Citation Nr: 22014666 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 16-28 191 DATE: March 14, 2022 ORDER Service connection for heart disease is granted. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran's heart disease is proximately due to his service-connected hypertension. CONCLUSION OF LAW The criteria for service connection for heart disease as secondary to service-connected hypertension are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1985 to October 1985 and from August 1986 to December 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA), which denied service connection for hypertension and a heart disorder. The Veteran presented testimony at a Board hearing in March 2019. A transcript of the hearing is associated with the Veteran's claims folder. This case was previously before the Board in June 2019 and January 2021, on which occasion the claims were remanded. While the appeal was pending on remand status, the RO in a September 2021 rating decision granted service connection for hypertension effective March 24, 2011. This constitutes a full award of the benefits sought on appeal with respect to the claims of service connection for hypertension. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). The record currently available to the Board contains no indication that the Veteran has initiated an appeal with respect to the initial apnea rating or the effective date assigned. Id. (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Thus, this issue is not in appellate status at this juncture. 1. HEART DISEASE ASSOCIATED WITH MIGRAINE SYNDROME The Veteran contends that service connection is warranted for heart disease, to include as secondary to service connected migraine. Alternatively, he has alleged that the current heart disease was related to in-service findings of cardiomegaly. Additionally he has submitted evidence linking his heart disease to the newly service connected hypertension. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96. For veterans who have served 90 days or more on or after December 31, 1946, certain chronic diseases, such as cardiovascular-renal disease are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1133; 38 C.F.R. §§ 3.307 (a), 3.309(a). A nexus between a current disability and an in-service injury or event may be established by evidence of continuity of symptomatology, if the condition is a chronic disease enumerated under 38 U.S.C. § 1101. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). 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. Service treatment records are silent for a formal diagnosis of a heart disease or disability, although incidental findings of a mild degree of cardiomegaly were noted in a March 1989 abdominal study. The evidence shows that the Veteran has been treated for heart disease decades after service, with heart catheterizations from February 2007 and September 2008 addressing known coronary artery disease (CAD) showing findings of coronary artery stenosis and occlusions. He also required multiple medical procedures to treat his heart disease including an emergency coronary artery bypass grafting (CABG) for severe CAD with occlusions of the left main, circumflex and right coronary arteries. He continued to have cardiac treatment including multiple prior percutaneous coronary interventions (PCI) and repeated heart catheterizations for an extensive history of CAD described repeatedly as "severe premature onset" with symptoms of recurrent chest pain/unstable angina throughout 2008 and 2009, with the records also noting a diagnosis of hypertension. The Veteran continued to have treatment for extensive CAD with a history of 3 CABG procedures with a total of 13 stents, with a history of chronic hypertensions and episodes of high blood pressure as noted in records from April 2015, June 2015, September 2015, and October 2015. The Veteran underwent multiple VA examinations to address the etiology of his heart disease with a focus of whether the heart disorder was incurred in service or alternately is being caused or aggravated by his service connected migraines. These included a December 2016 VA examination which diagnosed acute, subacute, or old myocardial infarction and coronary artery disease and gave an unfavorable opinion that the condition is less likely than not proximately due to or the result of his service connected migraine condition. The rationale noted that heart disease has a number of well determined risk factors, with the most common factors including smoking, family history, hypertension, obesity, diabetes, lack of exercise, high blood lipids. The Veteran was noted to have a medical history of many of the above named risk factors. A December 2019 VA examination diagnosed myocardial infarction (MI), CAD, congestive heart failure (CHF), and hypertensive heart disease. His medical history included treatment for a MI in 2008, history of CHF with no episodes in past year. He was noted to have a history of PCI and angioplasty in December 2008, January 2009, 2011, and September 2018 for CAD with blockage of coronary arteries. He also had a CABG in September 2008 and NSTEMI in January 2009. Examination was unremarkable and the examiner gave an unfavorable etiology opinion that the heart disease was less likely than not proximately due to or the result of his service connected migraine disorder. The examiner gave an opinion that his current heart disease is due to multiple factors which included his many year history of cigarette smoking, hypertension, diabetes, and hyperlipidemia. The Veteran's heart disease is secondary to and caused by his identified risk factors. Review of the medical records documented that the Veteran also has poorly controlled type 2 Diabetes, which also increases the risk for heart disease. Similarly, a January 2021 VA medical opinion finding that it was less likely than not that the Veteran's heart disease is related to an inservice diagnosis of cardiomegaly or proximately due to service connected migraine again noted that the Veteran has multiple well established risk factors for heart disease, including smoking, hypertension, diabetes, and hyperlipidemia. Another examination was conducted in September 2021. The VA examiner listed the relevant history, including acute, subacute, or old myocardial infarction diagnosed in 2004, coronary artery disease diagnosed in 2007, unstable angina diagnosed in 2021, valvular heart disease diagnosed in 2021, LV hypertrophy diagnosed in 6/26/15, interventricular conduction disorder diagnosed in 2015. The examiner noted that the Veteran reported a history of heart attack in 2004 and 4 more since. The conditions qualify as ischemic heart disease, CAD 2007, CABG, cardiac stent, and unstable angina. The examiner discussed etiology of MI due to CAD. The examiner stated that the CAD was hypertension related. Additional heart conditions were deemed hypertension-related, including CAGB, cardiac stent, valvular heart disease unknown etiology, and unstable angina due to CAD. Following a review of the history and examination of the Veteran, the examiner provided unfavorable opinions addressing the etiology of the heart disease including finding it less likely than not that it was incurred in service including the in-service diagnosis of cardiomegaly, and also finding it less likely than not that it was secondary to his service connected migraine disability. The same examiner provided a favorable etiology finding that hypertension was incurred in service. In June 2021 and September 2021 favorable opinions were obtained from the Veteran's VA cardiologist, A.H. MD, MBA. The cardiologist confirmed having treated the Veteran since July 2019 and noted an extensive history of arteriosclerotic cardiovascular disease involving heart and peripheral vasculature. He had his first coronary stent in 2007 followed by CABG surgery in 2008 which was complicated by immediate failure of his grafts within weeks. Since then he has had numerous repeat coronary interventions for recurrent MIs. His history includes lower extremity peripheral artery disease (PAD) and moderate aortic regurgitation in both June 2021 and September 2021, the cardiologist noted that hypertension is a well-established and quantitatively perhaps the most important modifiable risk factor for CVD, specifically CAD worldwide. By some estimates, it accounts for up to half of ischemic heart disease events globally. He has a history of difficult to control HTN dating back to Jan 2005 based on VA recs and this most definitely contributed to his history of CVD. In the September 2021 opinion the examiner noted that his primary cardiac history consists of CAD, which is extensive and heart failure with reduced ejection fraction. Hypertension is a well-established risk factor of both conditions as outlined below. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current heart disease of extensive CAD, and all other heart issues stemming diagnosis, as well as his CHF and MI, is proximately due to his service-connected hypertension. The Board notes that all the VA examination reports in providing unfavorable etiology opinions on other bases of entitlement, consistently cited hypertension as a risk factor for the Veteran's heart disease. Most significantly, the Veteran's treating cardiologist provided two opinions as noted directly above which linked his CAD and heart failure to his service connected hypertension. This opinion was provided by a cardiovascular specialist who was familiar with the Veteran's medical history and was supported by adequate rationale. Again the unfavorable VA opinions further supported a link between his heart disorder and hypertension and thus do not directly conflict with the cardiologist's opinion. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for heart disease is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102." Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Eckart 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.