Citation Nr: 22013136 Decision Date: 03/08/22 Archive Date: 03/08/22 DOCKET NO. 13-25 153A DATE: March 8, 2022 ORDER Service connection for coronary artery disease (CAD), to include as secondary to posttraumatic stress disorder (PTSD) with alcohol abuse, is denied. Service connection for stroke, to include as secondary to PTSD with alcohol abuse, is denied. Service connection for impairment of sphincter control and anal reconstruction is denied. FINDINGS OF FACT 1. The Veteran's CAD was secondary to the service-connected PTSD with alcohol abuse. 2. The Veteran's stroke was not secondary to the service-connected PTSD with alcohol abuse. 3. The Veteran's impaired sphincter and anal reconstruction was not secondary an in-service event or service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for CAD due to service-connected PTSD with alcohol abuse are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for a stroke due to service or service-connected PTSD with alcohol abuse are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for impaired rectal sphincter control and anal reconstruction due to service are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1958 to December 1962. He died in January 2017. The appellant is his surviving spouse. She has been substituted in this appeal, which was pending at the time of the Veteran's death. The case is on appeal from an April 2010 rating decision. In August 2015, the Board issued a decision that, as relevant, granted the Veteran's service connection claim for PTSD with alcohol abuse. Further, the Board remanded for further development the instant claims for CAD and stroke as secondary to service-connected PTSD and service connection for impairment of sphincter control and anal reconstruction. Most recently, in August 2020, the Board again remanded the instant claims of service connection. LEGAL CRITERIA Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. 1. Service connection for CAD 2. Service connection for stroke The Appellant contends that the Veteran's CAD was caused by or aggravated by service-connected PTSD with alcohol abuse. During his lifetime, in a May 2009 correspondence, the Veteran reported experiencing negative health and daily life effects from service. In a July 2009 correspondence, the Veteran reported that he underwent open heart surgery. In an August 2009, the Appellant reported that the Veteran experienced a heart attack and stroke. In a March 2011 correspondence, the Veteran reported that his providers informed him that each heart attack and stroke were caused by his service-connected PTSD. Also, he reported that he did not drink before service, but he did after an in-service sexual assault which led to PTSD. The Veteran's service treatment records (STRs) do not show reports or treatment for heart and brain disorders or PTSD. However, in a January 1962 psychiatric examination, the Veteran reported excessive drinking and drug abuse. In the October 1962 separation examination notes excessive drinking due to in-service harassment. The examination was marked normal for heart and brain. The Veteran was service-connected for PTSD with abuse of alcohol. This is not in material dispute. The Veteran's post-service private treatment show that in April 1995 a family history of CAD was noted during a hospital visit for chest pains related to a respiratory infection. A September 1997 hospital record shows that the Veteran was treated for and diagnosed with CAD. Also, the record shows that the Veteran continued to smoke against medical advice and stopped taking all prescribed cardiac medications. Further, strong family history of CAD is noted to include mother and father. A December 2002 hospital discharge notes shows that the Veteran experienced a stroke. A March 2004 hospital note shows that the Veteran was diagnosed with CAD again along with other heart related diagnosis. In a June 2004 correspondence, the Veteran's private physician reported that the Veteran underwent a coronary artery bypass surgery. He also referenced different diagnosis pertinent to the Veteran to include PTSD but did not provide a nexus opinion between CAD and PTSD. In October 2004, the Veteran submitted a private medical opinion. The private physician opined that the in-service events the Veteran incurred led him to abuse both alcohol and tobacco "clearly contributed to the development of his vascular disease. A January 2006 medical note indicated that the Veteran's CAD was stable. The Veteran's post-service VA treatment records show that in February 2000 he was noted to have a CAD diagnoses since 1995. A July 2000 clinic note shows that the Veteran received follow-up treatment for CAD. At an April 2013 telehealth initial evaluation, the Veteran reported that he "suffered a myocardial infarction due to a PTSD/anxiety episode." Pursuant to the August 2015 Board remand, in September 2015, the Veteran was afforded a VA examination. The Veteran reported he experienced a heart attack and was hospitalized in 1995. He also reported that he underwent another heart procedure. He further reported having 14 stents and a pacemaker due to bradycardia. Moreover, the Veteran reported a family history of CAD among parent and sibling and hyperlipidemia. He also reported that he was fed alcohol and cigarettes during service. The examiner reviewed the claims file. The examiner opined that the Veteran's CAD was less likely than not proximately due to or a result of the Veteran PTSD. As to the Veteran's CAD, the examiner reported CAD and ischemia. She noted that "although a few recent studies suggest a link between PTSD and cardiac conditions, the current well-documented evidenced-based medicine continue to support the major risk factors as noted." The examiner found the Veteran's documented intermittent use of alcohol following service to include reported six weeks of alcohol use during service does not usually result in a significant increase in cardiac risk. She found that the Veteran had multiple well-documented major risk factors that were likely to be the more significant factors in the development of CAD to include family history, hyperlipidemia, hypertension, obesity, and non-compliance with treatment. Also, she opined that the condition followed the natural progression. As to the Veteran's stroke, the September 2015 examiner remarked that the Veteran had significant carotid stenosis and also atrial fibrillation which she remarked were significant factors in the development of strokes. She reported that the Veteran's carotid stenosis required stenting and carotid endarterectomy. The examiner also reported that the Veteran's records showed that he used both tobacco and alcohol intermittently with periods of abstinence. She was unable to determine a baseline level of severity based on insufficient medical evidence. The examiner opined that PTSD was not a significant risk factor for the onset of stroke and was likely not the cause of the Veteran's stroke. Instead, the examiner opined that the Veteran's family history, non-compliance, atrial fibrillation and carotid stenosis likely played a major role in his development of stroke. Also, she opined that the condition followed the natural progression. Pursuant to the August 2020 Board remand, an addendum opinion was obtained in February 2021. The physician reviewed the claims file. The physician opined that the Veteran's CAD was less likely than not proximately due to or the result of the Veteran's PTSD. He reported that a review of the medical record shows the Veteran had significant atherosclerotic disease. The physician explained that while alcohol abuse is a risk factor for CAD, there are many other risk factors for developing atherosclerotic disease. The examiner further explained that atherosclerosis is a pathologic process that causes disease of the coronary, cerebral, and peripheral arteries. It begins in childhood with the development of fatty streaks. Also, the examiner remarked that advanced lesions of atherosclerosis occur with increasing frequency with aging. The physician noted that multiple factors contribute to the pathogenesis of atherosclerosis, including endothelial dysfunction, dyslipidemia, inflammatory, and immunologic factors, plaque rupture, and smoking. As to alcohol effects in the Veteran, the physician found that the Veteran had no evidence of peripheral neuropathy, a common finding with chronic alcohol abuse and no evidence of alcoholic liver disease which is a very prominent finding with chronic alcohol abuse. He remarked that there are many risk factors for the development of atherosclerosis, however, just because a person has one of the risk factors does not mean it caused the disease. The physician pointed out that it is usually not possible to know exactly why one person develops a condition and another does not. He explained that the research has shown that certain risk factors may increase a person's chances of developing a condition. The physician remarked that based on the review of the medical record, the Veteran had many more significant risk factors for developing atherosclerosis including the most prominent being long history of smoking which is evidenced by diagnosis of stage IV terminal lung cancer. The physician concluded that there is no evidence the Veteran's alcohol use caused or permanently aggravated atherosclerosis beyond the natural progression. Pursuant to the August 2020 Board remand, an addendum opinion was obtained in November 2020 for the stroke claim. The physician reviewed the claims file. The physician opined that the Veteran's stroke was less likely than not proximately due to or the result of PTSD. He explained that current medical literature does not support a physiological, biomechanical or anatomic mechanism for a mental health condition to cause or permanently aggravate cerebrovascular disease. The Board finds that, after reviewing the evidence, the September 2015, November 2020, February 2021, and March 2021 VA examiners' opinions are probative. The Board finds that they are clear and unequivocal and are based on the relevant information, including the Veteran's statements and post-service treatment records. Moreover, their explanations are logical and follow from the facts and information given. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this regard, all examiners provided medical opinions supported by cogent rationale and a thorough discussion of the facts and medical literature. In short, all VA examiners all opined that there is no causal relationship between PTSD due to alcohol abuse and CAD and stroke. Rather, they found that the Veteran's CAD had multiple risk factors, including hypertension, hyperlipidemia, obesity, and a family history of CAD, which were more likely the cause of his condition. Further, the September 2015 VA examiner found that the Veteran stroke was likely caused by the Veteran's family history, non-compliance, atrial fibrillation, and carotid stenosis likely played a major role in his development of stroke rather than PTSD. She opined that PTSD is not a significant risk factor for the onset stroke and was not likely the cause of the Veteran's stroke. In all of the examiners' opinions, the Veteran's PTSD appears to represent a negligible risk for heart disease or stroke. The Board notes that the Veteran submitted a private medical opinion in October 2004 from a provider who treated the Veteran for CAD and stroke. In this case, the Board finds that, Dr. S.R.'s opinion rendered medical opinion is inadequate. First, the examiner identified the Veteran as having cardiovascular disease and vascular disease. The post opinion only applied ot the vascular disease. It is not clear that the provider intended the positive opinion to apply to the cardiovascular disease. Even if so, the opinion is conclusory without any supporting rationale or discussion of the conflicting evidence. See Nieves-Rodriguez, 22 Vet. App. 295, 302-04 (2008). Thus, it is essentially nonprobative. The Veteran during his lifetime and the appellant at present believe his conditions resulted from service or were secondary to a service-connected disability. The Veteran and appellant in this case are not competent to provide a nexus opinion regarding this issue. These issues are medically complex, as they require knowledge of risk factors for these conditions and how they manifested in the context of the Veteran's case. It is outside the competence of the Veteran and appellant in this case because the record does not show that they have the medical training or credentials 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 the VA opinions. Accordingly, the evidence is persuasively again the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection for impairment of sphincter control and anal reconstruction. The Appellant contends that impairment of sphincter control and anal were a result of an in-service sexual assault, or alternatively, cause by service-connected hemorrhoidectomy. In an April 2009 correspondence, the Veteran reported that his physical health was deteriorating due to an in-service assault. In August 2009, the Appellant reported that the Veteran experienced uncontrollable bowel movements caused by the original anal surgery. Further, the Appellant reported that the Veteran did not have a social and sexual life due to the effects of his bowel disorder. Moreover, she reported that she had to perform frequent hygiene maintenance tasks as a result of the Veteran's condition. In a January 2011 VA application for increased compensation, the Veteran reported experiencing bowel movements 6 to 8 times a day affecting the worn garments while he worked. In August 2011, the Veteran reported being a victim of a sexual assault that involved a 2-inch diameter stick inside the rectum. Also, he reported that after the assault, while stationed in France, his rectum muscles were removed after a few reconstructive surgeries in a post clinic. Moreover, the Veteran reported undergoing a third reconstructive surgery which resulted in bowel control movement disorders. In February 2014, the Veteran reported that he wore padding daily for the disorder. The Veteran is service-connected for PTSD based on military sexual trauma (MST). The facts of the MST are not in dispute. The basis for the grant of service connection for PTSD involved sexual assault. His service treatment records (STRs) include an October 1960 clinical record cover sheet shows that the Veteran was diagnosed with hemorrhoids in Trois Fontaines and underwent hemorrhoid surgery. There is no evidence of impaired sphincter control anal reconstruction. At a September 1963 VA examination, the Veteran was noted to have rectal disorder due to a hemorrhoidectomy. He reported that he was "operated on for piles" in 1961. During a May 1994 VA examination for joints, the VA examiner diagnosed the Veteran with post hemorrhoidectomy with no evidence of recurrent hemorrhoids with occasion fecal soilage. Also, the examiner noted fecal leakage occurring twice a week. No reports or treatment for sphincter control impairment or anal reconstructions were noted. The Veteran's post-service VA treatment record shows that in February 2000 the attending physician reported good sphincter tone. In May 2002, the attending physician reported adequate external sphincter tone. In December 2004, a private (non-VA) physician filled out a questionnaire regarding the Veteran's case. The examining physician marked an option indicating that the Veteran sphincter and anal condition "damage in the anal canal could have been caused by repeated rape." In this regard, the physician also marked "yes" where asked if the Veteran had an enlarged scar tissue, damaged anal cavity, evidence of old surgery, evidence of anal reconstruction, evidence of prior and present bleeding, evidence that the surgery was poorly performed. Another post-service VA treatment record show that during a September 2008 medical consult, the Veteran reported experiencing worsening chronic fecal incontinence since being assaulted. The examining physician reported a slightly lax sphincter. A December 2008 medical consult record shows that the examining physician reported poor sphincter tone and weak contraction. A May 2009 outpatient note shows that the attending physician found fair sphincter tone but noted that the Veteran was unable to voluntarily contract the external anal sphincter. A September 2009 outpatient note shows that the examining physician found poor rectal function consistent with prior rectal trauma and sphincter loss. Pursuant to an August 2015 Board remand, the Veteran was afforded another VA examination in September 2015. The examiner reviewed the claims file. The Veteran reported undergoing only one rectal and anal surgery but denied a hemorrhoidectomy. Also, he reported poor rectal tone. Furthermore, he reported experiencing persistent fecal leakage. The examiner opined that the Veteran's sphincter impairment and anal reconstruction was less likely than not incurred in or caused by in-service injury, event, or illness. The examiner noted internal and external hemorrhoids since 1960. She also noted impairment of rectal sphincter control since 1960 based on the Veteran's report. The examiner referenced that while the Veteran reported anal reconstruction surgery, the STRs show the surgery was due to thrombosed hemorrhoids, which is further corroborated by the separation examination and civilian medical records. Further, the examiner opined that the Veteran's fecal incontinence is likely not related to the hemorrhoidectomy. She noted that complaints of fecal incontinence did not show in the medical record until 2004. The examiner concluded that the Veteran's fecal leaked may be caused by strokes he experienced. Pursuant to an August 2020 Board remand, this claim was inextricably intertwined with the stroke claim. As mentioned above, the addendum opinion was obtained in November 2020 for stroke claim provided a negative nexus opinion. The Board notes that the December 2004 VA examiner opined that the Veteran's sphincter and anal disorder is related to sexual assault. However, the Board finds that the September 2015 VA examiner's opinion is more probative because it was based on the complete medical record and addressed evidence against and for the claim. See McCray v. Wilkie, 31 Vet. App. 243, 257 (2019); Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds the September 2015 VA examination opinion and the medical records to be of great probative value. Indeed, the examiner considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). While the September 2015 VA examiner found that the Veteran's disorder may be caused by strokes, resulting in a Board finding of inextricably intertwined sphincter impairment control and anal reconstruction and stroke, the stroke is not service-connected. Thus, service-connection for impairment of sphincter control and anal reconstruction on a secondary basis cannot be established. The Veteran during his lifetime and the appellant at present believe his conditions resulted from service or were secondary to a service-connected disability. The Veteran and appellant in this case are not competent to provide a nexus opinion regarding this issue. These issues are medically complex, as they require knowledge of risk factors for these conditions and how they manifested in the context of the Veteran's case. It is outside the competence of the Veteran and appellant in this case because the record does not show that they have the medical training or credentials 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 the VA opinions. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Corey Bosely Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Nevarez-Myrick, Nancy 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.