BVA9500307 DOCKET NO. 89-14 238 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Susan Paczak, Attorney WITNESSES AT HEARING ON APPEAL Appellant and her daughter ATTORNEY FOR THE BOARD C. S. Freret, Counsel INTRODUCTION The veteran had active military service from January 1944 to April 1945. In June 1990, the Board of Veterans' Appeals (Board) denied entitlement to service connection for the cause of the veteran's death, on appeal from a rating decision by the Pittsburgh, Pennsylvania, Regional Office (RO). The appellant appealed to the United States Court of Veterans Appeals (Court). In March 1992, the Court granted a motion by the Secretary of the Department of Veterans Affairs (VA) to remand the case for additional development. Following the Court's remand, the Board obtained two independent medical evaluations as to whether the veteran's service-connected disabilities caused or contributed significantly to cause his death. CONTENTIONS OF APPELLANT ON APPEAL The appellant asserts that the veteran's service-connected residuals of rheumatic heart disease and polyarthritis of the spine, neck, and hip contributed significantly to cause his death. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the appellant's claim of entitlement to service connection for the cause of the veteran's death. FINDINGS OF FACT 1. The veteran's death, at the age of 76, occurred on May [redacted] 1988, and was caused by congestive heart failure due to coronary heart disease and chronic obstructive pulmonary disease. 2. At the time of his death, the veteran was service connected for polyarthritis of the spine, hip, and neck, with ankylosing, rated 60 percent disabling, and for residuals of rheumatic heart disease, rated 10 percent disabling. 3. Coronary heart disease and chronic obstructive pulmonary disease are not shown to have been present in service, and each was initially manifested many years later. 4. The veteran's service-connected polyarthritis of the spine, hip, and neck, with ankylosing, and residuals of rheumatic heart disease are not shown to have been etiologically or causally related to his coronary heart disease and chronic obstructive pulmonary disease. 5. The veteran's service-connected polyarthritis of the spine, hip, and neck, with ankylosing, and residuals of rheumatic heart disease were not a causal factor in his death, nor did they debilitate him to the extent that he was materially less capable of resisting the effects of the coronary heart disease and chronic obstructive pulmonary disease that caused death. CONCLUSIONS OF LAW 1. Coronary heart disease and chronic obstructive pulmonary disease were not incurred in or aggravated by wartime service, nor may coronary heart disease be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). 2. Coronary heart disease and chronic obstructive pulmonary disease are not shown to have been proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1993). 3. A disability incurred in or aggravated by service did not cause or contribute substantially or materially to cause death. 38 U.S.C.A. §§ 1310, 5107 (West 1991); 38 C.F.R. § 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The provisions of 38 U.S.C.A. § 5107(a) (West 1991) have been met, in that the appellant's claim is well-grounded and adequately developed. The appellant argues that service connection should be granted for the cause of the veteran's death because, she claims, his service-connected residuals of rheumatic heart disease and polyarthritis of the spine, neck, and hip played a significant role in causing his death. The evidence shows that the veteran died on May [redacted] 1988, at the age of 76, and that the cause of death was congestive heart failure due to coronary heart disease and chronic obstructive pulmonary disease. Copy of death certificate, dated May [redacted] 1988. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110 (West 1991). Additionally, where a veteran served continuously for 90 days or more during a period of war, and coronary heart 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); 38 C.F.R. §§ 3.307, 3.309 (1993). Service connection may also 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) (1993). To establish service connection for the cause of the veteran's death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. For a service-connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. For a service-connected disability to constitute a contributory cause, it is not sufficient to show that it casually shared in producing death, but, rather, it must be shown that there was a causal connection. 38 U.S.C.A. § 1310 (West 1991); 38 C.F.R. § 3.312 (1993). Rheumatic fever is an acute infectious disease, affecting the structures about the joints (though without permanent bone damage) and, frequently, the endocardium. Children are as a rule affected, usually before the age of 20 years. Seldom is the initial attack after 25 years. The disease tends to recur, and serious heart trouble may follow the first or a subsequent attack. With acute rheumatic fever in service, perhaps without manifest damage to the heart, a subsequent recurrence of the infection, should be accepted as service connected. With even a few days service, service connection may be given for an acute rheumatic fever and any cardiac residuals. On the other hand, a mitral insufficiency without a history of rheumatic fever, chorea, or tonsillitis, or definite complication in service, must be considered as functional. Aortic insufficiency with a history of rheumatic fever and manifestation within approximately 15 years from the date of syphilitic infection, if any, should generally be considered rheumatic and always so when there is associated mitral or aortic stenosis. With a history of rheumatic fever in service, an aortic insufficiency manifest some years later without other cause shown may be service connected. The subsequent progress of rheumatic heart disease, and the effect of superimposed arteriosclerotic or hypertensive changes cannot usually be satisfactorily disassociated or separated so as to permit differential service connection. It is for this reason, in part, that great insistence is placed upon ascertainment of the service-connected disease as a true pathological entity. A subsequent change of diagnosis from one of an organic condition to one reflecting the effect of psychic or nervous factors casts doubt on the original diagnosis, but unless the correction is promptly made continuance of the service connection and of the evaluation under the new diagnosis is required. Such a change does not reflect an improvement of the physical condition. 38 C.F.R. § 4.101 (1993). The veteran's service medical records show no complaints, findings, or treatment suggestive of coronary heart disease or pulmonary disease. He was hospitalized from March 25 to April 16, 1945, for treatment of symptomatology that was diagnosed as valvular heart disease with mitral stenosis that was caused by rheumatic fever. Form 55 A, Medical Department, U. S. Army. Examination of the heart during the period of hospitalization revealed that it was normal in size, shape, and position, with no arrhythmias. A high-pitched blurring diastolic murmur was noted just inside and along the apical impulse. Form 55 C, Medical Department, U. S. Army. X-ray examination of the veteran's chest in October 1946 revealed that there was no abnormality of shape of the heart and that the lungs were clear. Veterans Administration Form 2614 h, dated October 31, 1946. The veteran underwent a VA physical examination in September 1947. The respiratory system was reported to be normal and there was no evidence of edema, cyanosis, or dyspnea. A definite systolic murmur was heard at the apex and was not transmitted. Blood pressure was 102/60. VA Form 2545, Report of Physical Examination, dated September 23, 1947. A diagnosis of kyphoscoliosis, secondary to arthritis, was noted on a report of the veteran's hospitalization at a VA medical facility from March to April 1980. VA Form 10-1000, Hospital Summary, for the period from March 31 to April 7, 1980. An X-ray of his chest during the period of hospitalization showed ankylosing spondylitis in the thoracic spine and no other abnormality in the lung and heart. VA Form 10-5355, dated April 1, 1980. At an April 1981 VA medical examination, evaluation of the veteran's cardiovascular system revealed a regular rhythm, normal rate, and attenuated tones. Evaluation of the musculoskeletal system revealed severe ankylosing polyarthritis in the spine and left hip, with kyphoscoliosis of the spine and total ankylosis of the cervical spine. VA Form 21-2545, Report of Medical Examination, dated April 29, 1981. VA medical records show that the veteran was admitted to a VA medical facility on January 26, 1984, for evaluation of increasing shortness of breath and a productive cough of 24 to 48 hours duration. It was reported that the appellant had a70 pack/year history of smoking, and the diagnosis on discharge 10 days later was chronic obstructive pulmonary disease. VA Form 10-1000, Hospital Summary, for the period from January 26 to February 4, 1984. He was seen at a pulmonary clinic in May 1986 for evaluation of complaints involving shortness of breath on mild exertion, relieved with "alergent" inhaler, and a non- productive nighttime cough, without fever or night sweats. The assessment was restrictive/lung disease. General Services Administration Standard Form (GSASF) 509, Progress Notes, dated May 5, 1986. An assessment of chronic obstructive pulmonary disease/restrictive lung disease was reported in August 1986. General Services Administration Standard Form (GSASF) 509, Progress Notes, dated August 25, 1986. The veteran was hospitalized at a VA hospital from December 1987 to January 1988 for treatment of a cerebral hemorrhage, and the diagnoses included ankylosing spondylitis, chronic obstructive pulmonary disease, and stable angina. VA Form 10-1000, Discharge Summary, for the period from December 6, 1987, to January 13, 1988. He returned to the VA hospital in April 1988 for treatment of increasing sputum production and shortness of breath. An episode of prolonged substernal chest pain associated with hypotension and tachypnea on April 21 was ruled out for a myocardial infarction. The diagnoses included pneumococcal pneumonia, coronary artery disease/angina, chronic obstructive pulmonary disease, restrictive lung disease, left hemiparesis, status post cerebrovascular accident, and ankylosing spondylitis. VA Form 10-1000, Discharge Summary, for the period from April 17 to May 4, 1988. The veteran was transferred from the VA hospital to Aspinwall on May 4, 1988, for chronic care, which involved oxygen treatment and medications, including Lasix. He did not respond to treatment and died on May [redacted] 1988. The cause of death was reported as congestive heart failure and chronic obstructive pulmonary disease. VA Form 10-1000, Discharge Summary, for the period from April 17 to May [redacted] 1988. In March 1993, the VA requested an independent medical evaluation of the veteran's claims file by a private cardiologist for the purpose of ascertaining whether the veteran's service-connected residuals of rheumatic heart disease caused or contributed to his death from coronary heart disease. This independent medical evaluation was conducted by H. R. Horn, M.D., in April 1993. He indicated that the basic disorders listed on the chart problem list, and as diagnoses, on the terminal hospitalization record (VA Form 10-1000, Discharge Summary, for the period from April 17 to May [redacted] 1988) did not include rheumatic heart disease or valvular heart disease as diagnoses or problems that needed to be addressed, and that the absence of any documentation of rheumatic heart disease, valvular heart disease, or related entities in the medical records was noteworthy. He also pointed out that there was no mention, much less a diagnosis, of rheumatic heart disease or valvular heart disease as a clinical issue or problem during the veteran's many outpatient clinic visits over the years. The cardiologist noted in his April 1993 evaluation that some 43 years had elapsed between the reported diagnosis of the veteran's rheumatic heart disease in 1945 and his death at age 76 in 1988, and that, in general, one would expect significant rheumatic heart disease/valvular heart disease to have manifested itself and become clinically evident during that time if it were of significant magnitude to contribute to a patient's deteriorating clinical status and death. He indicated that, alternatively, one would certainly anticipate the demonstration and detection of any sequelae of rheumatic heart disease in a case where they were contributing to deteriorating cardiac function. The physician summarized his analysis of the case by opining that the medical records did not demonstrate that the veteran's service-connected residuals of rheumatic heart disease caused or substantially or materially contributed to his death, which was considered to be due to coronary artery disease. Medical statement from H. R. Horn, M.D., dated April 8, 1993. Pursuant to the VA's request in April 1994 for an independent medical evaluation by a pulmonary specialist, J. R. DuPre, M.D., evaluated the claims file for the purpose of determining whether the veteran's service-connected polyarthritis played any part in the cause of his death. The pulmonologist noted that the medical records showed that the veteran had severe polyarthritis, which was more precisely termed ankylosing spondylitis, and that he had pulmonary involvement of his ankylosing spondylitis, evidenced by no chest wall movement with respirations, which was a common finding in patients with severe ankylosing spondylitis due to costovertebral ankylosis and the secondary fixation of the thoracic cage. After carefully examining all of the medical evidence, particularly the records from the terminal period of hospitalization, the pulmonologist stated that the medical data indicated that, despite the veteran having had pulmonary involvement from his ankylosing spondylitis and thus a potential impairment in his pulmonary defense mechanism and predisposition to pneumonia, congestive heart failure, and not pneumonia, was the cause of his death. The pulmonologist reported that the data indicated that the veteran's pneumonia had resolved prior to his death, and went on to attribute the veteran's congestive heart failure as being due to coronary heart disease, given his age and tobacco use. He also reported that evidence of coronary artery disease was noted in an EKG that showed changes consistent with a previous anterior wall myocardial infarction. The pulmonologist opined that the medical evidence in the veteran's claims file did not support the conclusion or create a reasonable doubt that his service- connected ankylosing spondylitis played any part in his death. In evaluating the appellant's claim, the Board notes that the initial manifestations of coronary heart disease and chronic obstructive pulmonary disease are shown to have been many years after the veteran's separation from service. Additionally, the medical evidence since service reveals no treatment for the veteran's service-connected residuals of rheumatic heart disease. While we are cognizant of the fact that both the veteran's service-connected residuals of rheumatic heart disease and the coronary heart disease that caused his death are related to the cardiovascular system, each stems from a distinct pathology, with the veteran's service-connected cardiovascular disease having been rheumatic in nature and the coronary artery disease being arteriosclerotic in nature. Furthermore, there is no objective evidence of medical causality between the veteran's service- connected polyarthritis of the spine, hip, and neck, with ankylosing, and residuals of rheumatic heart disease and the cause of his death due to coronary heart disease and chronic obstructive pulmonary disease. After careful and thorough evaluation of the claims file, including all of the veteran's medical records, a medical specialist in pulmonology and a medical specialist in cardiology have opined that the evidence does not demonstrate that the veteran's service-connected polyarthritis of the spine, hip, and neck, with ankylosing, and residuals of rheumatic heart disease caused or contributed substantially or materially to cause his death. Although the appellant and her representative have offered opinions as to the relationship between the veteran's service- connected diseases and the cause of his death, particularly in testimony at an April 1992 personal hearing at the RO, they lack medical expertise and are not qualified to render an opinion regarding a causal relationship between the veteran's service- connected diseases and the cause of his death. See Espiritu v. Derwinski 2 Vet.App. 492 (1992). Therefore, because the preponderance of the evidence establishes that the veteran's death was caused by diseases that were unrelated to service or to a service-connected disability, the Board is unable to identify a basis to grant service connection for the cause of the veteran's death. ORDER Service connection for the cause of the veteran's death is denied . JACK W. BLASINGAME Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE) The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been so assigned. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue that was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.