Citation Nr: 21024532 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 14-00 643 DATE: April 23, 2021 REMANDED Entitlement to service connection for the cause of the Veteran’s death is remanded. REASONS FOR REMAND The Veteran had active service from May 1948 to May 1952 and from January 1954 to April 1955. He died in September 2011. The appellant is his surviving spouse. In a January 2012 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied the appellant’s claim for service connection for the cause of the Veteran’s death. The appellant appealed that denial to the Board of Veterans’ Appeals (Board). In September 2014 the appellant had a Board videoconference hearing before the undersigned Veterans Law Judge. In June 2015, March 2020, and January 2021, the Board remanded the claim to the RO for additional VA medical opinions. The appellant contends that the Veteran’s service-connected disorders caused or contributed to causing his death. A certificate of death for the Veteran, as amended by the certifying physician, provided myocardial infarction and congestive heart failure as the immediate cause of his death. For other significant conditions contributing to death but not resulting in the underlying cause, the certifier listed Raynaud’s syndrome, posttraumatic stress disorder (PTSD), cold injury, and residuals of cold injury. During the Veteran’s life VA established service connection for his Raynaud’s phenomenon, PTSD, cold injury residuals, and hearing loss. The appellant’s specific contentions include her contention that the Veteran’s PTSD contributed to causing his death. In the September 2014 Board hearing and in written statements she explained that manifestations of his PTSD included a severe startle response, triggered when he was surprised by a person’s approach, particularly when he was approached from behind. The appellant stated that the Veteran’s service-connected hearing loss increased the likelihood that he would be caught unaware of a person’s approach. The appellant reported that, a month or less before the Veteran’s death, a remodelling project began at their home. She stated that workers passed behind the Veteran’s chair multiple times each day. She related that the Veteran had an exaggerated startle response each time. She reported that sometimes this became so troubling that he had to go lie down in another room. VA clinicians provided opinions regarding the Veteran’s cause of death in October 2015 and June 2020. In 2016 and 2020 the appellant submitted medical articles in support of the claim. In the January 2021 remand, the Board sought medical opinion regarding the contention that the Veteran’s PTSD-related startle reactions contributed to causing his death from myocardial infarction. In a February 2021 opinion a VA physician addressed that question. In opining that it is less likely than not that the Veteran’s startle response contributed to causing his myocardial infarction, the physician relied in part on his medical literature search having produced no medical articles indicating that PTSD startle reactions can contribute to causing myocardial infarction. In March 2021 the appellant again submitted medical articles. A 2014 article from the journal Cardiology, which was not previously submitted to VA, and which indicates that PTSD increases the risk of coronary heart disease and the prevalence of myocardial infarction. The Board is remanding this case again for further medical opinion that includes consideration of that article. The matters are REMANDED for the following action: (Continued on the next page)   1. Provide the claims file to an appropriate clinician for review and opinion as to possible contributions to the cause of the Veteran’s September 2011 death, which had as its immediate causes myocardial infarction and congestive heart failure. Ask the reviewer to specifically review and discuss the article Posttraumatic Stress Disorder and Cardiometabolic Disease, by A. Bradley Levine and others, published in Cardiology in 2014 and associated with the Veteran’s claim file in March 2021. Ask the reviewer to provide an opinion as to whether it is at least as likely as not that the Veteran’s PTSD, with manifestations included frequent startle reactions, particularly around the time of his death, contributed substantially or materially to causing his death, combined to cause his death, or aided or lent assistance in producing his death. Ask the reviewer to provide clear and thorough explanation of all conclusions and opinions. 2. Then review the expanded claims file and review the remanded claim. If the claim remains denied, issue a supplemental statement of the case, and allow the appellant and her representative to respond. Then return the case to the Board for appellate review, if otherwise in order. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. J. Kunz, 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.