Citation Nr: 0001184 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 93-05 695 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a heart disorder, including as secondary to a service connected anxiety disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Eckart, Associate Counsel INTRODUCTION The veteran had active service from May 1943 to October 1945. This appeal arises from a rating decision of September 1992 from the Regional Office and Insurance Center in Philadelphia, Pennsylvania (RO), which denied service connection for a heart disorder as secondary to a service connected anxiety disorder. The Board remanded the case to the RO for additional development in January 1995, and again in November 1997. The Board is satisfied that the requested development has been accomplished. FINDINGS OF FACT 1. A heart disorder was not manifested in service, nor is one shown to have been manifest to a compensable degree within one year following the veteran's discharge from active duty or to be related to service. 2. The veteran's service-connected anxiety disorder is not shown to have caused, or caused an increase in the severity of, his heart disorder. CONCLUSION OF LAW A heart disorder was not incurred or aggravated in service, may not be presumed to have been incurred in service, and is not shown to be proximately due to or the result of the veteran's service-connected anxiety disorder. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran asserts that his heart disease is proximately due to his service connected anxiety disorder. The report from the veteran's entrance examination of May 1943 revealed a normal cardiovascular system, with blood pressure readings of 140/80. Service medical records reveal no evidence of cardiovascular problems. He was treated in August 1945 for complaints of nervousness and insomnia. His heart was described as normal, with X-ray revealing that heart was of the elongated type. He was assessed in September 1945 and by medical board in October 1945 with a personality disorder. On the veteran's December 1945 VA psychiatric examination, psychoneurosis, mixed type was diagnosed. No cardiovascular findings were reported. A rating decision of December 1945 awarded the veteran service connection for psychoneurosis. On January 1948 VA examination, the veteran was noted to have a normal heart, with blood pressure readings of 130/79 and no arrhythmia. The nervous condition was assessed as psychoneurosis, anxiety, chronic moderate. A chest X-ray in September 1959 noted an unremarkable heart. On December 1964 VA examination there was no evidence of heart enlargement or murmurs, and the veteran's blood pressure was 116/74. Psychiatrically, his anxiety symptoms were said to include easy excitability, and he was observed to become hostile and show flushing of the face and overactivity in a display of anger. Emotionally, he was extremely unstable. The first evidence of possible cardiovascular pathology comes from private treatment notes from 1977. A May 1977 hospital discharge summary gave a history of the veteran having, in the past two to four weeks, a left, precordial, severe chest pain, associated with weakness, tiredness and exhaustion, unrelated to exertion. He also complained of frequent palpitations, skips and pauses in his beat, chest pain could occur following the pause. He denied any significant cardiovascular history. Left heart catheterization and ventriculogram and coronary arteriography, revealed findings of normal coronary arteriography and normal ventricular end diastolic pressure and normal left ventriculogram. The circumflex coronary vessel however, seemed to originate from the right coronary artery. The impression was essential hypertension; anxiety reaction; and chest pain of undetermined origin. A May 1977 treatment note listed a diagnosis of paroxysmal tachycardia. A June 1977 private physician's certificate contained the opinion that the veteran "suffers from severe anxiety and there are times that he suffers chest pain, which is totally incapacitating, and who's (sic) etiology appears to be this same anxiety." The diagnoses were anxiety and essential hypertension. On November 1977 VA psychiatric examination, complaints of intense anxiety, tension and depression, with symptoms including frequent chest pain, palpitations and dyspnea were noted. No organic heart disease had been found after work-up at a private medical center. The diagnoses included chronic anxiety and depressive psychoneurosis, moderately severe, with psychophysiologic disturbance of the cardiovascular system. VA treatment notes from 1980 through 1993, include treatment for cardiac-type complaints. The veteran was repeatedly treated for complaints of chest pains, between 1980 and 1989. Diagnoses included "atypical chest pain" in September 1988, angina pectoris in November 1988, and simple angina through 1989. The treatment notes also document that the veteran suffered from chronic obstructive pulmonary disease (COPD), and anthracosilicosis. Private medical records reveal that the veteran was hospitalized for chest pain in July 1991, and underwent testing, including catheterization and stress test. It was noted that prior such testing yielded normal findings. The diagnoses based on the July 1991 tests included unstable angina, coronary artery disease, COPD, anemia and hypertension. Subsequent private treatment notes reveal a significant cardiac history, including hospitalization in September 1993 for diagnostic studies which yielded findings that included, unstable angina; coronary atherosclerotic heart disease and restenosis of the right coronary artery since a July 1991 procedure. In April 1994, the veteran underwent a repeat of the procedures done in September 1993, and once again, coronary atherosclerotic heart disease was diagnosed. An October 1995 VA examination report recites an inaccurate history of the veteran already being service connected for heart problems. The examiner explained to the veteran that it was more likely that his heart problems were secondary to lung problems and black lung, rather than to any emotional trauma. Private medical records reveal the veteran was hospitalized again in April 1995, with complaints of chest pain, and underwent a left heart catheterization without complication. In February 1996, he was hospitalized for a suspected transient ischemic attack. Carotid ultrasound revealed fairly extensive plaque formation in the left carotid artery. An echogram from February 1996 yielded findings of trace tricuspid regurgitation, aortic valve sclerosis and concentric left ventricular hypertrophy. On January 1997 VA psychiatric examination, anxiety disorder with depressive features was diagnosed. VA treatment notes from July 1994 through January 1999, report treatment for problems other than cardiac complaints, but also reveal that he had an abnormal EKG in February 1998. A thallium stress test in November 1998 revealed no exercised induced ischemia, no ventricular dilatation, and a left ventricular ejection fraction of 67 percent. In March 1999, an examination and claims file review was conducted by a board-certified cardiologist, and chief of Cardiology. It was noted that the veteran was service connected for a nervous condition. The first mention of chest pain was noted to have been in an April 1977 hospital admission report, which ruled out myocardial infarction. The cardiologist reported the veteran's subsequent cardiovascular medical history. When asked whether his chest pains got better after each of his two angioplasties, the veteran was unsure, but his chart did indicate that his chest pain was less frequent. The assessment was that the veteran clearly had coronary artery disease due to atherosclerosis and, for some time between 1990 and 1993, had significant obstruction of the right coronary artery causing myocardial ischemia. He had chest pain throughout that time, but also had chest pain throughout the 1980's and after 1993, when he did not have significant coronary artery disease. Probably much of his chest pain was a symptom of anxiety, not due to myocardial ischemia. However, it was reasonable to assume that during the time he had significant obstructive coronary disease, that anxiety provoked chest pain due to myocardial ischemia. As to whether the veteran's heart disease was etiologically related to his service connected anxiety disorder, the answer was clearly "no." The examiner stated that anxiety disorder was not the etiology of the veteran's atherosclerotic coronary artery disease and that anxiety, per se does not cause coronary artery disease, but like exercise, anxiety can precipitate myocardial ischemia in someone who has coronary artery disease. The examiner commented on the meaning of a June 1977 medical report which, in part stated, "the patient suffers from severe anxiety and there are times that he suffers chest pain which is totally incapacitating and whose etiology appears to be the same anxiety." The examiner observed that at the time of this report, the veteran had normal coronary arteries, and took the statement to mean that the chest pain at that time was a direct symptom of anxiety. The examiner reiterated that the anxiety did not cause coronary artery disease and stressed that coronary artery disease did not manifest until many years after the veteran left service, so that a heart disorder was not shown to be directly related to service. A handwritten addendum drafted in May 1999, apparently to clarify whether the veteran's heart disorder was aggravated by anxiety states as follows: 1. Baseline manifestations which are due solely to the effects of myocardial ischemia are zero. 2. The increased manifestations of myocardial ischemia are directly affected by service connected anxiety. Myocardial ischemia is the direct expression of coronary artery disease and cannot be separated. This addendum was unsigned and was drafted by a physician other than the cardiologist who performed the March 1999 VA examination. In July 1999 A further examination to clarify whether anxiety played a part in aggravating the veteran's heart disorder was conducted by the cardiologist who had conducted the March 1999 VA examination. He specifically addressed the handwritten addendum of March 1999, and expressed disagreement with the second statement of the addendum. The examiner pointed to the history of the veteran having developed anxiety in the 1940's and the first mention of chest pain shown in 1977. The history of chest pain continuing into the 1980's, but with negative findings on stress tests and cardiac catheterizations was reviewed. Severe coronary artery disease was first documented between 1991 and 1993, and the veteran was treated with angioplasties. The most recent catheterization of April 1995 showed no coronary lesions greater than 50 percent and the most recent stress test of November 1998 showed no perfusion defects. The conclusion drawn was that the veteran had significant obstructive coronary disease between 1991 and September 1993. He still has coronary artery disease, but has no significant obstructions that could cause myocardial ischemia since 1993. The examiner clarified his earlier statement that anxiety does not cause atherosclerosis but could precipitate myocardial ischemia if significant coronary obstructions were present. The examiner noted that the veteran's chest pain was atypical for angina. It sometimes occurred as a series of quick stabbing pains, and sometimes lasted a few minutes. There was no clear relationship to exertion, and the veteran indicated that nitroglycerin helped. His limitations to exercise resulted from back pain rather than chest pain. There was no clear relationship in frequency or severity to when he had significant coronary obstructions. It started when he did not have any coronary disease, continued in similar fashion when he did have significant coronary obstruction, but did not stop when the obstruction was removed. The examiner's opinion was that it was most likely that none of the veteran's chest pain was related to myocardial ischemia and all of it was is a symptom of anxiety. However, the examiner acknowledged that it is possible that between 1991 and 1993 when the veteran had significant coronary obstructions, his service connected anxiety could have precipitated myocardial ischemia. Since the evidence does not reveal the veteran to currently have significant coronary obstructions, there is no basis for concluding that his anxiety is precipitating myocardial ischemia at present. In conclusion, the reviewing cardiologist stated: The baseline manifestations which currently are due to the nonservice connected coronary artery disease are none. His chest pain is solely due to anxiety. The increased manifestations which are due to his service connected anxiety are the chest pains which occur in a pattern not typical of angina and not due to myocardial ischemia. The most current evaluation of his coronaries suggests that he does not have significant coronary obstructions and therefore his anxiety is not precipitating myocardial ischemia. II. Analysis The Board finds that the veteran's claim for service connection for heart disease, as secondary to a service connected anxiety disorder, is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991) in that it is a "plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). In this regard, the Board notes that the medical evidence, up to and including the March 1999 claims file review and July 1999 follow up report, reveals the veteran to presently have a cardiac disability. There is also competent medical evidence from the private medical records of 1977, which provides a nexus between his cardiac complaints, and a service connected anxiety disorder. Specifically, the June 1977 letter from a private physician that suggests the etiology of chest pains stem from anxiety and the report from a November 1977 VA examination that diagnosed chronic anxiety and depressive psychoneurosis with psychophysiologic disturbance of the cardiovascular system, serve to well ground this claim. See Caluza v. Brown, 7 Vet.App. 498, 506 (1995). The Board further finds that the statutory duty to assist has been satisfied through the development of evidence, including by remand orders of January 1995 and November 1997. The law permits the grant of service connection for a disability which results from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110. There are some disabilities, including cardiovascular disease, where service connection may be presumed if the disorder is manifested to a degree of 10 percent within one year of separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection on a secondary basis, under 38 C.F.R. § 3.310(a), is warranted for disability which is proximately due to or the result of a service-connected disease or injury. When a service-connected disability aggravates, but is not the proximate cause of, a non-service- connected disability, service connection may be established for the increment of the nonservice-connected disability attributable to the service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that the evidence does not establish, nor is it even alleged, that direct service connection for a heart disorder, including on a presumptive basis, is warranted. Such disease was not manifested in service or in the first postservice year, and there is no medical opinion relating it to service. As was previously noted, the veteran alleges that his cardiovascular disability was caused, or at least aggravated, by his service connected psychiatric disorder. Upon review of the evidence, the Board finds that the preponderance of the evidence is against a grant of service connection for a heart disorder as secondary to the service connected anxiety. The veteran has been shown to suffer from chest pains since 1977. A June 1977 physician's opinion is to the effect that the chest pains the veteran was having were related to his anxiety. The medical evidence clearly establishes that the veteran subsequently developed coronary artery disease. All evidence of record has been carefully considered. The Board finds most persuasive the opinion from the cardiologist who reviewed the entire record and examined the veteran in March 1999 and prepared the July 1999 clarification. That specialist found that the veteran's heart disease was the direct result of coronary artery disease. As to whether the veteran's heart disease, is etiologically related to his service connected anxiety disorder, the answer was clearly "no." The examiner stated that anxiety disorder was not the etiology of the veteran's atherosclerotic coronary artery disease and that anxiety, per se does not cause coronary artery disease. The cardiologist also addressed the matter of whether the veteran's anxiety disorder aggravated his heart disease. While he acknowledged that it was possible that, between 1991 and 1993, when the veteran had significant coronary obstructions, his service connected anxiety could have precipitated myocardial ischemia, he concluded that as medical evidence did not reveal current significant coronary obstructions, there was no basis for concluding that anxiety is precipitating myocardial ischemia at the present time. The cardiologist further expressed an opinion that none of the veteran's chest pain, which he described as "atypical" of angina, was related to myocardial ischemia and all of it is a symptom of anxiety. In light of the foregoing, the Board finds that the preponderance of the evidence is against a holding that the veteran's claimed heart disorder was caused or aggravated by his service-connected anxiety. Consequently, secondary service connection is not warranted. Incidentally, it is noteworthy that the reviewing VA cardiologist found that the veteran's chest pain was a symptom of his service connected anxiety. Accordingly, any disability/impairment due to chest pain should be considered when the veteran's anxiety disorder is rated. ORDER Service connection for a heart disorder, including as secondary to a service-connected anxiety disorder is denied. George R. Senyk Member, Board of Veterans' Appeals