Citation Nr: A25035461 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 210713-214642 DATE: April 17, 2025 ORDER Entitlement to service connection for the cause of the Veteran's death is granted. FINDINGS OF FACT 1. The Veteran died in August 2018 of acute myocardial infarction. 2. At the time of the Veteran's death, the Veteran was service connected for the disabilities of posttraumatic stress disorder (PTSD), retrolisthesis of C4 in respect to C5 with invertebral disc syndrome; and bilateral upper extremity radiculopathy. 3. The evidence is in approximate balance as to whether the Veteran's service-connected PTSD contributed materially and substantially to his myocardial infarction which led to his death. CONCLUSION OF LAW The criteria for entitlement to service connection for the cause of the Veteran's death are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1995 to August 1995 and from March 2003 to August 2004. The Veteran died in August 2018. The Appellant is the Veteran's surviving spouse. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2020 higher-level review decision of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In the July 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the July 2019 AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran with, or within 90 days of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Entitlement to service connection for the Veteran's cause of death The Appellant is seeking service connection for the cause of the Veteran's death, which she generally contends is due to his service-connected PTSD. See July 2021 Correspondence -Article entitled, Chronic Stress: A Critical Risk Factor for Atherosclerosis, (discussing physiological response to chronic stress exposure has been recognized as a potent modulator in the occurrence of atherosclerosis, and research has confirmed the correlation between atherosclerosis and cardiovascular events). To establish entitlement to service connection for the cause of a veteran's death, the evidence of record must show that a disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. The service-connected disability will be considered as the principal cause of death when such disability, singly or jointly with another condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). To be considered a contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. It is not sufficient to show that the service-connected disability casually shared in producing death; rather, a causal connection must be shown. 38 C.F.R. § 3.312(c)(1). Medical evidence is required to establish a causal connection between service or a disability of service origin and the Veteran's death. See Van Slack v. Brown, 5 Vet. App. 499, 502 (1993). Generally, to establish service connection a veteran must show: "(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 incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be granted for any or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the veteran. 38 U.S.C. § 5107(b) Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Secondary service connection may be granted where a non-service-connected disability would have been less severe but for a service-connected disability. Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023). In this case, the Veteran's death certificate identifies his immediate cause of death as acute myocardial infarction. See October 2018 Death Certificate. At the time of his passing, the Veteran was service connected for PTSD; retrolisthesis of C4 in respect to C5 with invertebral disc syndrome; and bilateral upper extremity radiculopathy. See July 2018 Rating Decision-Codesheet. The Board notes that VA has made a formal finding that the Veteran's service treatment records (STRs) cannot be located, and therefore, are unavailable for review for the period of service from March 2003 to August 2004. Further, VA found that all efforts to obtain these records have been exhausted, and that further attempts to obtain them would be futile. See January 2008 VA Memo. When service records cannot be located through no fault of the Veteran, VA has a heightened obligation to explain its findings and conclusions, a heightened duty to search for records and explain the efforts to that effect, and a requirement to carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The case law, however, does not lower the legal standard for proving a claim for service connection in this circumstance, instead, increases VA's obligation to evaluate and discuss in its decision all evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). There is no presumption, either in favor of the claimant or against VA, arising from missing records. Here, the AOJ has made direct requests for records from military facilities and obtained all available records. The Appellant has been advised of the unavailability of records and the types of alternative evidence which could help substantiate her claim. Turning to the evidence, the Appellant submitted a private positive secondary nexus opinion in July 2021. Based on her review of the claims file, medical records, the Veteran's death certificate, and medical research, Dr. M.B. opined that it is "as likely as not the [V]eteran's service connected PTSD contributed materially and substantially to the myocardial infarction which ultimately resulted in his death." Dr. M.B. noted that the Veteran's treatment notes showed he had been suffering from significant mental health symptoms for many years, to include self-isolation, nightmares, fearful of the dark and being alone, excessive sleeping, suicidal ideation, fatigue, interpersonal conflicts, irritable behavior and angry outbursts, hyperviligence, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, suspiciousness, panic attacks more than once per week, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, obsessional rituals which interfere with routine activities, impaired impulse control and neglect of personal appearance and hygiene. See July 2021 Medical Treatment Record -Government Facility Dr. M.B. explained that medical research has shown "[c]hronic psychological stress is an independent risk factor for atherosclerotic diseases including strokes and heart attacks," "chronic stress causes stress hormones such as cortisol and catecholamines to regulate blood flow and blood pressure, leading to endothelial injury," and the "release of catecholamines as a result of sympathetic excitement not only causes coronary artery contraction but also causes the rupture of vulnerable plaques." Id. This opinion from Dr. M.B. serves to link the Veteran's PTSD condition to his acute myocardial infarction and includes an adequate rationale for the opinion rendered with supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no contrary opinion of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary is required to give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. Accordingly, the Board resolves reasonable doubt in the Appellant's favor and finds that the Veteran's cause of death is linked to his service-connected PTSD. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The claim is granted. S. Merrick Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Hampl, Samantha 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.