Citation Nr: 0002988 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 94-31 099 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for cardiovascular disease, claimed as secondary to (service-connected) post-traumatic stress disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL The appellant and his spouse ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The veteran served on active duty from July 1944 to April 1946. This case was previously before the Board of Veterans' Appeals (Board) in July 1996, at which time it was remanded for additional development. The case is now, once more, before the Board for appellate review. FINDINGS OF FACT 1. Service connection is currently in effect for post- traumatic stress disorder, evaluated as 100 percent disabling. 2. The veteran's cardiovascular disease is not causally related to service-connected post-traumatic stress disorder. CONCLUSION OF LAW The veteran's cardiovascular disease is not proximately due to or the result of service-connected post-traumatic stress disorder. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp. 1998); 38 C.F.R. § 3.310(a) (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background A review of service clinical records reveals that, in October 1944, the veteran was seen for what he described as a "heart attack." A physical examination at that time revealed no evidence of pathology, but rather of a "nervous attack." No pertinent cardiovascular diagnosis was noted. In December 1945, the veteran stated that he felt as if his chest were "crushed." A physical examination of the heart conducted at that time was negative, with no change in respiration or pulse following pressure over the carotid sinus. No pertinent diagnosis was noted. A service separation examination conducted in April 1946 was negative for history, complaints, or abnormal findings indicative of the presence of cardiovascular disease. Department of Veterans Affairs (VA) general medical examinations in August 1948 and November 1949 were similarly negative for evidence of cardiovascular disease. In a private medical certificate of November 1949, it was noted that the veteran had been seen for complaints of pain and pressure in the epigastrium. Physical examination of the veteran's heart, lungs, and abdomen conducted at that time was essentially normal, and no pertinent diagnosis was noted. During the course of a private medical consultation in August 1970, it was noted that, for the previous 10 days, the veteran had noted an irregularity of his pulse accompanied by some dizziness, in particular, when bending over and getting up from a stooped position, or when straining or lifting heavy objects. On physical examination, the veteran's chest was symmetrical, though his heart was "slightly irregular and somewhat distant." No pertinent diagnosis was noted. On VA fee basis examination in November 1973, the veteran stated that, while in service, he was transferred to Korea, following which he experienced fever, abdominal distress, sweating, and a "pounding of the heart." The veteran further commented that he had "been to at least 20 doctors" regarding his complaints, including "racing of the heart." The veteran stated that his heart felt "as if it were going to quit." Reportedly, this began shortly following his discharge from service in 1946. According to the veteran, he had been hospitalized in early July 1973 for a period of nine days for what he described as "a heart attack." At this time, he had chest pains radiating into his arms, and was also very nervous. According to the veteran, he continued to awaken "with his heart racing," but without the severe pain which he experienced in July 1973. Occasionally, he suffered some "dull ache" in his left chest, though this usually came on "with nervousness." On physical examination, the veteran's blood pressure was 130/90 in both arms in the sitting position. The pulses in his neck were equal bilaterally, and his chest was clear to percussion and auscultation. The veteran's heart rate and rhythm were regular, with no apparent murmurs or cardiac enlargement. Electrocardiographic examination taken at rest showed no significant abnormality. Following examination, the veteran was described as suffering recurrent bouts of nervousness and apparent tachycardia. While in July 1973, he received treatment for an apparent heart attack, there was no evidence of any scar on current electrocardiogram indicating an old myocardial infarction. His current electrocardiogram was, in fact, normal. In the opinion of the examiner, the veteran's "most likely diagnosis" was of marked anxiety with some underlying depression and recurrent bouts of probable paroxysmal tachycardia. There was no evidence of any arteriosclerotic heart disease or hypertension, and no evidence of any other medical problem. In correspondence of mid-September 1974, the veteran's private physician gave clinical impressions of observation for chest pain, rule out ischemic heart disease; a history of intermittent cardiac arrhythmias, of unspecified type, to be further evaluated; and of an ill-defined neuropsychiatric disorder, previously documented. In the opinion of the veteran's private physician, he was a "most difficult person to obtain a reasonably clear history from or to make any sense of his story or findings." Approximately one week later, the veteran's private physician wrote that, during the course of a multistage treadmill test, the veteran did not develop any ischemic response to exercise, nor were there any exercise-induced arrhythmias. In the opinion of the examiner, the veteran had reasonable exercise tolerance. Additionally noted was that, while the veteran was not describing typical angina, he did have an episode of chest tightness, which raised that possibility. Apparently, the veteran had previously experienced paroxysmal atrial fibrillation. In correspondence dated in late September 1974, the veteran's private physician wrote that, following a review of the veteran's previous records, he (the veteran) did in fact experience paroxysmal atrial fibrillation. During the course of a private psychiatric examination in April 1979, the veteran complained of his "pulse going haywire," which appeared to be his reference to an irregular heartbeat. According to the veteran, he had been in the hospital on two different occasions, where cardiologists said "there was nothing wrong with his heart." At the time of a private psychiatric examination in September 1979, the veteran gave a history of an on-the-job injury in August 1973, at which time he injured his low back. While undergoing treatment for this injury in the spring of 1977, he was reportedly discharged early due to "cardiac difficulties." At that time, it was recommended that the veteran undergo electroshock to the heart to convert his apparent arrhythmia. However, following a second medical opinion, it was decided that the veteran could be managed conservatively. Regarding his past history, the veteran stated that his heart difficulties began following his injury of August 1973, and that he had experienced similar difficulties following an earlier injury in 1964. The veteran described his heart difficulty as an apparent arrhythmia of ectopic beat time. Otherwise, he had suffered no major medical illnesses, surgeries, or fractures. In correspondence of May 1991, the veteran's private physicians wrote that his (the veteran's) present problems were unrelated to "shell shock" during World War II. During the course of a VA mental status examination in September 1991, the veteran gave a history of coronary artery disease, for which he was receiving medication. In correspondence of July 1993, the veteran's private physician wrote that the veteran was under his care for atherosclerotic heart disease and that, at times, he (the veteran) described a "sharp, stabbing-type of chest pain." Additionally noted was that the veteran was being treated for post-traumatic stress syndrome. In the opinion of the veteran's private physician, his (the veteran's) pain was "probably anxiety-induced." In correspondence of August 1993, the veteran's private physician wrote that the veteran was being followed for organic heart disease, including arteriosclerotic coronary artery disease, with a remote myocardial infarction in 1972; hypertensive cardiovascular disease, with previous congestive heart failure, now compensated; and chronic atrial fibrillation of over 20 years' duration with a history of embolic CVA. In addition, the veteran apparently suffered from post-traumatic stress syndrome. Correspondence from a private physician dated in October 1993 is significant for a clinical impression of a limited treadmill (test), with hypertensive blood pressure response, and nondiagnostic ST changes. Following a period of VA hospitalization in April 1994, the veteran received pertinent diagnoses of angina pectoris/coronary artery disease; atrial fibrillation; and post-traumatic stress disorder/anxiety. During the course of VA outpatient treatment in May 1994, the veteran complained of severe angina at times, in particular, when waking up from "bad dreams" due to post-traumatic stress disorder. The clinical assessment was of severe angina, Class IV, Canadian classification; and post-traumatic stress disorder, followed at the American Lake (VAMC). Following a period of VA hospitalization during the months of June and July 1994, the veteran received pertinent diagnoses of post-traumatic stress disorder, major depression, coronary artery disease with angina (post-coronary artery bypass graft), and hypertension. In a statement of November 1996, the veteran's private physician wrote that the veteran suffered from coronary artery disease which "had been stress aggravated in the past." Following a review of the veteran's chart, a VA specialist in the field of cardiovascular disease, in February 1997, noted the following: The patient has had paroxysmal atrial fibrillation and, more recently, chronic atrial fibrillation since 1972, and a similar long history of hypertension. In the records, there are allusions to a myocardial infarction in 1972, but there are no records to support such an event. An electrocardiogram dated March 30, 1994 does not show any evidence for prior myocardial infarction, and a left ventricular angiogram on December 27, 1993 does not show evidence for a prior infarction. There is no history of diabetes, elevated lipids, or tobacco use. The first documented presence of coronary artery disease is from a heart catheterization on December 27, 1993, which demonstrated minor irregularities of the right and circumflex coronary arteries, and a high grade (90%) left anterior descending coronary stenosis, and a more distal 70% lesion. The patient subsequently had angioplasty of lesions. The patient had repeated angioplasties to the left anterior descending lesions and, finally, coronary artery bypass surgery to the left anterior descending in July 1994. The patient has been on various antihypertensive medications for a number of years. Summary of Chart Review. The patient has well-documented hypertension and atherosclerotic coronary artery disease, and chronic atrial fibrillation. In response to a question regarding the etiologic relationship between post-traumatic stress disorder and the veteran's cardiovascular disease, the physician commented that: There is no known or recognized etiologic relationship between post-traumatic stress disorder and cardiovascular disorders. None of the major textbooks on cardiovascular medicine include post- traumatic stress disorder as an etiologic factor in atherosclerotic or hypertensive cardiovascular disease. A literature search in the National Library of Medicine Database back to 1980 searching on the key word post-traumatic stress disorder resulted in 934 references. Searching on the Major and Minor subject headings of heart or cardiac or heart diseases resulted in only 19 references. There were no matches searching on atherosclerosis or hypertension. A search on the key words post-traumatic stress disorder and cardiac or heart diseases produced 26 references. The majority of these do not provide any useful information regarding potential relationship between post-traumatic stress disorder and the etiology of heart disease. There are a few relevant studies, however, the first of these by Eberly and Engdahl in Hospital and Community Psychiatry, 1991; 42:807-813, compared former prisoners of war with general population groups, and found there were no differences in the rates of hypertension, diabetes, or myocardial infarction, although the rate of post- traumatic stress disorder was considerably elevated. McFall et al in Biology and Psychiatry 1992; 31:50-56 looked at measures of basal sympatho- adrenal function, including plasma norepinephrine and epinephrine as well as heart rate and blood pressure, in post- traumatic stress disorder subjects, and compared them to controls. There was no difference in the basal sympathetic tone between the post-traumatic stress disorder subjects and the controls, although the post-traumatic stress disorder subjects had a more exaggerated response to laboratory stressors than did the controls. The findings of normal basal sympatho-adrenal function would mitigate against this being a cause for hypertension. Bremner et al provided a review of the noradrenergic mechanisms in stress and in anxiety in Synapse 1996; 23:39-51. In this extensive literature review with 118 references, the authors concluded these studies provide evidence for increased noradrenergic responsiveness in panic and post-traumatic stress disorder, although there does not appear to be alternation in base line noradrenergic function in these patients. Thus, currently there does not appear to be any etiologic relationship between post-traumatic stress disorder and any of the cardiovascular diseases present in this patient. In response to the question whether post-traumatic stress disorder affects the cardiovascular disorder by increasing or otherwise accelerating the cardiovascular disorders, the physician responded: From the reviews noted above, it is possible to extrapolate that the patient's symptoms of angina pectoris might be exacerbated during a period of acute post-traumatic stress disorder decompensation or during flashbacks. However, these symptoms would last only as long as the post-traumatic stress disorder episode lasted. A prolonged post-traumatic stress disorder episode associated with an excessive outpouring of catecholamines with resultant exacerbation of the hypertension could potentially result in atherosclerotic plaque rupture and coronary thrombosis. To date, this does not appear to have occurred in this patient. In response to a request to define the level of cardiovascular disability attributable to aggravation by post-traumatic stress disorder, the examiner commented: This question is not answerable. In correspondence of late May 1997, the veteran's private physician wrote that the veteran was "apparently going through the VA Board of Veterans' Appeals for coverage for post-traumatic stress disorder denying relationship or bearing to his cardiovascular status." In the opinion of the veteran's physician, their (presumably, the VA's) direct statements that the two were not related really "had little bearing and truth." He further commented that "it is one of those disorders that is hard to prove one way or the other, but stress always plays a role with deteriorating risk factor control, and, in that manner, certainly can be aggravated." In October 1999, the Board sought the opinion of an independent medical expert regarding the nature and etiology of the veteran's cardiovascular disease. That expert, in correspondence of late December 1999, responded as follows: This patient has a history of coronary artery disease, with coronary artery bypass graft surgery in 1994 after a percutaneous transluminal angioplasty. He has a history of atrial fibrillation, which initially was paroxysmal, but has been chronic for many years. He has a long history of hypertension. He apparently had a CVA in 1977 resulting in left arm weakness, and a subsequent CVA in 1994 causing visual deficits. He has a history of post-traumatic stress disorder dating to trauma that developed during combat in the Philippines during World War II. This apparently surfaced in 1964 secondary to a back injury and resulting stress. He is currently considered 100 percent service connected for post-traumatic stress disorder, and he would like to be service connected for cardiovascular problems as well. To summarize his cardiovascular disorders, he has chronic coronary artery disease, chronic atrial fibrillation, and hypertension. He has in fact been evaluated for service connection for cardiovascular disease repeatedly in the past, and has been denied on all occasions. These include denials dated from December 5, 1973, February 28, 1994, June 14, 1995, as well as apparently others. The most recent evaluation was by Dr. James H. Caldwell, M.D., of February 19, 1997. Dr. Caldwell judged his cardiac ailments not to be service connected. Dr. Caldwell included a concise review of the literature of the relationship of post-traumatic stress disorder to cardiovascular disease. The conclusion was that there is little or no evidence in the literature to support a connection between the presence of post- traumatic stress disorder and cardiovascular disease. However, a subsequent evaluation by Dr. John P. Nagle of May 27, 1997 stated that the relationship between post-traumatic stress disorder and this patient's heart disease was uncertain; this opinion led to the current outside review. In my opinion, the weight of the evidence favors the opinion supported by Dr. Caldwell. This patient's traumatic experience occurred during World War II, preceding by at least 20 years any objective development of cardiovascular disease. Although the presence of post- traumatic stress disorder seems well established, there seems to be no evidence at all that the post-traumatic stress disorder led to the heart disease in any way. There is also no evidence that the post-traumatic stress disorder contributed in any way to exacerbation of the cardiac disease. This has been established repeatedly on previous evaluations, and there does not seem to be any new developments or other data that support having a different opinion. Therefore, I do not believe the post- traumatic stress disorder and it's symptomatology directly caused any of the patient's cardiovascular disorders, and I do not believe that any of his cardiovascular disorders accelerated or increased in severity or accelerated in progress as the result of the post- traumatic stress disorder. Analysis At the outset, the Board notes that the veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998). That is, the Board finds that he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required in order to comply with the duty to assist him mandated by 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 1998). Moreover, where a veteran served ninety (90) days or more during a period of war, and cardiovascular disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.307, 3.309 (1998). Finally, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1998). In the present case, service medical records fail to demonstrate the presence of chronic cardiovascular disease. While in October 1944, during the veteran's period of active military service, he gave a history of a "heart attack," a physical examination conducted at that time failed to reveal evidence of cardiovascular pathology. Moreover, an examination of the veteran's heart conducted in December of the following year was essentially negative, with no change in respiration or pulse following pressure over the carotid sinus. On service separation examination in April 1946, the veteran's cardiovascular system was within normal limits, and no pertinent diagnosis was noted. The earliest clinical indication of the presence of arguably chronic cardiovascular pathology is revealed by private medical records dated in 1974, almost 30 years following the veteran's discharge from service, at which time there was noted the presence of atrial fibrillation. Coronary artery disease was first noted no earlier than 1991, 45 years following the veteran's service separation. The veteran argues that his current cardiovascular disease is by and large the product of his service-connected post- traumatic stress disorder. In that regard, there are of record various statements from one of the veteran's private physicians to the effect that the veteran's cardiovascular disease has, at a minimum, been "aggravated" by his service-connected post-traumatic stress disorder. However, a VA specialist in cardiovascular disease, following a full review of the veteran's chart, was of the opinion that there was no etiologic relationship between the veteran's post- traumatic stress disorder and his cardiovascular disease. While the veteran's symptoms of angina pectoris "might" be exacerbated during a period of acute post-traumatic stress disorder decompensation or flashbacks, these symptoms would last "only as long as the post-traumatic stress disorder episode lasted." The Board observes that, in December 1999, an independent medical expert, after having reviewed the veteran's entire claims folder, was essentially in agreement with the aforementioned VA specialist, including the conclusion that there was "little or no evidence in the literature to support a connection between the presence of post-traumatic stress disorder and cardiovascular disease." In the opinion of the medical expert, the weight of the evidence favored the conclusion that there was no relationship between the veteran's cardiovascular disease and his service-connected post-traumatic stress disorder. This conclusion was buttressed by the fact that the veteran's traumatic experience occurred during World War II, preceding by at least 20 years any objective development of cardiovascular disease. Moreover, there was no evidence that post-traumatic stress disorder "led to heart disease," or "contributed in any way to exacerbation of (the veteran's) cardiac disease." Following a review of the entire evidence of record, the medical expert was of the opinion that the veteran's post- traumatic stress disorder and its symptomatology did not directly cause any of the veteran's cardiovascular disorders, nor were his cardiovascular disorders accelerated or increased in severity, or "accelerated in progress as a result of post-traumatic stress disorder." ORDER Service connection for cardiovascular disease is denied. John E. Ormond, Jr. Member, Board of Veterans' Appeals