Citation Nr: 0007047 Decision Date: 03/15/00 Archive Date: 03/23/00 DOCKET NO. 97-28 349 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to service connection for heart disease claimed as secondary to the veteran's service-connected generalized anxiety disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Cryan, Associate Counsel INTRODUCTION The veteran served on active duty in the military from February 1941 to May 1945. He served less than thirty days as a prisoner of war (POW) after being shot down during a mission over Germany in April 1945. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 1997 rating decision by the Manchester, New Hampshire Regional Office (RO) of the Department of Veterans Affairs (VA), which denied service connection for arteriosclerotic heart disease, claimed as secondary to the veteran's service-connected anxiety disorder. The veteran timely perfected an appeal to the Board. He testified before a hearing officer at the RO in December 1997. The case was remanded back to the RO in July 1999 for further development. After completion of the requested development, the RO continued to deny the claim, and the matter has been returned to the Board for further appellate consideration. During the pendency of this appeal, the veteran raised the issue of his entitlement to ischemic heart disease based upon his POW experiences. As such a claim appears to pertain to primary, rather than secondary service connection, it is referred to the RO for all appropriate action. FINDING OF FACT While the evidence of record includes medical indication that anxiety and stress related disorders may contribute to or aggravate heart problems, there is no persuasive medical evidence of any nexus between current heart disease and the veteran's service-connected generalized anxiety disorder. CONCLUSION OF LAW Heart disease is not proximately due to or the result of service-connected anxiety. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303(a), 3.310(a) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this case, the veteran has been diagnosed with a heart disability that he contends is due to his service-connected generalized anxiety disorder. Service connection may be granted for disability resulting from an injury or disease that was incurred in or aggravated by active service, or, on a secondary basis, for disability that is proximately due to or the result of a service- connected condition. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303(a), 3.310(a) (1999). 38 C.F.R. § 3.310(a) also has been interpreted to permit service connection for the degree of impairment resulting from aggravation of a nonservice-connected condition by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection for heart disease, on a primary basis, was denied by the RO in January 1956 and in October 1983. In this claim, however, the veteran contends that his heart disease is secondary to his service-connected anxiety disorder. A review of the numerous VA inpatient hospitalization reports and outpatient treatment records clearly shows that the veteran has current cardiovascular disabilities, to include heart disease, for which he underwent bypass surgery in 1995. In addition to chronic heart disease, the veteran also has a long history of numerous medical problems that include hyperlipidemia, hypertension, peripheral vascular disease, esophageal reflux, lumbago, congesting heart failure, paroxysmal atrial tachycardia, obesity, and prior surgery for aortic aneurysm. In July 1996, the veteran was afforded a VA general medical examination. The examiner noted the veteran's heart disability, but did not offer any opinion as to the etiology of the disability. Likewise, during the veteran's July 1996 VA examination for mental disorders, the examiner never suggested that the veteran may have developed heart problems as a result of his generalized anxiety disorder. In March 1997, the veteran was afforded a VA examination for diseases of the heart. The examiner noted that the veteran had a long-standing history of peripheral vascular disease, that he has a past history of tobacco abuse with a 50 to 60 pack per year smoking history prior to becoming abstinent in his early 50's. In addition, the examiner noted a long- standing history of dyslipidemia and hypertension, as well as diffuse vascular disease. After a physical examination, the examiner's impression was: 1. ischemic heart disease with coronary atherosclerosis, status post coronary artery bypass grafting and a long-standing history of paroxysmal supraventricular tachycardia - cured by ablation; 2. obesity; 3. dyslipidemia; 4. hypertension; 5. exertional dyspnea of uncertain etiology; 6. arteriosclerotic cerebrovascular disease - right carotid bruit, status post transient ischemic attack; 7. arteriosclerotic peripheral vascular disease - status post abdominal aortic aneurysmectomy with aortobifemoral and right femoropopliteal grafts, and bilateral leg edema; 8. past history of ulcers, gastritis and gastroesophageal reflux disease; 9. and status post cholecystectomy, right inguinal herniorrhaphy and transurethral resection of the prostate. In conclusion, the examiner noted that the veteran clearly had typical arteriosclerotic heart disease. The examiner noted the veteran's generally accepted multiple risk factors for its development, including tobacco abuse, hypertension, dyslipidemia and gender. Furthermore, the examiner added that the veteran has developed vascular disease in other vascular beds, including his aorta, carotids and femoral arteries. The examiner stated that he was unaware of any credible medical literature that would support the veteran's allegation that his heart condition is directly due to generalized anxiety disorder. The veteran testified before a hearing officer at the RO in December 1997. During the hearing, the veteran submitted three articles from a Harvard Medical School journal (called the "Harvard Heart Letter") suggesting there is a correlation between anxiety and an individual's heart problems. The Board found that the articles were relevant to the issue on appeal and therefore remanded the case back to the RO for further development. Specifically, the Board requested that the veteran be reexamined, and, with consideration given to the three articles submitted by the veteran. In addition, the Board requested a medical opinion as to the etiology of the veteran's heart condition. The veteran was afforded the VA reexamination in August 1999. The examiner reviewed the claims folder, including the particular additions of the Harvard heart letter. With regard to his service-connected generalized anxiety disorder, the veteran stated that his war and service experiences "affected his life" and that during the 1950's he did go through a stage of depression for which he was treated with medications. Importantly, at the time of the examination, the veteran indicated that he was not suffering any particular anxiety, and had not experienced any recurrent episodes of depression. The veteran felt that he has led a normal life. The examiner noted that the veteran had been married for nearly 50 years, that he has six children, and that his wife is still alive. In addition, the veteran had been successfully employed as a radio announcer. The veteran described himself as being "very happy" with his life and not despondent over his current physical disabilities. The examiner noted that that anxiety, stress-related and similar conditions can contribute to and aggravate heart disease in general. However, he also noted the veteran's prior 80 to 100 pack per year history of smoking, which along with his history of obesity, hyperlipidemia, and hypertension, probably were the more proximate causes of his abdominal aortic aneurysm and peripheral vascular disease. The examiner noted that the veteran developed clinically evident heart problems approximately six years prior, at the age of 75. Given the fact that the veteran's mental health has not been a significant problem to the veteran, and given his other known medical problems, the examiner did not feel that an emotional problem caused, contributed to or aggravated his heart disease. In conclusion, the examiner stated, "It is less likely than not that his heart disease is causally related to a service-connected anxiety disorder; that there are no signs, by history and examination, that his emotional state caused or aggravated his general arteriosclerotic problem, that there are no signs that his disability is attributed to his anxiety problem and that his opinion is based on the patient's medical history obtained by interview and examination as well as review of his medical record, claims folder, prior examinations and his copy of his Harvard heart letter." Thus, the record includes medical indication that stress related disorders may contribute to and aggravate heart problems, in general. While this evidence may be sufficient to render the veteran's claim at least plausible (see Wallin v. West, 11 Vet. App. 509, 514 (1998)), there is no persuasive medical evidence that any current heart disease suffered by this veteran was caused or aggravated by his service-connected anxiety disorder. Indeed, in the only medical opinion to address this question on the basis of all the evidence of record, to include the articles from the "Harvard Heart Letter" offered by the veteran, and consideration of the veteran's other risk factors, the August 1999 examiner concluded that it was "less likely than not" that the veteran's emotional problems caused, contributed to, or aggravated his heart disease. Further, as noted during the hearing, the veteran was unable to say that any of his physicians had stated that his heart condition was related to his anxiety. The Board does not doubt the sincerity of the veteran's belief that a nexus between his heart condition and his anxiety disorder, in fact, exists, as a layperson without medical training or expertise, he is not competent to render a probative opinion on such a medical matter. See Jones v. Brown, 7 Vet. App. 134, 137 (1994); Espiritu, 2 Vet. App. at 494-95. 11 (1992). In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). ORDER The claim for service connection for heart disease secondary to service-connected anxiety disorder is denied. JACQUELINE E. MONROE Member, Board of Veterans' Appeals