Citation Nr: 21024651 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 17-09 978 DATE: April 23, 2021 REMANDED Service connection for heart disorder.   REASONS FOR REMAND The Veteran served on active duty from October 1980 to December 1983, including service at Camp Lejeune. The case is on appeal from a September 2015 rating decision. In March 2018, the Veteran testified at a Travel Board hearing. In a September 2018 decision, the Board reconsidered a previously denied claim of service connection for a heart disorder. At that time, the Board also remanded nine claims for further development. Other than the heart disorder issue, the other claims were all granted when the case was in remand status. Thus, it is the sole issue remaining on appeal. In September 2019, the Veteran perfected an appeal of a TDIU claim. As he requested a Board hearing, this issue will be addressed in the future, when in order. Service connection for a heart disorder. The Veteran seeks service connection for a heart disorder. He contends that his hypertension and coronary artery disease (CAD) are related to exposure to Camp Lejeune contaminated water (CLCW) or, alternatively, are secondary to his service-connected posttraumatic stress disorder (PTSD). There is no indication of a heart disorder upon entry to the military or during service, but the Veteran’s military records are incomplete. The Veteran’s service records demonstrate sufficient service at Camp Lejeune to qualify for the VA established presumption of exposure to contaminated water. See 38 C.F.R. § 3.30(a)(7). Hypertension and CAD are not entitled to presumptive service connection due to exposure to CLCW. 38 C.F.R. § 3.307(a)(7), 3.309(f). Yet, where a presumption does not exist, VA is to consider whether service connection is warranted on a direct basis. The Veteran was diagnosed with hypertensive heart disease in 2006. He has been treated with Metroprolol and Lisinoril, standard medications for hypertension. In December 2005 CAD was diagnosed based on a stress test which showed a small area of reversible ischemia. A September 2007 stress test showed that this small area was no longer present and there was overall improvement in the patient’s myocardial perfusion with excellent exercise tolerance. Notes in the file show unremarkable physical findings and stable blood pressure under continuous and regular treatment. In September 2012, Veteran’s diagnoses included hyperlipidemia and hypertension, for which medications were prescribed. A March 2014 physical notes a history of hyperlipidemia and hypertension with use of medication and a normal examination. The Veteran related that he had about ten episodes of chest pain in 2019. The Veteran has received multiple VA examinations. Most recently, in August 2020, a VA examiner opined that the Veteran’s heart disorder is less likely as not caused by or a result of the Veteran’s exposure to CLCW. The examiner noted the Veteran was diagnosed with hypertension and CAD more than twenty years after CLCW exposure. The examiner stated the Agency for Toxic Substances and Disease Registry shows no association between CLCW exposure and heart disease and no medical literature or epidemiological studies supports such an association either. The examiner indicated Veteran’s heart condition is essentially high blood pressure, which is not a condition that is associated with toxic solvent exposure, but is due to genetics, lifestyle choices, and, in most instances, completely of idiopathic origin. The August 2020 VA examiner’s medical opinion did not opine on a link between the Veteran’s heart disorder and service-connected PTSD, but he did cite two articles supporting a link between mental health problems, in particular depression and traumatic stress, and cardiovascular diseases. The articles indicate mental health problems are known to be associated with risk factors for cardiovascular diseases such as smoking, poor diet, and a sedentary lifestyle, but that these factors alone do not explain the increased risk for cardiovascular disease seen in depression, stress, and anxiety. Additionally, PTSD was identified as independently associated with increased risk for incident coronary heart disease, even after adjusting for depression and other covariates. Previously, in November 2019, the Veteran underwent a VA examination to evaluate whether the Veteran’s heart disorder is at least as likely as not proximately due to or the result of his service-connected PTSD. The VA examiner explained that mental health and cardiac conditions may be co-morbid, existing side by side, but one is not causative of the other. The VA examiner opined that the Veteran’s hypertension and CAD are less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. The VA examiner acknowledged the Veteran’s baseline level of severity of the condition was normotensive until diagnosis in 2006 and that the Veteran’s condition has worsened to hypertensive with CAD. However, the VA examiner stated the Veteran’s hypertension and CAD are a result of the commonly recognized risk factors, all of which occurred decades after military service, and none of which are influenced by PTSD. Also earlier, in November 2016, another VA examiner came to the same conclusion that the Veteran’s heart condition is less likely than not proximately due to or the result of the Veteran’s service-connected PTSD. She referenced a study by the National Center for PTSD which concluded that it was premature to draw any firm conclusions regarding a causative relationship between PTSD and cardiovascular disease. She recognized a great deal of data support PTSD is associated to coronary heart disease, but she also noted PTSD is associated with higher rates of cigarette smoking and may be associated with other traditional cardiovascular disease risk factors. She cited an editorial comment in the Journal of the American College of Cardiology pointing out that studies showing a link between PTSD and heart disease have been limited in their design and methodology. Even earlier, in July 2016, a different VA examiner opined that the Veteran’s heart condition is less likely than not due to or the result of the Veteran’s service-connected PTSD. She stated that although there is an increasing body of evidence that indicates PTSD is associated with major forms of cardiovascular disease, definitive evidence as to whether PTSD is a risk factor or cause of hypertension is still inconclusive. However, she also opined that the Veteran’s heart disorder was at least as likely as not aggravated beyond its natural progression by his PTSD. She stated persons suffering from PTSD and chronic PTSD have been shown to have increases in basal heart rate and blood pressure and increased heart rate and blood pressure in response to stimuli. Therefore, the VA examiner concluded it is at least as likely as not that the Veteran’s heart condition was at least as likely as not aggravated beyond its natural progression by his PTSD. Based on the contrary VA examiner opinions, the case is remanded to schedule a VA examination to resolve if Veteran’s hypertension or CAD are the result of the Veteran’s exposure to CLCW or caused or aggravated by his service-connected PTSD. In light of the remand, any outstanding treatment records should be obtained. Accordingly, the matter is REMANDED for the following action: 1. Ask the Veteran to identify and authorize VA to obtain any outstanding private treatment records relevant to his claim. The Veteran should return any authorizations to obtain such records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the heart disorder. Following a review of the record, the examiner should address the following: (a.) State whether it is at least as likely as not that the heart disorder had its onset during service, within one year of discharge, or is otherwise related to service, to include the Veteran’s presumptive exposure to contaminants in the water supply at Camp LeJeune. (b.) State whether it is at least as likely as not that the heart disorder is secondary to (caused by or aggravated by) the Veteran’s service-connected PTSD. “Aggravation” is an increase in severity beyond the natural progress of the disease. (Continued on the next page)   A complete explanation or rationale should be provided. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.L. Thomas 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.