Citation Nr: 0003275	
Decision Date: 02/09/00    Archive Date: 02/15/00

DOCKET NO.  98-01 437	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Medical and Regional Office 
Center in Wichita, Kansas


THE ISSUE

Entitlement to service connection for cardiovascular disease.  


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of 
the United States


WITNESSES AT HEARING ON APPEAL

Appellant and spouse


ATTORNEY FOR THE BOARD

Christopher J. Gearin, Associate Counsel


INTRODUCTION

The veteran had active service from November 1942 to October 
1945.  He is a veteran of the Air Offensive over Europe and 
received the Purple Heart Medal.  He was a prisoner of war of 
the German government from May 1944 to May1945.  

This matter comes before the Board of Veterans' Appeals 
(Board) on appeal from a decision of the Department of 
Veterans Affairs (VA) Regional Office (RO) in Wichita, 
Kansas.  

In a statement received by the RO in September 1999, the 
veteran withdrew his request for a hearing.


FINDINGS OF FACT

1.  Sufficient evidence necessary for an equitable 
disposition of the veteran's appeal has been obtained by the 
RO.  

2.  The veteran was a prisoner of war of the German 
government from May 1944 to May 1945.  

3.  The veteran experienced localized edema during his period 
of internment as a prisoner of war.  

4.  The veteran currently has coronary artery disease 
(ischemic heart disease) to a compensable degree.  



CONCLUSION OF LAW

Incurrence of coronary artery disease (ischemic heart 
disease) during active duty is presumed.  38 U.S.C.A. 
§§ 1101, 1110, 1112, 1113 (West 1991 & Supp. 1999); 38 C.F.R. 
§§ 3.303, 3.307, 3.309 (1999).  


REASONS AND BASES FOR FINDINGS AND CONCLUSION

The appellant contends that service connection should be 
granted for cardiovascular disease as a result of his 
confinement as a prisoner of war.  

In view of the veteran's status as a prisoner of war and the 
presence of coronary artery disease to a compensable degree, 
the Board finds that his claim for service connection for 
cardiovascular disease is well grounded within the meaning of 
38 U.S.C.A. § 5107(a).  Greyzck v. West, 12 Vet. App. 288, 
291 (1999).  The Board is also satisfied that all relevant 
facts have been properly developed with respect to this issue 
and that no further assistance to the appellant is required 
to comply with the duty to assist mandated by statute.  

Service connection may be granted for disability resulting 
from disease or injury incurred in or aggravated by active 
service.  38 U.S.C.A. § 1110.  Regulations also provide that 
service connection may 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).  For the showing 
of chronic disease in service, there is required a 
combination of manifestations sufficient to identify the 
disease entity, and sufficient observation to establish 
chronicity at the time, as distinguished from merely isolated 
findings or a diagnosis including the word "chronic."  
Continuity of symptomatology is required where the condition 
noted during service is not, in fact, shown to be chronic or 
where the diagnosis of chronicity may be legitimately 
questioned.  When the fact of chronicity in service is not 
adequately supported, then a showing of continuity after 
discharge is required to support the claim.  38 C.F.R. § 
3.303(b).  

Beriberi (including beriberi heart disease) is presumed to 
have been incurred during active military service if it is 
manifest to a degree of 10 percent at any time following 
active service if the veteran is a former prisoner of war and 
was interned or detained for not less than 30 days.  38 
U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(c).  
For purposes of presumptive prisoner-of-war diseases, "the 
term beriberi heart disease includes ischemic heart disease 
in a former prisoner of war who had experienced localized 
edema during captivity."  38 C.F.R. § 3.309(c), Note.  

Factual Background

As noted in the Introduction, the veteran served from 
November 1942 to October 1945 and was a prisoner of war of 
the German government from May 1944 to May 1945.  He received 
the Purple Heart Medal in the Air Offensive over Europe.  The 
service medical records are negative for complaints or 
findings of cardiovascular disability prior to his internment 
as a prisoner of war.  His separation examination, which was 
conducted about five or six months following his return to 
military control, was likewise negative for cardiovascular 
abnormality.  

After discharge the veteran complained of foot trouble, 
generally claimed as due to frostbite.

In June 1954, Ward Cole, M.D., the veteran's private 
physician, reported that the veteran had complained of 
swelling of the feet and sensitivity to cold in winter since 
World War II.  Dr. Cole essentially felt that this was a 
continuing disability.  

According to a February 1973 orthopedic examination report, 
the veteran reported that his feet would swell when they were 
cold.  

VA performed a cardiology examination in April 1973.  The 
veteran complained of swollen feet, particularly in cold 
weather.  The physical examination was negative for dependent 
edema.  

The veteran described his prisoner-of-war experiences in a 
May 1983 VA social and industrial survey.  He recounted that 
from February to May 1945, when he was repatriated, his 
captors forced him and the other prisoners to march day after 
day with little food.  

The veteran indicated on a prisoner-of-war medical history 
report, received by the RO in June 1983, that he had 
experienced swollen legs and feet during internment.  

The veteran testified about swollen feet before the Board in 
November 1983.  As the war against the Germans came to a 
close, the conditions worsened.  The weather was below 
freezing and snow covered the ground.  Marching in these 
conditions caused his feet to swell and go numb.  He also 
indicated that his feet had continued to bother him since 
service.  

With respect to an unrelated issue, in December 1984 the 
Board granted entitlement to service connection for residuals 
of frostbite of the feet.  Of note, however, the Board 
accepted as credible evidence the veteran's complaints of 
pain and foot swelling at the time of his separation from 
service.  

VA outpatient records show that beginning around 1985, the 
veteran complained of angina.  Subsequent VA medical records 
show that he continued to be treated for complaints of 
angina.  

In January 1993, the VA performed a cardiac catheterization 
on the veteran.  The surgeon's impression after performing 
the procedure was that the veteran had coronary artery 
disease (CAD) involving the branches of the left anterior 
descending and the left circumflex arteries.  The final 
diagnosis on discharge from the hospital was atherosclerotic 
coronary artery disease.  

In January 1997, the RO received a December 1947 transcript 
taken by the United States War Crimes Office of the Civil 
Affairs Division as part of an investigation into the 
mistreatment of American prisoners of war at Stalag Luft #4 
from November 1944 to May 1945.  (Separate evidence of record 
indicates that the veteran was also imprisoned in Stalag Luft 
#4.)  The transcript reflects testimony provided by a Leslie 
Caplan, M.D.  Dr. Caplan was a prisoner of war in Stalag Luft 
#4 from November 1944 to February 1945.  There is no 
indication in the doctor's testimony that he knew the 
veteran.  Nevertheless, Dr. Caplan described the terrible 
conditions in Stalag Luft #4.  In summary, Dr. Caplan 
testified that the medical conditions were terrible.  In 
February 1945, the Russian offensive threatened to engulf 
Stalag Luft #4; so, according to his records, the enemy 
captors forced the prisoners to march for 53 days and 330 
miles.  He recounted that they were underfed during this 
time.  He estimated that they ate about 1,300 calories a day, 
far less than the minimum required to maintain body weight, 
even without the physically strenuous marching.  Dr. Caplan 
was later transferred to Stalag #2B, where the conditions 
were somewhat better.  

According to a May 1996 VA Medical Center discharge report, 
the veteran was diagnosed with three-vessel CAD.  Likewise, a 
June 1996 VA Medical Center discharge report reveals a 
diagnosis of CAD.  He was scheduled for a coronary artery 
bypass.  

A July 1996 VA Medical Center discharge report reflects a 
diagnosis of CAD with a history of progressive exertional 
angina.  A history of transient ischemic attacks was also 
noted.  

In December 1997, the veteran appeared before a hearing 
officer at the RO.  He testified that he experienced swollen 
feet as a prisoner of war.  It was cold from September 1944 
to February 1945 and the snow was deep on the ground.  His 
captors forced him to stand in formations for hours in this 
weather.  His shoes would get wet and cold, and his feet 
would swell.  Beginning in February 1945, he marched for 88 
days on the road.  This caused his feet to swell.  He 
reiterated that he had swollen feet as a prisoner of war.  

In December 1997, a VA physician essentially opined that the 
veteran's heart problems referred to in the record were not 
associated with ischemic cardiac disease.  

Analysis

Upon review of the record, the Board finds that the evidence 
supports the appellant's claim of entitlement to service 
connection for CAD.  First, the record clearly shows that the 
veteran was interned as a prisoner of war for more than 30 
days.  

Second, the veteran's reported prisoner-of-war medical 
history indicates that he experienced frostbite with edema of 
the feet while in captivity.  This contention is credible and 
consistent with the circumstances of his service.  For 
example, the veteran has consistently asserted that he 
experienced swollen feet during his internment as a prisoner 
of war.  The testimony of Dr. Caplan in December 1947 
corroborates the veteran's experiences as a prisoner in 
Stalag Luft 4B.  Although the veteran does not contend that 
he knew Dr. Caplan while at Stalag Luft 4B, the doctor's 
first-hand medical descriptions of his treatment of prisoners 
of war support the veteran's descriptions of malnutrition and 
swollen feet, due to constant marching in the snow over a 
period several months.  Therefore, based on this evidence, 
the Board finds that the veteran experienced edema while a 
prisoner of war.  

Third, the veteran is currently diagnosed with CAD.  In light 
of this diagnosis, it is important to note that medical 
treatises indicate that "coronary artery disease" and 
"ischemic heart disease" are terms that are used to 
identify conditions manifested by inadequate myocardial 
perfusion.  Harrison's Principles of Internal Medicine 1365 
(14th ed. 1998) (indicating that atherosclerotic disease of 
epicardial coronary arteries (or CAD) causes a decrease in 
myocardial perfusion, otherwise known as ischemia).  

As noted above, for purposes of presumptive prisoner-of-war 
diseases, beriberi heart disease includes ischemic heart 
disease in a former prisoner of war who had experienced 
localized edema during captivity.  38 C.F.R. § 3.309(c).  The 
Board notes that 38 C.F.R. § 3.309(c) was only recently 
amended to include the notation that "the term beriberi heart 
disease includes ischemic heart disease in a former prisoner 
of war who had experienced localized edema during captivity."  
Thus, the Board finds that this evidence compellingly shows 
that the veteran likely experienced edema as a prisoner of 
war.  It is undisputed that he currently has CAD.  The Board 
therefore finds that he is entitled to the presumption that 
he developed heart disease as a result of his internment as a 
prisoner of war, as it is not now possible to disassociate 
the edema he experienced in service from edema as a 
manifestation of beriberi heart disease.  38 C.F.R. § 
3.309(c).  The veteran has been accorded the benefit of the 
doubt with respect to this material issue.  38 U.S.C.A. 
§ 5107(b).  

In contrast, the Board does not find that the December 1997 
VA medical opinion rebuts the presumption of service 
incurrence.  That opinion found that the veteran's diagnosed 
transient ischemic attacks were not related to his recognized 
coronary artery disease.  This much is conceded.  However, 
the opinion did not find that the edema the veteran appears 
to have suffered during his internment as a prisoner of war 
was related solely to residuals of frostbite and could 
therefore be disassociated from any claimed beriberi heart 
disease as result of the veteran's internment.  Hence, it 
appears that the December 1997 VA opinion was not complete 
and does not rebut the presumption accorded prisoners of war 
situated such as the veteran was in this case.  

Furthermore, in July 1996 a VA Medical Center discharge 
report diagnosed him with CAD with a history of transient 
ischemic attacks.  As noted above, CAD and ischemic heart 
disease are essentially the same thing.  Harrison's 
Principles of Internal Medicine 1365.  The Board finds that 
the physician in December 1997 did not provide a sufficient 
explanation as to why the diagnosis of CAD does not equate to 
ischemic heart disease in light of the evidence of record.  
Therefore, the Board does not find the December 1997 VA 
opinion persuasive.  It follows that service connection for 
cardiovascular disease on a presumptive prisoner-of-war basis 
must be granted.  38 C.F.R. § 3.309(c), and Note.  


ORDER

Service connection for cardiovascular disease is granted.  



		
	WILLIAM W. BERG 
	Acting Member, Board of Veterans' Appeals