Post a clear title like ‘Need help preparing PTSD claim’ or “VA med center won’t schedule my surgery”instead of ‘I have a question.
Knowledgeable people who don’t have time to read all posts may skip yours if your need isn’t clear in the title.
I don’t read all posts every login and will gravitate towards those I have more info on.
Use paragraphs instead of one massive, rambling introduction or story.
Again – You want to make it easy for others to help. If your question is buried in a monster paragraph, there are fewer who will investigate to dig it out.
Post straightforward questions and then post background information.
Question A. I was previously denied for apnea – Should I refile a claim?
Adding Background information in your post will help members understand what information you are looking for so they can assist you in finding it.
Rephrase the question: I was diagnosed with apnea in service and received a CPAP machine, but the claim was denied in 2008. Should I refile?
Question B. I may have PTSD- how can I be sure?
See how the details below give us a better understanding of what you’re claiming.
Rephrase the question: I was involved in a traumatic incident on base in 1974 and have had nightmares ever since, but I did not go to mental health while enlisted. How can I get help?
This gives members a starting point to ask clarifying questions like “Can you post the Reasons for Denial of your claim?”
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Most Common VA Disabilities Claimed for Compensation:
You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons …Continue reading
DOCKET NO. 04-16 551A ) DATE
On appeal from the
Department of Veterans Affairs Regional Office in Columbia,
Entitlement to service connection for cardiovascular
disability (to include coronary artery disease and/or
hypertension) as secondary to the veteran's service connected
post traumatic stress disorder (PTSD).
Appellant represented by: Rebecca Patrick, Attorney at
WITNESS AT HEARING ON APPEAL
ATTORNEY FOR THE BOARD
M. Prem, Counsel
The veteran served on active duty from May 7, 1973 to May 18,
1973; and from October 1973 to September 1982; and from
November 1990 to April 1991.
This matter comes to the Board of Veterans' Appeals (Board)
on appeal from a July 2003 rating decision by a Regional
Office (RO) of the Department of Veterans Affairs (VA). The
veteran presented testimony at a Board hearing in February
2009. A transcript of the hearing is associated with the
veteran's claims folder.
FINDING OF FACT
The evidence of record is in equipoise on the question of
whether the Veteran's coronary artery disease and
hypertension are secondary to his service-connected PTSD.
CONCLUSION OF LAW
Coronary artery disease and hypertension are proximately due
to the veteran's service-connected PTSD. 38 U.S.C.A.
§§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.102, 3.159,
REASONS AND BASES FOR FINDING AND CONCLUSION
The issue before the Board involves a claim of entitlement to
service connection. Applicable law provides that service
connection will be granted if it is shown that the veteran
suffers from disability resulting from an injury suffered or
disease contracted in line of duty, or for aggravation of a
preexisting injury suffered or disease contracted in line of
duty, in the active military, naval, or air service.
38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury
occurred in service alone is not enough; there must be
chronic disability resulting from that injury. If there is
no showing of a resulting chronic condition during service,
then a showing of continuity of symptomatology after service
is required to support a finding of chronicity. 38 C.F.R.
§ 3.303(B). Additionally, for veteran's who have served 90
days or more of active service during a war period or after
December 31, 1946, certain chronic disabilities, such as
cardiovascular disease, are presumed to have been incurred in
service if manifest to a compensable degree within one year
of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38
C.F.R. §§ 3.307, 3.309. Service connection may also be
granted for any 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).
Additionally, disability which is proximately due to or the
result of a service-connected disease or injury shall be
service connected. 38 C.F.R. § 3.310. The Board also notes
that secondary service connection on the basis of aggravation
is permitted under 38 C.F.R. § 3.310, and compensation is
payable for that degree of aggravation of a non-service-
connected disability caused by a service-connected
disability. Allen v. Brown, 7 Vet.App. 439 (1995).
The veteran contends that his current heart problems, to
include coronary artery disease, were caused by or aggravated
by his service connected PTSD. At his February 2009 Board
hearing, he pointed out that he has presented four medical
opinions that substantiate his belief. These opinions are
The veteran submitted a January 2005 correspondence from a VA
outpatient treatment physician (Dr. M.B.G.) that states in
toto: "To Whom It May Concern: I have been treating the
veteran for coronary artery disease. I have reviewed the
previous medical records and my current treatment records and
believe that it is more likely than not that the cardiac
conditions are directly related to and aggravated by PTSD, a
service connected condition."
The veteran subsequently submitted the results of an internet
search from the georgia.gov website. The printout reflects
that according to the Composite State Board of Medical
Examiners, Dr. M.B.G.'s specialty is "Cardiovascular
The veteran underwent a VA examination in January 2006. The
claims file was not available for review. At the time of the
examination, the veteran believed that his coronary artery
disease and cerebrovascular disease was caused by exposure to
toxic chemicals while in the military. The examiner stated
that he did not agree with the veteran. He pointed out that
the veteran had a long history of cigarette smoking and
hyperlipidemia. He stated that "it is my opinion that he
has had premature atherosclerotic disease that is unrelated
to military service. I believe that it is less likely than
not that his coronary artery disease, myocardial infarction,
and cerebrovascular accident is related to military
The veteran underwent another VA examination in June 2006.
The examiner reviewed the claims file in conjunction with the
examination. The examiner opined that the veteran's coronary
artery disease is less likely as not a result of or
aggravated by PTSD. Her rationale was that "there is no
current scientific evidence to support a connection between
[PTSD] and coronary artery disease. On the contrary;
however, persons who have coronary artery disease events are
more likely to develop [PTSD]."
The veteran submitted an article from a medical journal in
which Dr. Joseph A. Boscarino discusses the results from
clinical and epidemiologic studies regarding PTSD and
physical illness. Dr. Boscarino noted that "there is
growing evidence that exposure to psychologically traumatic
events is related to increased medical morbidity, including
the onset of different diseases and premature mortality. The
evidence for cardiovascular disease is particularly strong
and comes from a wide range of studies spanning different
populations with traumatic exposures." Dr. Boscarino's
studies and their findings have been noted in the Federal
The veteran submitted a September 2007 report from Dr.
J.S.K., who is a retired Colonel in the US Army Medical
Corps. and a Clinical Assistant Professor in Psychiatry at
the UCLA Neuropsychiatry Institute. He stated that
"Although I have not been able to examine [the veteran]
directly, I have had a lengthy series of Email exchanges with
him and reviewed copies of his records." Dr. J.S.K. noted
that he was consulted because the veteran originally
hypothesized that his various medical problems were caused by
his tour at Edgewood Arsenal in 1974. The veteran hoped that
Dr. J.S.K. could confirm this hypothesis since Dr. J.S.K. had
recently published a book describing the detailed history of
the Edgewood volunteer program. Dr. J.S.K. reported that he
could not confirm this hypothesis. However, he did note that
the veteran had suffered some genuine traumatic events in
service. He provided a thorough history of the veteran from
1973 to the present as well as large excerpts from email
exchanges between him and the veteran. Regarding the central
issue of whether the veteran's heart problems were caused or
aggravated by PTSD, he noted that "Dr. Boscarino's studies,
widely accepted scientifically, reveal a previously
unexpected but highly significant association between PTSD
and medical disorders, including hypertension and
arteriosclerotic heart disease...the demonstration of specific
impairments of the immune system and abnormalities of
hormonal balance resulting from PTSD had not, to my
knowledge, been clearly demonstrated before his studies."
He ultimately concluded that "In my opinion [the veteran's]
hypertension and early onset of arteriosclerotic heart
disease is more likely than not caused, or at least severely
aggravated, by service connected PTSD."
The veteran submitted a March 2008 correspondence from D.W.,
D.O. (Doctor of Osteopathy). In it, D.W. stated that that he
performed an extensive review of the veteran's claims file
and the existing medical literature. He did not examine the
veteran himself. D.W.'s correspondence included a thorough
summary of the veteran's military history and past medical
history. He noted that primary risk factors for coronary
artery disease include: age, family history, smoking,
hypertension, diabetes mellitus and hyperlipidemia. He also
noted that males and postmenopausal females are at greater
risk. Finally, he noted that generally accepted secondary
risk factors include: race, obesity, metabolic syndrome,
vascular inflammation, sedentary lifestyle, autoimmune
disorders, stress, alcohol, and renal failure. He noted that
the veteran has the following risk factors: male gender,
smoking history, hypertension, hyperlipidemia, obesity,
autoimmune disorder (psoriasis), stress, and alcohol.
D.W. opined that it was more likely than not that the onset
of the veteran's coronary artery disease occurred (but was
undiagnosed) during service. He pointed out that in July
1974, the veteran was diagnosed with a grade 2 systolic
ejection murmur; and that he was diagnosed with hypertension
in 1982. He noted that the veteran began smoking while in
service, thus adding another risk factor for coronary artery
disease. He noticed that on several military medical
examinations, the veteran complained of fatigue and dyspnea
on exertion which are symptoms of ischemic heart disease.
Finally, he noted that the veteran suffered his first acute
myocardial infarction in 1994 (just three years after
service). He stated that cardiovascular disease is a slowly
progressive disease in which atherosclerotic plaque
deposition over many years leads to an acute cardiac event.
As such, the onset of the 1994 acute myocardial infarction
likely began years earlier, while the veteran was still in
service. He opined that that it was as likely as not that
the veteran developed coronary artery disease (which was left
undiagnosed) during military service, and that it may have
begun as early as 1974, when he was diagnosed with a heart
D.W. also opined that "[the veteran's] posttraumatic stress
disorder is a major contributing factor leading to his
accelerated (aggravated) coronary artery disease." He once
again noted that "It is generally accepted in the medical
literature that stress is a secondary factor for the
development of coronary artery disease." He referenced the
aforementioned studies by Dr. Joseph A. Boscarino.
The veteran underwent another VA examination in April 2008.
The examiner reviewed the claims file in conjunction with the
examination. The examiner opined that it is less likely than
not that the veteran's PTSD exacerbated hypertension and his
heart condition. The examiner also did not believe that the
heart condition was first manifested in service. He
explained that "An extensive review was performed on Cochran
Library, as well as up to date and I can find no definite
scientific evidence to support a connection between [PTSD]
and coronary artery disease or hypertension."
The veteran submitted a January 2009 correspondence from Dr.
J.R.H. (Managing Partner at Palmetto Cardiology Associates
and Chief of Cardiology at Providence Hospital) along with
his curriculum vitae which reflects substantial training and
expertise in the field of cardiology. Dr. J.H.R. conducted
an examination of the veteran and he reviewed the veteran's
claims file. After examination of the veteran and the claims
file, Dr. J.H.R. stated that "I do believe that there is
some correlation between stress and cortisol levels.
Elevated cortisol levels have been shown to have deleterious
side effects on health in general. I do believe that long
term administration of corticosteroids can elevate
cholesterol and triglyceride levels, both of which are as
likely as not to promote cardiovascular disease in general
and epicardial coronary disease specifically. It is fairly
well established that posttraumatic stress disorders indeed
do elevate endogenous cortisol levels...Final summary is that
this patient with extensive epicardial coronary artery
disease laid down the substrate for coronary artery disease
while he was in service. It is as likely as not [the
veteran's] PTSD exacerbated his epicardial coronary artery
disease and the severity thereof and thus contributed to his
epicardial coronary artery disease."
The Board notes that the medical evidence (specifically the
various opinions regarding a medical nexus) is in conflict.
The Court has held that the Board must determine how much
weight is to be attached to each medical opinion of record.
See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater
weight may be placed on one medical professional's opinion
over another, depending on factors such as reasoning employed
by the medical professionals and whether or not, and the
extent to which, they reviewed prior clinical records and
other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994).
The Board has carefully considered the conflicting medical
opinions of record. The underlying question is clearly
medical in nature. The opinions of record all claim to be
based on extensive review of medical literature, and they all
appear to be supported by a rationale. The Board notes with
interest the fact that one medical study apparently
recognizing a causal relationship between PTSD and
cardiovascular disease was determined to be significant
enough to warrant inclusion in the Federal Register. Under
the circumstances of this particular case, the Board finds
that at the very least, the evidence with respect to
secondary service-connection is in approximate balance, with
no sound basis for choosing one medical opinion over the
other. As the weight of the evidence for and against the
claim is at least in relative equipoise on the question of
whether the veteran's service-connected PTSD caused or
contributed to his development of coronary artery disease and
hypertension, service connection for coronary artery disease
and hypertension secondary to service-connected PTSD is
Veterans Claims Assistance Act of 2000
The Veterans Claims Assistance Act of 2000 (VCAA) requires
certain notice and assistance to a claimant for VA benefits.
See generally 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106,
5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and
3.326(a). A discussion of compliance with VCAA is not
necessary since there is no resulting prejudice to the
appellant as a result of any possible VCAA deficiency in
light of the Board's favorable decision. The Board notes
that required notice regarding effective dates and disability
evaluations was furnished to the Veteran by letter in April
2008, followed by readjudication of the claim. See generally
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).
Service connection for coronary artery disease and
hypertension secondary to the veteran's service connected
PTSD is warranted. The appeal is granted.
ALAN S. PEEVY
Veterans Law Judge, Board of Veterans' Appeals
Department of Veterans AffairsEdited by Pete53
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