Citation Nr: 21030269 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 14-32 118A DATE: May 18, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is granted. FINDINGS OF FACT 1. The Veteran died in January 2004; the immediate cause of his death was myocardial infarction, due to or as a consequence of coronary artery disease. 2. Competent evidence shows that, at least as likely as not, the Veteran's cause of death was etiologically related to his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW Service connection for the cause of the Veteran's death is warranted. 38 U.S.C. §§ 1131, 1310, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from June 1975 to October 1977. He died in January 2004, and the appellant is his surviving spouse. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2014 Department of Veterans Affairs (VA) rating decision. In November 2014, the appellant withdrew her request for a hearing before a Veterans Law Judge. A February 2019 Board decision denied service connection for the cause of the Veteran's death. The appellant appealed the Board's decision to the United States Court of Appeals for Veterans Claims (CAVC). A December 2019 CAVC Order granted a Joint Motion for Remand (JMR) of the parties, thereby vacating the Board's decision and remanding the case to the Board for further readjudication consistent with the terms of the JMR. The case has been returned to the Board. Entitlement to service connection for the cause of the Veteran's death The appellant contends that the Veteran's cause of death was due to his service-connected PTSD. She alleges that his fatal heart attack was related to his PTSD. She alternatively claims that the medication he took to treat PTSD led to a weight gain of over 100 pounds, which contributed to his death. When a veteran dies from a service-connected disability, the veteran's surviving spouse, children and parents are entitled to dependency and indemnity compensation. 38 U.S.C. § 1310. A death will be considered to result from a service-connected disability when the evidence establishes that such disability, which is causally related to service, was either the principal or a contributory cause of the veteran's death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(a). For a service-connected disability to constitute a principal cause of death, it must be shown to be the primary cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). For a service-connected disability to constitute a contributory cause of death, it must be shown that it contributed substantially or materially, that it combined to cause death, that it aided or lent assistance to the production of death; it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Alternatively, 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. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The question for the Board is whether the Veteran's cause of death was proximately due to, or aggravated beyond natural progress by, his service-connected PTSD, that is, whether PTSD was a principal or contributory cause of his death. Upon review of the record, the Board concludes that, at least as likely as not, the Veteran's fatal myocardial infarction and coronary artery disease were etiologically related to his PTSD. The Veteran died in January 2004, and his death certificate lists the immediate cause of death as myocardial infarction due to (or as a consequence of) coronary artery disease. There were no other significant conditions contributing to his death. An autopsy was not performed. At the time of his death, service connection was established only for PTSD, rated 10 percent, but he had initiated an appeal of the initial rating assigned for PTSD. The appellant pursued his appeal, and a September 2013 Board decision granted an initial 70 percent rating for PTSD and a total disability rating based on individual unemployability due to the PTSD, each for accrued benefits purposes and effective in June 1999. Thus, the question here now is whether the Veteran's fatal myocardial infarction, which was a consequence of his coronary artery disease, was etiologically related to his service-connected PTSD. On this question there are probative opinions for and against the claim. The evidence against the claim includes VA medical opinions of March 2005, August 2014, and December 2018. The examiner in 2005, with reference to treatment records and tracking the Veteran's history of weight gain and loss, concluded that the Veteran's gross obesity was a primary contributor for the ultimate cause of his death from myocardial infarction (heart attack), and that his PTSD and his psychiatric medications did not contribute significantly to either his obesity or his heart attack. He further found that the Veteran's various medications were prescribed "to help prevent detrimental outcomes from his obesity." The examiner in 2014 opined that the Veteran's cardiac condition leading to death was less likely than not proximately due to or the result of his PTSD. She referenced a 2013 medical resource providing an overview of cardiovascular disease risk factors and psychosocial and other social factors in acute myocardial infarction. She found the major risk factors for the Veteran's coronary heart disease (including positive family history, hyperlipidemia, hypertension, smoking, diabetes, and male gender) were much more likely causes of coronary heart disease than the "possible contribution of psychosocial factors, including PTSD, stress, depression and anxiety." She also found the Veteran's numerous risk factors for coronary artery disease and the disease itself were not aggravated by his PTSD (she stated that medical records showed his PTSD was stable on medications). The 2018 examiner concluded that it was not at least as likely as not that the Veteran's PTSD caused or aggravated his fatal cardiac disease. She addressed a 2013 internet article the appellant submitted from National Institutes of Health (NIH), pertaining to a study showing Vietnam veterans with PTSD were more likely to have heart disease. She found the 2014 VA opinion to be "compelling" in that the Veteran had many traditional cardiovascular risk factors and a medical record (specifically, a January 2004 psychiatry note) that indicated his PTSD symptoms were minimal. She also cited to the 2005 opinion about the Veteran's gross obesity as a significant risk factor for his heart attack and his medications given to him for preventing detrimental outcomes on account of his obesity. She referenced research studies on the link between PTSD and cardiovascular disease (including the article submitted by the appellant) but found that the Veteran's records suggested his "trauma symptoms were not severe and as such, his other risk factors were much more likely to have contributed substantially or materially" to his cause of death. (Notably, the parties to the JMR in November 2019 found the 2018 examiner's rationale about the lack of severity of the Veteran's PTSD symptoms to be insufficient in light of the Board's September 2013 decision that the Veteran was entitled to a 70 percent rating for PTSD due to serious symptoms from June 1999.) The evidence in favor of the claim includes the aforementioned July 2013 internet article, submitted by the appellant, from NIH titled Vietnam Vets with PTSD More Likely to Have Heart Disease (discussing a study that "suggests" that PTSD may be a risk factor for heart disease). More significantly, the appellant's attorney submitted a private medical opinion, dated in March 2021, wherein a physician who reviewed the relevant medical records, medical opinions, and the Veteran's treatment records, concluded that the Veteran's PTSD, more likely than not, caused the development of his coronary artery disease and eventual death from myocardial infarction. He also found that the PTSD was a "significant factor in [the Veteran's] development of OSA [obstructive sleep apnea] and more likely than not contributed to his hyperlipidemia, hypertension, glucose intolerance, obesity and smoking habit." He stated that medical literature he cited to numerous publications was clear in showing PTSD to be a risk factor for the development of all of the Veteran's disabilities which are "classic risk factors for heart disease." He explained in detail his disagreement with each of the VA medical opinions against the claim, to include noting that the medical resource upon which the 2014 examiner relied had since been revised to reflect that psychosocial factors are associated with the onset of acute coronary syndrome (and asserting that the 2018 examiner "parroted the identical rationale" of the 2014 examiner). Finally, he commented that the three prior VA examiners failed to consider the role that the Veteran's PTSD played as a causative factor in the development of the classic risk factors for heart disease present in the Veteran or coronary artery disease directly. Upon review of the record, the Board finds that the competent evidence of record is at least in equipoise as to whether the Veteran's service-connected PTSD was a proximate cause of his fatal myocardial infarction and underlying coronary artery disease. Resolving reasonable doubt in the appellant's favor (as required in such circumstances), the Board concludes that service connection for the cause of the Veteran's death is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. George R. Senyk Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debbie Breitbeil, 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.