hypertension Bva Decision I Hope This Explaisn It Better Than I Have

[Testvet]

http://www.va.gov/vetapp09/files2/0912815.txt

DOCKET NO. 04-16 551A ) DATE

)

)

On appeal from the

Department of Veterans Affairs Regional Office in Columbia,

South Carolina

THE ISSUE

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).

REPRESENTATION

Appellant represented by: Rebecca Patrick, Attorney at

Law

WITNESS AT HEARING ON APPEAL

Appellant

ATTORNEY FOR THE BOARD

M. Prem, Counsel

INTRODUCTION

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,

3.310(a) (2008).

REASONS AND BASES FOR FINDING AND CONCLUSION

Service Connection

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

discussed below.

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

Disease/Cardiology."

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

service."

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

Register.

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

murmur.

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

warranted.

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).

ORDER

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 Affairs

Edited June 16, 2009 by Pete53
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[carlie]

Testvet,

Is this YOUR BVA case?

carlie

[Testvet]

yes they just put it online today I have been checking for months

[MikeR]

Did the AMC approve you first?

[Testvet]

whats the AMC? No I went from many DRO denials to the BVA

[carlie]

Testvet,

Congrats !

This is a great example of BVA acknowledging the weight of the evidence for and against the

claim as at least in relative equipoise and applying the BOD.

This shows us all that,when we have a claim and the medical evidence we must remain tenacious!

Good job.

carlie

[Testvet]

thank you Carlie it was the people here that encouraged me to keep fighting Mike, Berta, Tom, and a lot of others some now gone friends like John, even Paladine rofl this is a bunch but at least we understand each other we is fambly