascular risk factors already in place for his past two heart attacks and is still at risk of additional heart attacks due to these risk factors which include: being overweight, high cholesterol, high blood pressure, high blood sugar (diabetes mellitus), hyperlipidemia (high triglycerides), and lastly, chronic obstructive pulmonary disease (COPD) which requires oxygen. See December 2017 and October 2019 VA opinions by Dr. G. Further, Dr. G. opined that the Veteran’s 2009 heart attack and subsequent residuals were less likely as not aggravated by any stress and pain from his right shoulder disability, including his 2008 right shoulder surgery. In making this determination, Dr. G. examined the medical records concerning the Veteran’s right shoulder surgery in 2008. She noted that the only residual from this right shoulder surgery was subjective ongoing pain and a rocky post-operative course with a stitch protruding through the wound incision. The stitch was removed with local anesthetic and sterile precautions. See February 2008 VA treatment records from the Spokane VAMC. Prior to his right shoulder surgery, Dr. G. noted that the medical records reflected that the Veteran’s right shoulder caused him pain and he was taking medication for pain management. Essentially, Dr. G. acknowledged that the Veteran experienced pain in his right shoulder both prior to and after his 2008 right shoulder surgery; however, she opined that it was less likely as not that his right shoulder pain and mental stress from the pain, aggravated or heightened his risk of having a heart attack. In summary, Dr. G. found that the Veteran’s prior heart attack in 2004 coupled with his multiple cardiovascular risk factors were the most likely culprits for his 2009 heart attack. She explained that it was less likely as not that any pain or stress from his right shoulder surgery resulted in or contributed to his heart attack or subsequent residuals. See October 2019 VA opinion. The Board affords Dr. G.’s opinion significant probative weight. Dr. G. reviewed the claims file, including the records pertaining to the Veteran’s 2008 right shoulder surgery, as well as considering all other relevant risk factors specific to the Veteran that could have caused or aggravated his 2009 heart attack. She offered a thorough, detailed rationale and noted that in making her assessment, she had consulted with several internal medicine specialists, including many cardiologists. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; a threshold consideration is whether the person opining is sufficiently informed). The Veteran believes his heart attack and subsequent residuals were due to or aggravated by his service-connected right shoulder disability. However, in this case, the Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex and outside the competence of the Veteran as 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). Consequently, the Board gives more probative weight to Dr. G.’s medical opinion. Therefore, the Board concludes that the preponderance of the evidence is against finding that his residuals of a heart attack are proximately due to or aggravated beyond their natural progression by his service-connected right shoulder disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alison M. Mecone, 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.