Citation Nr: 21026910 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 15-20 944 DATE: May 4, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or on the account of by reason of being housebound is denied. FINDINGS OF FACT 1. The cause of the Veteran's death developed many years after service and was not the result of a disease or injury incurred in active service. 2. The appellant is not in receipt of Dependency and Indemnity Compensation (DIC) benefits. CONCLUSIONS OF LAW 1. The criteria for service connection for the cause of the Veteran's death are not met. 38 U.S.C. §§ 1110, 1131, 1310, 5103, 5103A, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.312 (2019). 2. The criteria for SMC based on the need for regular aid and attendance or by reason of being housebound have are not met. 38 U.S.C. §§ 1114, 5107 (2018); 38 C.F.R. § 38 C.F.R. §§ 3.351, 3.352 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1971 to November 1972, and from July 1973 to December 1975. He died in June 2010, and the appellant is his surviving spouse. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In July 2018, the appellant withdrew her request for a Board hearing. In August 2018 and May 2020, the Board remanded the claims for additional development. The case has since been returned to the Board for further appellate review. Service Connection Cause of Death The Veteran's death certificate indicated that the immediate cause of his death was congestive heart failure. During his lifetime, he was service connected for posttraumatic stress disorder (PTSD), rated at 100 percent since May 2003. He had no other service-connected disabilities. The appellant maintains that the Veteran's death was due to exposure to Agent Orange while stationed in Vietnam and Korea. She asserts that his diabetes mellitus and heart disease, presumed to be associated with Agent Orange exposure, contributed to his death. Alternatively, she maintains that his heart disease was caused and/or aggravated by his service-connected PTSD. A March 2009 private treatment record indicated that the Veteran was admitted to the hospital with an altered mental status, which was apparently due to problems with polypharmacy. It was noted that he was on a bunch of medications for anxiety as well as chronic pain complaints. Associated with this, he reported problems of an inability to void and there was evidence of urinary retention. It was also noted that he had early diabetic nephropathy with fairly well-preserved function but significant proteinuria. Treatment was centered on optimization of blood pressure control. In April 2009, a private treatment record indicated that the Veteran was admitted to the hospital with altered mental status. Pictures of decubitus ulcers were taken. He was given fluids and antibiotics. Echocardiogram revealed normal left ventricular function. He eventually left against medical advice to go home. A May 2009 private treatment record indicated that the Veteran was admitted to the hospital for pneumonia. It was also noted that he had chronic renal failure, coronary artery disease, Type 2 diabetes, and chronic sacra decubitus ulcer. He was treated with antibiotics and eventual clearing of his lungs. A September 2009 private treatment record indicated that the Veteran was admitted to the hospital for treatment of congestive heart failure. He was given antibiotics and fluids were removed with Lasix. Wound care was also given for his ulcers. A January 2010 private treatment record indicated that the Veteran was admitted for a malfunctioning Groshong catheter. It was noted that he had multiple medical problems, including bipolar disorder, and that during one of those episodes it was believed he had pulled out the catheter and had fractured it well outside the chest wall. The catheter was repaired. A June 2010 private treatment record indicated that the Veteran's wife reported that he had locked himself in the home, was combative, and threatening her. He had not taken his medication for two to three days, including his psychiatric medications, and then took two days' worth of pills at once. His wife stated that she was not able to get him in with various nursing homes and requested help. A June 2010 private treatment record indicated that the Veteran was being treated for chronic kidney disease, stage IV. It was noted that had diabetic nephropathy and hypertension along with a history of congestion heart failure. He was admitted to the hospital with bilateral foot ulcers and uncontrolled diabetes due to infection. It was also noted that he had some mental status changes and had been more agitated recently, was getting worse, and that he was aware his wife could not handle him. It was also noted that he continued to smoke one pack per day. A chest X-ray showed no evidence of acute pulmonary or pleural disease. In a January 2011 letter, a private physician, Dr. J.W., opined that he felt the Veteran's exposure to Agent Orange during service in Vietnam was a contributing factor in the development of his medical conditions, to include asthma, PTSD, and renal insufficiency. He did not provide any rationale for his opinion. Furthermore, as explained below, there is no evidence that the Veteran served in Vietnam or was otherwise exposed to Agent Orange during service. Therefore, the opinion has no probative value. The appellant has also submitted medical journal articles in support of her claim. A November 2009 article, entitled "Excess heart-disease-related mortality in a national study of patients with mental disorders: identifying modifiable risk factors", indicated that patients with psychoses were more likely to die from heart disease, and suggested that early interventions that promote smoking cessation and physical activity among veterans with psychotic disorders was warranted. A June 2012 article, entitled "Post-traumatic Stress Disorder: A Fast Track to Premature Cardiovascular Disease?", noted that an increasing body of evidence reported in the literature indicated a possible role of PTSD as a cause for cardiovascular disease but that mechanistic evidence was lacking. The authors surmised several possible potential paths by which cardiovascular disease could occur in individuals with PTSD, noting that research was exceeding limited and that it was the hope that further research would be conducted. In July 2012, the appellant submitted information from the Mayo Clinic's website, which noted that diabetes mellitus dramatically increased the risk for various cardiovascular problems, including coronary artery disease. In April 2020, the appellant submitted an article from PTSD Research Quarterly entitled "Posttraumatic Stress Disorder and Cardiovascular Disease." The article noted that numerous population-based studies had demonstrated that patients with PTSD were more likely to develop and die from cardiovascular disease. It was noted that despite those studies, professional cardiovascular societies had not officially recognized PTSD as a cardiovascular risk. The article also noted one study, which indicated that patients with PTSD were more likely to have coronary artery calcium deposits and a higher coronary artery calcium score, suggesting a greater burden of atherosclerotic heart disease. Another study measured blood flow to the heart in twin pairs, noting that twins with PTSD had an increased risk of cardiovascular heart disease over 13-years of follow-up, and decreased myocardial perfusion after pharmacologically induced vascular stress. Regarding possible mechanisms, the authors noted that numerous studies found evidence of increased inflammatory biomarkers in patients with PTSD and that one study showed impacts of stress on autonomic function and detailed how those changes could interact to cause cardiovascular disease. The authors noted that there was much work remaining to be done and that they had moved from an era of establishing an association between PTSD and cardiovascular disease to an era of elucidating the exact mechanisms and finding the best methods to prevent and control cardiovascular disease. In December 2016, a VA examiner reviewed the claims file and opined that it was less likely than not that the Veteran's service-connected PTSD substantially or materially contributed to his death or that it caused debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. He noted the Veteran's death certificate indicated that the immediate cause of death was congestive heart failure and that PTSD was not listed as a contributing condition. He further noted, that it was not clearly and consistently shown in the record that PTSD was a causal agent in the development of the conditions leading to death or that the Veteran's mental health condition impaired his ability to understand, participate, or benefit from care such that the condition was grossly agitated beyond its natural progression and thus expedited death. The examiner noted that in such circumstances, the records would typically reflect a series of ongoing urgent referrals from medical to mental health and joint collaborative planning with the chief stated goal of treating mental illness so that they could access and benefit from care for life-threatening conditions. The examiner stated that none of that was present in this case. The examiner also noted that documents were submitted showing a correlation between mental health/PTSD and medical issues/heart failure but that the research was correlational and not causational. It reflected the host of potential risk factors for conditions, not a singular cause. The examiner further stated that there would have to be substantial veteran-specific evidence within the records. The examiner noted that records in 2010 noted extreme isolation/avoidance and concerns for self-harm/safety. It was also noted that the Veteran's refusal to cooperate and/or leave the house compounded efforts to get him care. The examiner stated had that data been a common theme across all post-military separation medical and mental health records, and medical professions indicated a direct causal effect, it would have provided some support for the claim. The examiner, however, stated that it appeared more isolated in the degree in which it impacted access to care and there was nothing to suggest that that singular event caused heart failure or that the delay in care caused early death. The examiner stated that the majority of his medical records did not cite mental health as the primary cause for medical conditions nor as grossly and irreversibly worsening medical conditions beyond their natural progression. The examiner cited medical records in the claims file to support his opinion. The December 2016 VA examiner, a psychologist, stated that he could not provide an opinion as to the potential effects of medication to treat PTSD on any other disorder because he was not a physician and it was outside his area of competence. In August 2018, the Board remanded the claims to obtain an additional VA medical opinion from a physician. In April 2019, a VA examiner reviewed the claims file and opined that the Veteran's PTSD was less likely than not a cause or contributing factor in his death through congestive heart failure. The examiner noted that congestive heart failure occurs when your heart muscle does not pump blood as well as it should and that certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently. The examiner stated that PTSD did not affect how the heart muscle pumps blood or the ejection fraction and was not an aggravating condition for congestive heart failure. In addition, the April 2019 VA examiner opined that the Veteran's congestive heart failure was at least as likely as not proximately due to or aggravated beyond its natural progression by diabetes and coronary artery disease. However, the examiner, a physician's assistant, did not provide an opinion as to whether the medication used to treat the Veteran's service-connected PTSD caused or contributed to his death through chronic heart failure. In May 2020, the Board remanded the claims to obtain an additional VA medical opinion by a physician to address whether the Veteran's medication used to treat his service-connected PTSD caused or contributed to his death, to include aggravating his chronic heart failure. In March 2021, a VA examiner, a staff physician, reviewed the claims file and opined it was less likely as not that the medications used to treat the Veteran's service-connected PTSD were a contributory cause of death, including through aggravation of his congestive heart failure. The examiner noted that the Veteran was being treated with Celexa and Prozac, which were serotonin reuptake inhibitors (SSRIs). The examiner noted that a VHA cohort study found no elevation in risks of cardiac mortality, including congestive heart failure, in individuals taking Celexa (citalopram). The examiner also cited to a study which noted that in depressed patients with heart disease, Prozac (fluoxetine) treatment was not associated with the cardiovascular effects documented for the tricyclic antidepressants or with significant adverse cardiac events. The VA examiner also opined that the Veteran's PTSD was less likely as not a contributory cause of death, including through the aggravation of his congestive heart failure. The examiner noted that the Veteran's congestive heart failure and subsequent cause of death was more likely than not a result of his long-standing smoking history. It was noted that he had smoked one to four packs per day for over 40 years. The examiner noted that current smokers have 182 percent increased risk of chronic heart failure, and that individuals who smoked 20 or more cigarettes per day, such as the Veteran, had a 248 percent increased risk of chronic heart failure. The VA examiner cited several studies to support his opinion. He also addressed the articles submitted by the appellant and her attorney, which revealed an association between PTSD and cardiovascular disease. The examiner noted that those articles did not adjust for non-PTSD mental illnesses and/or antipsychotic and anticonvulsant/mood stabilizer medications. The examiner addressed each article and explained the limitations of those studies, e.g., the study did not adjust for comorbid psychiatric diagnoses, the study showed correlation but not causation, and the study failed to adjust for current tobacco use or other traditional risk factors. The examiner noted that one scientific article submitted by the appellant did adjust for comorbid psychiatric diagnoses and that study identified no association between PTSD and cardiovascular disease. The examiner stated that the scientific literature that controlled or adjusted for comorbid psychiatric diagnoses and psychotropic medications did not demonstrate a causal relationship between PTSD and cardiovascular disease. In this case, the Board will first address whether the Veteran's diabetes mellitus and/or coronary artery disease were related to service. As noted above, the April 2019 VA examiner opined that the Veteran's congestive heart failure was at least as likely as not proximately due to or aggravated beyond its natural progression by diabetes and coronary artery disease. Furthermore, the appellant argues that those conditions were related to exposure to Agent Orange during military service in Vietnam and Korea. Although the Veteran was diagnosed with diabetes and coronary artery disease, the evidence does not indicate that those conditions manifested in service or within a year of separation from service, or that the Veteran was exposed to Agent Orange during service. The Veteran's service treatment records are unremarkable for any complaints, treatment, or diagnoses related to diabetes mellitus, coronary artery disease, or congestive heart failure. His November 1975 discharge examination indicated that his heart, vascular system, and endocrine system were normal. His urinalysis was negative for sugar and albumin. On his Report of Medical History, he denied having any heart trouble and having any sugar or albumin in his urine. Post-service, a March 2001 VA treatment record noted that the Veteran reported that he was diagnosed with diabetes in 1993. In March 2000, a private physician indicated that the Veteran had never had any cardiac problems to his understanding. A March 2001 VA treatment record noted a diagnosis of coronary artery disease. Regarding Agent Orange exposure, the evidence does not indicate that the Veteran served in the Republic of Vietnam. Although he served in the Republic of Korea from October 1971 to November 1972, and from July 1973 to July 1974; only veterans who served from April 1968 to 1971 in a unit that operated in or near the Korean Demilitarized Zone may be presumed to have been exposed to herbicides. The evidence does not indicate that the Veteran served in Korea during that time period or that he was otherwise exposed to Agent Orange during service. Based on the foregoing, the evidence does not indicate that the Veteran's diabetes mellitus or coronary artery disease manifested during service or within one year of separation from service, or that the conditions were otherwise related to service. Therefore, service connection for the cause of his death based on the premise that his diabetes mellitus and/or coronary artery disease were related to service and cause or contributed to his death is not warranted. Next, the Board will address whether the Veteran's service-connected PTSD caused or contributed to his death, to include aggravation of his chronic heart failure, which was the immediate cause of his death. The evidence in favor of the claim primarily consists of medical articles submitted by the appellant, which show a relationship between PTSD and cardiovascular disease. With regard to medical treatise evidence, such evidence "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, however, the medical articles submitted by the appellant are not accompanied by a medical opinion of a medical professional. In addition, they fail to demonstrate with any degree of certainty that the Veteran's PTSD caused or aggravated his coronary artery disease or congestive heart failure. The March 2021 VA examiner address those articles in detail and noted their limitations, specifically with respect to showing causation rather than correlation and the lack of consideration for comorbid conditions or other risk factors. In this particular case, the VA examiner noted that the Veteran has a significant smoking history, which likely caused or aggravated his coronary artery disease and/or congestive heart failure. Furthermore, the record notes other risk factors for cardiovascular disease specific to the Veteran, such as obesity, hypertension, diabetes mellitus, and family history. In this case, the medical articles are too general and do not provide information specific enough to draw a conclusion that the Veteran's PTSD caused or aggravated his cardiovascular disease, especially in light of other risk factors. For this reason, the Board finds the medical articles lack probative weight. The evidence against the claim primarily consists of VA medical opinions provided in December 2016, April 2019, and March 2021, which all indicated that it was less likely than not that the Veteran's PTSD caused or contributed to his death. While the December 2016 and April 2019 opinions were not provided by a physician and limited to a degree as to their probative value, the Board notes that the March 2021 VA examiner was provided by a physician as directed in the Board's May 2020 remand. The March 2021 VA examiner opined that it was less likely than not that the Veteran's PTSD or the medication used to treat his PTSD caused or contributed to his death, to include aggravation of his chronic heart failure. The VA examiner reviewed the claims file, considered the appellant's contentions, and provided rationale for his opinion. Therefore, the Board finds the opinion significantly probative. Furthermore, there are no medical opinions to the contrary. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for the cause of the Veteran's death is not warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Special Monthly Compensation (SMC) The appellant maintains that she is entitled to a higher rate of DIC benefits because she requires the regular aid and attendance of another person and/or is housebound. In her October 2010 application for benefits, she indicated that she had had three back surgeries, three hip surgeries, and was unable to do a lot of things any longer. In a March 2009 letter, a private physician, Dr. T.K., indicated that he had treated both the Veteran and his spouse, and that due to their severe medical conditions, they were both permanently disabled. Where DIC is in place, a surviving spouse may be entitled to a higher monthly rate (SMC) of DIC by reason of being housebound or based on the need of regular aid and attendance. 38 U.S.C. § 1311; 38 C.F.R. § 3.351. In this case, however, the appellant is not in receipt of DIC benefits. As explained above, the Board has denied DIC benefits based on service connection for the cause of Veteran's death. Moreover, the evidence does not indicate that she receives or is entitled to receive DIC benefits pursuant to 38 U.S.C. § 1318. Therefore, she does not meet the basic eligibility criteria for an award of SMC. Accordingly, the claim is denied as matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.