ARTERIOSCLEROTIC HEART DISEASE (CORONARY ARTERY DISEASE)

Summary

The Veteran, a Marine Corps, Air Force, and Army veteran who served from March 1964 to March 1968, June 1971 to June 1979, and October 1979 to January 1988, appeals decisions denying service connection for coronary artery disease (CAD), erectile dysfunction (ED), PTSD, chronic headaches secondary to PTSD, a genitourinary disability (including voiding dysfunction), and increased ratings for degenerative disc disease with spondylolisthesis, right and left knee strain with replacement and osteoarthritis, and left lower extremity radiculopathy. The Board granted service connection for CAD and ED. For CAD, the Board found the evidence in approximate balance between a private physician's opinion favoring service connection and a VA examiner's opinion finding it less likely than not related to service, ultimately resolving the doubt in the Veteran's favor due to the private physician's detailed rationale and the Veteran's service-connected hypertension. For ED, the Board found the evidence weighed in favor of the claim, granting service connection based on a private physician's opinion that it was likely caused by medication for his service-connected hypertension, with no contrary opinions. The claims for PTSD and chronic headaches were remanded due to unclear AOJ handling of new evidence. The genitourinary disability claim was remanded due to an inadequate VA examination regarding voiding dysfunction and left testicle atrophy. Increased ratings for back and knee conditions were remanded due to inadequate VA examinations failing to address flare-ups and functional impact. The left lower extremity radiculopathy claim was deferred pending the back disability readjudication.

Rationale

Evidence in approximate balance; Benefit of the doubt resolved in Veteran's favor; Private physician opinion found equally probative; Service-connected hypertension aggravated CAD

Full Decision Text

Citation Nr: A26033244
Decision Date: 04/09/26	Archive Date: 04/09/26

DOCKET NO. 251211-603192
DATE:  April 9, 2026

ORDER

Entitlement to service connection for coronary artery disease (CAD) is granted. 

Entitlement to service connection for erectile dysfunction (ED) is granted.

REMANDED

Whether new and relevant evidence has been presented or secured to warrant readjudication of the claim for service connection for posttraumatic stress disorder (PTSD) is remanded. 

Whether new and relevant evidence has been presented or secured to warrant readjudication of the claim for service connection for chronic headaches secondary to PTSD is remanded. 

Entitlement to service connection for a genitourinary disability (other than ED), to include a voiding dysfunction, is remanded. 

Entitlement to a rating in excess of 20 percent for degenerative disc disease with spondylolisthesis (back disability) is remanded.

Entitlement to an initial rating in excess of 10 percent for right knee strain with replacement and osteoarthritis (right knee disability) is remanded.

Entitlement to an initial rating in excess of 10 percent for left knee strain with replacement and osteoarthritis (left knee disability) is remanded.

Entitlement to an initial rating in excess of 10 percent for left lower extremity radiculopathy is remanded. 

FINDINGS OF FACT

1. The evidence indicates that the Veteran's CAD was caused or aggravated by his service-connected hypertension.

2. The evidence indicates that the Veteran's ED was caused by the medication used to treat his service-connected hypertension. 

CONCLUSIONS OF LAW

1. The criteria for service connection for CAD are met. 38 U.S.C. §§ 1110, 1131, 5107 (2024); 38 C.F.R. § 3.102, 3.303, 3.310 (2025). 

2. The criteria for service connection for ED are met. 38 U.S.C. §§ 1110, 1131, 5107 (2024); 38 C.F.R. § 3.102, 3.303, 3.310 (2025). 

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from March 1964 to March 1968 in the United States Marine Corps (USMC), from June 1971 to June 1979 in the United States Air Force, and from October 1979 to January 1988 in the United States Army. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2025, March 2025, and September 2025 decisions issued by a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). The Board notes that the January 2025 decision was a Higher-Level Review (HLR) decision issued in response to the Veteran's HLR request of an October 2023 rating decision. 

In December 2025, the Veteran appealed to the Board by filing a VA Form 10182 and selecting the evidence submission option. Therefore, the Board may only consider the evidence before the AOJ at the time of October 2023, March 2025, and September 2025 decisions, as well as any evidence submitted with his notice of disagreement (NOD) or within 90 days following the receipt of his NOD. 38 C.F.R. §?20.303. If evidence was submitted either (1) during the period after the AOJ issued the October 2023, March 2025, and September 2025 decisions and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. 

Regarding any claims decided by the Board, if the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

Regarding any claims remanded by the Board, any evidence the Board could not consider will be considered by the AOJ in the readjudication of those claims. 38 C.F.R. § 
 any claims decided by the Board, if the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

Regarding any claims remanded by the Board, any evidence the Board could not consider will be considered by the AOJ in the readjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

The Board notes that the claims for service connection for CAD and ED were previously denied. In a March 2025 rating decision, after correcting a duty-to-assist error, the AOJ readjudicated the claims on the merits. The Board is bound by the AOJ's favorable findings. 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).

?

Service Connection - CAD

The Veteran maintains that his CAD was incurred in or is related to his military service. Alternatively, he asserts that his CAD was caused or aggravated by his service-connected hypertension. 

A July 1985 service treatment record indicated that the Veteran complained of pain in the right side of his chest and tingling in his right arm. In April 1986, it was noted that he had an episode of chest pain that lasted several weeks, worsened while running, and that eventually resolved. In May 1986, a thallium stress test showed findings compatible with vascular disease, and it was noted that the findings should be clarified with a coronary angiogram. In June 1986, it was noted that a thallium stress test suggested atherosclerotic heart disease. He was started on aspirin and Corgard (a beta blocker). In September 1986, it was noted that he stopped Corgard because of vague symptoms, and that he had stopped smoking two months previously and had no further chest pain. In September 1986, a cardiac catheterization was performed, and no coronary artery disease was shown. It was noted that he was referred because of noninvasive data suggesting myocardial ischemia in multiple coronary beds, but that catheterization demonstrated normal coronary arteries. It was recommended that the patient not be treated with any antianginal therapy and that he be considered normal from a cardiac standpoint. On his October 1987 Report of Medical History, he noted a history of heart trouble. The examining clinician noted that the Veteran had a history of hypercholesterolemia. It was noted that during a work-up for hypercholesterolemia, he had a stress test suggestive of atherosclerotic heart disease but that a subsequent cardiac catheterization was entirely normal. It was also noted that the Veteran never had symptoms of angina. 

Post service, a March 2019 private treatment record indicated that he complained of a four- to five-month history of increased shortness of breath. He underwent a cardiac catheterization, which revealed severe disease in the right coronary artery. In April 2019, he underwent percutaneous coronary artery intervention with stent placement to the mid and ostial right coronary artery. 

In January 2020, the Veteran filed a claim for service connection for a heart condition. 

The report of a March 2020 VA examination noted that the Veteran had been diagnosed with coronary artery disease and an acute, subacute, or old myocardial infarction. The examiner indicated that the Veteran had a myocardial infarction in 1985, which was inconsistent with his service treatment records. The examiner opined that the claimed condition was less likely than not incurred in or caused by service. As rationale, the examiner stated that the medical records were insufficient regarding a heart condition during service and requested assistance with locating and providing records. Therefore, it is unclear whether the Veteran's complete claims file was made available to the examiner. Accordingly, the Board does not find the opinion probative. 

The report of an April 2023 VA examination noted diagnoses of CAD and acute, subacute, or old myocardial infarction. It was again noted that the Veteran had a myocardial infarction in 1985, which is inconsistent with his records. The examiner opined that the claimed condition was at least as likely as not incurred in or caused by service but then stated that she was unable to state that his current condition was due to his chest pain and cardiac catheterization in the past without resorting to speculation. Therefore, the opinion has no probative value. 

The report of a March 2025 VA
 claims file was made available to the examiner. Accordingly, the Board does not find the opinion probative. 

The report of an April 2023 VA examination noted diagnoses of CAD and acute, subacute, or old myocardial infarction. It was again noted that the Veteran had a myocardial infarction in 1985, which is inconsistent with his records. The examiner opined that the claimed condition was at least as likely as not incurred in or caused by service but then stated that she was unable to state that his current condition was due to his chest pain and cardiac catheterization in the past without resorting to speculation. Therefore, the opinion has no probative value. 

The report of a March 2025 VA examination indicated that the Veteran was diagnosed with stable angina and CAD in April 2019. The examiner opined that the claimed condition was less likely than not incurred in or caused by service, to include toxic exposure risk activities (TERAs). As rationale, the examiner stated that it was clear that the Veteran never had a myocardial infarction, heart attack, or heart condition in 1986 as he underwent a cardiac catheterization, which did not reveal any evidence of CAD. Therefore, a heart condition was ruled out at that time, and his chest pain was found to be non-cardiac. The examiner noted that heart catheterization is a diagnostic procedure, which by itself does not cause CAD. Regarding TERA exposure, the examiner noted that the Veteran had significant risk factors for CAD which he developed 30 years after he was discharged in service, including a history of tobacco use, hypertension, and family history of heart disease. 

In a December 2025 letter, a private physician, Dr. B.T., indicated that he had reviewed the claims file and consulted with the Veteran. He opined that it was at least as likely as not that the Veteran's CAD began during service and that the abnormal diagnostic findings were early manifestations of the disease, which later progressed to severe CAD requiring intervention. He noted that the thallium perfusion scan showed multi-territory ischemia and was a major abnormal finding even if a later catheterization did not reveal obstructive disease. He noted that the Veteran had hypercholesterolemia, which when combined with ischemic symptoms and abnormal testing strongly suggested that pathologic plaque formation was at least as likely as not already underway during service. In support of his opinion, the physician noted medical literature, which noted that there were a few exceptions in which patients with myocardial infarctions who underwent coronary arteriograms failed to show evidence of coronary obstructive lesions. In addition, the physician opined that the Veteran's long-standing hypertension placed persistent mechanical and metabolic stress on the coronary arteries beginning during service and continuing thereafter, accelerating the formation for atherosclerotic plaque and increasing the likelihood of ischemic injury making it at least as likely as not that the CAD was caused by or permanently aggravated by his service-connected hypertension. The physician also noted the Veteran's nonservice-connected risk factors but indicated that there was no acceptable methodology for quantifying the risk factors proportionally against one another. 

In this case, the Board finds that the evidence for and against the claim is in approximate balance. 

Although the Veteran had chest pain on exertion during service and a thallium stress test was indicative of atherosclerotic heart disease, a September 1986 cardiac catheterization was normal and did not show evidence of CAD. The first indication of CAD was in March 2019, approximately 30 years after discharge from service. The Board notes that the passage of time between discharge from service and initial documentation of a disability is a factor that tends to weigh against a claim for service connection. In addition, the March 2025 VA examiner, who is a cardiologist, opined that is was less likely than not that the Veteran's CAD was incurred in or related to service. The examiner reviewed the claims file, considered the relevant medical history, and provided rationale for his opinion. For this reason, the Board finds the opinion significantly probative. 

On the other hand, the December 2025 private physician also completed a thorough review of the claims file and noted the relevant medical evidence. Although Dr. B.T. is a family physician and not a cardiologist, he provided detailed rationale for his opinion and cited medical literature. Thus, the Board finds his opinion equally probative. 

Notably, however, the March 2025 VA examiner did not provide an opinion as to whether the Veteran's service-connected hypertension caused or aggravated his CAD. The December 2025 private physician addressed this contention and found that it was at least as likely as not that the Veteran's service-connected hypertension caused or aggravated his CAD. There are no medical opinions to the contrary. 

Based upon the above, the Board finds that the evidence for and against the claim is in
 also completed a thorough review of the claims file and noted the relevant medical evidence. Although Dr. B.T. is a family physician and not a cardiologist, he provided detailed rationale for his opinion and cited medical literature. Thus, the Board finds his opinion equally probative. 

Notably, however, the March 2025 VA examiner did not provide an opinion as to whether the Veteran's service-connected hypertension caused or aggravated his CAD. The December 2025 private physician addressed this contention and found that it was at least as likely as not that the Veteran's service-connected hypertension caused or aggravated his CAD. There are no medical opinions to the contrary. 

Based upon the above, the Board finds that the evidence for and against the claim is in approximate balance. Therefore, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to service connection for CAD is warranted. 38 U.S.C. § 5107(b) (2018); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

Service Connection - ED

The Veteran maintains that his ED was incurred in or caused by service. Alternatively, he asserts that his ED was caused or is aggravated by his service-connected hypertension. 

The Veteran's service treatment records are unremarkable for any complaints, treatment, or diagnoses related to ED. In February 1975, he underwent a bilateral vasectomy. He experienced some tenderness and swelling but no other complications. In February 1976, he underwent a right vasectomy after pathology determined that the right vas deferens was not closed. 

During an April 2023 VA examination, the Veteran reported that he had a vasectomy during service and was currently unable to obtain or maintain an erection. The diagnosis was erectile dysfunction. It was also noted that had a voiding dysfunction, characterized by weak stream and decreased force and decreased force of stream. On physical examination, the examiner indicated that the Veteran's penis and both testes were normal but also indicated that there was complete atrophy of the left testicle. It was noted that there was no epididymitis. The examiner opined that the claimed condition was at least as likely than not incurred in or caused by service; however, she did not provide any rationale. She noted that it was common to have discomfort and swelling up to two weeks after a vasectomy, and that epididymitis can occur after a vasectomy but was not common. She indicated that she was unable to state whether his current urinary problems were the result of his previous vasectomies. 

In August 2023, the examiner was asked to provide an addendum opinion addressing whether the Veteran's ED and voiding dysfunction were related to the vasectomies he had during service. The examiner indicated that most studies have thus far shown that a vasectomy does not affect sexual function and cited medical literature to support that conclusion. She also noted that there was no relationship between vasectomy and urge incontinence, noting that the voiding dysfunction could be more psychological. In a March 2024 addendum, the examiner noted that the Veteran's vasectomy does not negatively affect sexuality and that the body's process for erections and climaxing were unrelated to the procedure. 

In March 2024, a different VA examiner opined that the claimed condition was less likely than not caused by TERAs. The examiner stated that the current scientific literature showed no causation between the Veteran's TERAs and the claimed reproductive condition. 

In a December 2025 letter, a private physician, Dr. B.T., opined that the Veteran's ED was at least as likely as not caused by the medication used to treat his service-connected hypertension. The clinician noted that ED had been associated with hypertension in several epidemiological observational studies and that hypertension was one of the risk factors for ED. The clinician cited medical literature to support his opinion. 

In this case, the Board finds that the evidence weighs in favor of the claim. Although the evidence does not indicate that the Veteran's ED was incurred in service or caused by the vasectomies he had during service, Dr. B.T. opined that his ED was at least as likely as not caused by the medication used to treat his service-connected hypertension. The physician reviewed the claims file, discussed the relevant medical evidence, and provided rationale for his opinion. Therefore, the Board finds the opinion significantly probative. Furthermore, there are no medical opinions to the contrary. 

Based upon the above, the Board finds that the evidence for and against the claim is in approximate balance. Therefore, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to service connection for ED is warranted. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776.

REASONS FOR REMAND

Readjud
. B.T. opined that his ED was at least as likely as not caused by the medication used to treat his service-connected hypertension. The physician reviewed the claims file, discussed the relevant medical evidence, and provided rationale for his opinion. Therefore, the Board finds the opinion significantly probative. Furthermore, there are no medical opinions to the contrary. 

Based upon the above, the Board finds that the evidence for and against the claim is in approximate balance. Therefore, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to service connection for ED is warranted. 38 U.S.C. § 5107(b); Lynch, 21 F.4th 776.

REASONS FOR REMAND

Readjudication - PTSD and Chronic Headaches

In the September 2025 rating decision on appeal, the AOJ initially indicated that new evidence had been received and that the claims for service connection for PTSD and headaches were being reconsidered. Later in the decision, however, the AOJ indicated that the evidence submitted was not new and material and the claims were not reopened, which was the standard under a prior regulation no longer in effect. Thus, it is unclear whether the claims were considered on their merits and whether the AOJ applied the correct regulatory standard. Therefore, as the AOJ failed to satisfy its regulatory or statutory duties in this case, the Board finds that a remand is necessary. 38 C.F.R. § 20.802(a).

Service Connection - Genitourinary Disability

As noted above, the report of an April 2023 VA examination indicated that the Veteran had a voiding dysfunction and possible atrophy of the left testes. The examiner initially indicated that she could not state whether the Veteran's urge incontinence was the result of his vasectomies, but then later stated that his symptoms were unrelated and probably due to psychological factors. She did not provide any rationale for that opinion. Furthermore, the examination report was inconsistent as to whether the Veteran had atrophy of the left testes. For these reasons, the Board finds the VA examination and medical opinion inadequate. The AOJ's failure to obtain an adequate VA examination and medical opinion constituted a pre-decisional duty to assist error. Accordingly, the Board finds that a remand is necessary to correct that error. 38 C.F.R. § 20.802(a).

Increased Rating - Back Disability

The reports of November 2021 and January 2024 VA examinations indicated that the Veteran stated that his back symptoms were worse during cold weather. The examiners, however, indicated that the Veteran did not experience flare-ups without addressing the Veteran's statements that his symptoms were worse during cold weather. For this reason, the Board finds the VA examinations inadequate. The AOJ's failure to obtain an adequate VA examination constituted a pre-decisional duty to assist error. Accordingly, the Board finds that a remand is necessary to correct that error. 38 C.F.R. § 20.802(a).

Increased Rating - Right and Left Knees

The report of a November 2021 VA examination indicated that the Veteran reported that his bilateral knee symptoms varied depending on usage, activities, and weather. The examiner indicated that the Veteran did not experience flare-ups and that his symptoms did not significantly limit functional ability with repeated use over time without addressing the Veteran's statements. Therefore, the Board finds the VA examination inadequate. 

The report of an April 2023 VA examination indicated that the Veteran experienced limitation in range of motion due pain when climbing stairs, walking, bending, or sitting for prolonged periods of time. The examiner, however, indicated that his symptoms did not significantly limit functional ability with repeated use over time without addressing the previous finding regarding limitation of motion due to pain with repeated use. Therefore, the Board finds the VA examination inadequate. 

The AOJ's failure to obtain an adequate VA examination constituted a pre-decisional duty to assist error. Accordingly, the Board finds that a remand is necessary to correct that error. 38 C.F.R. § 20.802(a).

Increased Rating - Left Lower Extremity Radiculopathy

The Board finds that the claim for an increased rating for left lower extremity radiculopathy is inextricably intertwined with the increased rating for a back disability remanded herein. Action on that issue is therefore deferred. 

The matters are REMANDED for the following action:

1. Correct the error in satisfying a regulatory or statutory duty in the determination of whether new and relevant evidence has been presented or secured to warrant readjudication of the claims for service connection for PTSD and chronic headaches. 

2. Schedule the Veteran for an examination by an examiner with appropriate expertise to determine the nature and etiology of his claimed genitourinary disability other than ED. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed
 the claim for an increased rating for left lower extremity radiculopathy is inextricably intertwined with the increased rating for a back disability remanded herein. Action on that issue is therefore deferred. 

The matters are REMANDED for the following action:

1. Correct the error in satisfying a regulatory or statutory duty in the determination of whether new and relevant evidence has been presented or secured to warrant readjudication of the claims for service connection for PTSD and chronic headaches. 

2. Schedule the Veteran for an examination by an examiner with appropriate expertise to determine the nature and etiology of his claimed genitourinary disability other than ED. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed.

After examining the Veteran and considering the pertinent medical history and lay statements regarding reported symptoms, the examiner should identify all genitourinary disabilities present other than ED, to specifically include any voiding dysfunction. The examiner should also clarify whether there is atrophy of the left testicle. 

For each disability identified, the examiner should provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the disability manifested during active service or is otherwise causally or etiologically related to the Veteran's active service, to include a TERA. 

In providing this opinion, the VA examiner must consider and discuss: 1) the total potential exposure through all applicable military deployments; and 2) the synergistic, combined effect of all toxic exposure risk activities of the Veteran.

A rationale for all opinions expressed must be provided. 

3. Schedule the Veteran for appropriate VA examination to determine the current level of severity of all impairment resulting from his service-connected back disability. All indicated tests should be performed and all findings should be reported in detail. The examiner should provide all information required for rating purposes, to specifically include a full description of the functional impact of the service-connected disability on the Veteran's ordinary activity and findings consistent with the decisions in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The examiner should address the Veteran's reports of worsened symptoms (flare-ups) during cold weather. 

4. Schedule the Veteran for appropriate VA examination to determine the current level of severity of all impairment resulting from his service-connected right and left knee disabilities. All indicated tests should be performed and all findings should be reported in detail. The examiner should provide all information required for rating purposes, to specifically include a full description of the functional impact of the service-connected disabilities on the Veteran's ordinary activity and findings consistent with the decisions in Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017).

 

 

Kristin Haddock

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Mishalanie, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.