MYOCARDIAL INFARCTION

Summary

The veteran, who served in the U.S. Army from August 1985 to August 1991, appeals the denial of service connection for ischemic heart disease, myocardial infarction, and obstructive sleep apnea. The veteran claimed these conditions were related to in-service exposures in Southwest Asia, including burn pits, oil well fire smoke, and other toxins, and also claimed sleep apnea was secondary to service-connected asthma and PTSD. The Board reviewed evidence including VA examinations, private medical opinions, lay statements from the veteran and his wife, and a fellow service member. A VA examiner in 2010 opined that the veteran's coronary artery disease was less likely than not secondary to environmental exposures, citing multiple risk factors and a lack of clear pathophysiological mechanism linking PTSD or asthma to sleep apnea. Conversely, multiple private medical opinions and lay statements suggested a link between in-service exposures, PTSD, asthma, and the development of heart disease and sleep apnea. The Board found conflicting medical opinions but afforded the veteran the benefit of the doubt, granting service connection for ischemic heart disease, myocardial infarction, and obstructive sleep apnea, concluding they were related to service.

Rationale

Conflicting medical opinions regarding service connection.; VA examiner found less likely than not secondary to environmental exposures.; Private opinions and lay statements linked condition to in-service exposures.; Board afforded veteran benefit of the doubt.

Full Decision Text

Citation Nr: A26037867
Decision Date: 04/22/26	Archive Date: 04/22/26

DOCKET NO. 210414-153599
DATE: April 22, 2026

ORDER

Entitlement to service connection for ischemic heart disease and myocardial infarction, status post stent placement, is granted.

Entitlement to service connection for obstructive sleep apnea is granted.

FINDINGS OF FACT

1.  Affording the Veteran the benefit of the doubt, his ischemic heart disease and myocardial infarction, status post stent placement, is related to service.

2.  Affording the Veteran the benefit of the doubt, his obstructive sleep apnea is related to service.

CONCLUSIONS OF LAW

1.  The criteria for service connection for ischemic heart disease and myocardial infarction, status post stent placement, are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2.  The criteria for service connection for obstructive sleep apnea are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS FOR FINDINGS AND CONCLUSIONS

The Veteran had active service in the United States Army from August 1985 to August 1991.

In January 2021, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of the heart and sleep apnea claims most recently addressed in a January 2015 Statement of the Case (SOC) and a November 2011 rating decision.  In February 2021, the agency of original jurisdiction (AOJ) issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claims based on the evidence of record at the time of that decision.  Therefore, the Board may only consider the evidence of record at the time of the decision on appeal and any evidence submitted during an applicable evidentiary window.

In the April 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket.  A Board hearing was held in November 2024.

Therefore, the Board may only consider the evidence of record at the time of the February 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing.  38 C.F.R. § 20.302(a).  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

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 claims, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision. 

Service Connection

Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service.  38 U.S.C. §§ 1110, 1131.

To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service."  Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may be granted for a disability that is due to, or aggravated by, service-connected disease or injury.  38 C.F.R. § 3.310.

During the pendency of this appeal, the PACT Act created a statutory duty for VA to provide a Toxic Exposure Risk Assessment (TERA) examination to any Veteran determined
) a causal relationship between the present disability and the disease or injury incurred or aggravated during service."  Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may be granted for a disability that is due to, or aggravated by, service-connected disease or injury.  38 C.F.R. § 3.310.

During the pendency of this appeal, the PACT Act created a statutory duty for VA to provide a Toxic Exposure Risk Assessment (TERA) examination to any Veteran determined to have been exposed to toxic substances, when there is not sufficient evidence to establish service connection without such an examination.  38 U.S.C. § 1168(a).  When providing the Secretary with a TERA opinion, the health care provider must consider (1) the total potential exposure through all applicable military deployments of the veteran; and (2) the synergistic, combined effect of all toxic exposure risk activities of the veteran.  38 U.S.C. § 1168(a)(2)(A-B).  This requirement shall not apply if the Secretary determines there is no indication of an association between the disability claimed by the veteran and the toxic exposure risk activity for which the veteran submitted evidence.  38 U.S.C. § 1168(b).

A July 2024 VA memorandum concluded that the Veteran participated in a TERA due to his service in Southwest Asia, which included exposure to burn pits, Gulf War oil well fire smoke, particulate matter, ethyl benzene, o-xylene, vanadium, p-xylene, iron, toluene, m-xylene, and naphthalene.  Thus, the Veteran participated in a TERA.

The sub-regulatory guidance defines four exceptions to the requirement to obtain a TERA examination and medical opinion: physical trauma, mental disorders, disabilities that have not been shown to have any positive association with herbicide agents exposure, and disabilities that manifested during service or with a clear etiology that is not associated with toxic exposure (to include due to post-service events).  VBA Letter 20-22-10, 10-13, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78,543 (Dec. 22, 2022).  TERA opinions for the claimed disabilities are not of record.  As will be discussed below, however, the Board will afford the Veteran the benefit of the doubt and grants the claims as being directly related to service.

1.  Entitlement to service connection for a heart disability, to include ischemic heart condition / cardiovascular symptoms

The Veteran believes that his current heart problems had their onset in service, otherwise were caused by service, or were caused or aggravated by a service-connected disability.

The service treatment records include no complaints, treatment, or diagnosis of a heart disability or chronic symptoms related thereto.

In August 2004, heart sounds were normal.  An April 2005 chest x-ray noted no heart abnormalities.  

A March 2008 private treatment record documented that the Veteran had no known history of coronary artery disease, previous myocardial infarction, or congestive heart failure.  In April 2008, the Veteran described chest pain and shortness of breath.  Hypertension was noted to be a potentially contributory factor.  An echocardiogram showed moderate concentric left ventricular hypertrophy with normal left ventricular function.  An April 2008 nuclear exercise stress testing showed no evidence of myocardial infarction or ischemic disease.  In July 2009, the Veteran's heart was indicated to be "regular."  

A June 2010 private treatment record included assessments of acute coronary syndrome.  The Veteran had been hospitalized for substernal chest pain.  The record stated, "It is still at a very low level, but that with the chest pain suggests acute myocardial infarction or some form of coronary syndrome."

A November 2010 VA Gulf War examination report included a diagnosis of coronary artery disease.  The Veteran took multiple medications for the heart.  The report indicated that, "Echocardiogram was not completed because coronary artery disease is not secondary to environmental exposure."  The examiner indicated that the coronary artery disease was a diagnosable condition with a clear etiology.  The examiner concluded, "This condition is less likely than not secondary to environmental exposures in the presence of multiple other risk factors for heart disease."

A June 2013 statement from the Veteran stated that his heart disability was "on the presumptive list of disease for Gulf War Veteran."

An October 2013 statement from the Veteran's wife discussed the Veteran's sleep apnea
A November 2010 VA Gulf War examination report included a diagnosis of coronary artery disease.  The Veteran took multiple medications for the heart.  The report indicated that, "Echocardiogram was not completed because coronary artery disease is not secondary to environmental exposure."  The examiner indicated that the coronary artery disease was a diagnosable condition with a clear etiology.  The examiner concluded, "This condition is less likely than not secondary to environmental exposures in the presence of multiple other risk factors for heart disease."

A June 2013 statement from the Veteran stated that his heart disability was "on the presumptive list of disease for Gulf War Veteran."

An October 2013 statement from the Veteran's wife discussed the Veteran's sleep apnea and how, "Our primary care physician told him that left untreated, long-term effects could result in high blood pressure, stroke or heart attack.  On June 25, 2010, [the Veteran] had a heart attack."

In an October 2013 statement, the Veteran reported in-service exposure to oil well fires and burning human feces / trash / diesel fuel.  He also was exposed to decomposing bodies.  The Veteran believed that his lack of sleep, asthma, sleep apnea, and PTSD caused his heart problems.  The Veteran had a heart attack at age 42 and the Veteran's doctors all told him "you are way too young to have all these issues."  

An October 2013 letter from a private medical professional discussed the Veteran's in-service exposure to toxins and concluded that the Veteran "also suffered cardiac complications requiring a stent placement [in June 2010] that may indeed be linked to the cardiopulmonary disorders brought on by the original fire exposures during the military service in Operation Desert Storm"

During a January 2014 AOJ hearing, the Veteran discussed his exposure to toxins during service in Southwest Asia.  The Veteran and his wife believed that the heart disabilities were due to that in-service exposure.  

A January 2014 private medical professional's letter stated that the Veteran's ischemic heart disease, myocardial infarction, and the need for stent placement was "associated" with PTSD and that the obstructive sleep apnea contributed to the heart disabilities.  In addition, "there is compelling evidence in the medical literature supporting this claim for a relationship between PTSD and his cardio-pulmonary conditions, which were all triggered by Gulf War Syndrome."  

In March 2016, the Veteran had unstable angina pectoris and prior myocardial infarction with percutaneous coronary intervention.  

A June 2016 letter from a private medical professional indicated that the Veteran "had extensive exposure to fire and smoke in Operation Desert Storm, triggering severe Asthma, PTSD, and obstructive sleep apnea, all leading to eventual multiple vessel coronary artery disease, myocardial infarction, and need for placement of stents."

In support of his claim, the Veteran submitted an article titled, "Asthma Could Raise Your Risk for Heart Disease."  

During the November 2024 Board hearing, the Veteran discussed his in-service exposure to various toxins, including sandstorms, oil well fires, burning feces and trash, and burning diesel fuel.  The Veteran discussed his 2010 heart attack and medical professionals had told him that the combined effect of his PTSD, asthma, and sinusitis had put additional stress on his heart.  

Thus, there are positive and negative medical opinions as to whether the Veteran's current heart disabilities were incurred in service or otherwise caused by service.  The positive medical opinions cited to medical literature in support of the conclusions reached and were based on an accurate factual basis.  The negative VA opinion was based on a complete review of the Veteran's claims file at the time of the opinion.  The Board finds all the medical opinions of probative value to be probative evidence.  Affording the Veteran the benefit of the doubt, based on the above medical opinions and the competent and credible lay statements the Board concludes that entitlement to service connection for ischemic heart disease and myocardial infarction, status post stent placement, is warranted.

2.  Entitlement to service connection for sleep apnea 

The Veteran believes that his current sleep apnea disability had its onset in service, otherwise was caused by service, or was caused or aggravated by a service-connected disability.

The Veteran's service treatment records include no complaints, treatment, or diagnosis of sleep apnea or chronic symptoms related thereto.  

An October 2002 sleep study showed obstructive sleep apnea.  The diagnostic impressions also included the notation, "Decreased REM sleep, not improved by the use of nasal CPAP.  This is rather atypical because patients usually have a large REM sleep rebound while on nasal CPAP.  I am not certain how to exactly explain this.  The patient does not appear to be taking any drugs that could cause
 connection for sleep apnea 

The Veteran believes that his current sleep apnea disability had its onset in service, otherwise was caused by service, or was caused or aggravated by a service-connected disability.

The Veteran's service treatment records include no complaints, treatment, or diagnosis of sleep apnea or chronic symptoms related thereto.  

An October 2002 sleep study showed obstructive sleep apnea.  The diagnostic impressions also included the notation, "Decreased REM sleep, not improved by the use of nasal CPAP.  This is rather atypical because patients usually have a large REM sleep rebound while on nasal CPAP.  I am not certain how to exactly explain this.  The patient does not appear to be taking any drugs that could cause this.  Antidepressants can sometimes produce this [].  It is conceivable that posttraumatic stress may have some influence here, and also there may be some interference with going into REM sleep due to the equipment on his face."

In November 2002, the Veteran had diagnoses that included obstructive sleep apnea.  He underwent a septoplasty and uvulopalatopharyngoplasty.  

February 2003 and March 2004 private treatment records indicated that the Veteran's sleep apnea symptoms, including snoring, had essentially resolved following the November 2002 surgery.  A February 2007 letter from the surgeon who performed the November 2002 surgery also stated that the Veteran's "snoring is completely resolved."

A December 2009 VA treatment record documented a history of sleep apnea, possibly with onset during Desert Storm in 1992.  

In a November 2011 statement, the Veteran contended that his sleep apnea was "related to the asthma for which I am service connected."  

A June 2013 statement from the Veteran stated that his sleep apnea was "on the presumptive list of disease for Gulf War Veteran."

In an October 2013 statement, the Veteran discussed his service in Southwest Asia and how after he "returned home from war I started to experience irregular disruptive sleep patterns due to my sleep apnea.  I have nightmares concerning my family and the fear of dying.  Some of my nightmares are due to my sleep apnea.  I become restless.  When you are exposed to combat your mind and body becomes on high alert everywhere you go."  The Veteran discussed in-service exposure to oil well fires, burning human feces and trash with diesel, and decomposed bodies.  

An October 2013 statement from a former supervisor indicated that the Veteran had to miss work due to asthma and "I understood his condition and time missed to be related [to] sleep apnea and his asthma."

An October 2013 statement from the Veteran's wife stated, "Many years ago he was diagnosed with sleep apnea.  This diagnosis made perfect sense as I knew he had sleeping issues.  He would constantly wake up and becomes restless to fall back asleep.  When he would fall back to sleep, his breathing became shallow and then would suddenly stop.  During the night I hear him gasp for breath as if someone were choking him.  At first I thought he was having trouble acclimating to sleeping in a regular bed versus a cot.  Our primary care physician told him that left untreated, long-term effects could result in high blood pressure, stroke or heart attack.  On June 25, 2010, [the Veteran] had a heart attack."

During a January 2014 AOJ hearing, the Veteran discussed his exposure to toxins during service in Southwest Asia.  The Veteran believed that the sleep apnea was due to his service-connected asthma.

A February 2014 VA sleep apnea examination report noted a diagnosis of obstructive sleep apnea from 2002.  The Veteran stated that in 2002 he had a sleep study showing sleep apnea and was started on a CPAP machine.  The sleep study followed the Veteran's wife noticing that the Veteran stopped breathing at night and he would wake up gasping with difficulty breathing.  An ENT concluded that nasal polyps and oropharyngeal anatomy likely contributed to the sleep apnea.  In 2002, the Veteran had surgery to remove the nasal polyps.  In 2010 or 2011, the Veteran underwent a second nasal polypectomy along with uvuloplasty for sleep apnea.  The Veteran also had PTSD symptoms that affected sleep, including nightmares that would awake him and difficulty falling asleep due to anxiety.  The Veteran also reported symptoms of asthma with wheezing at night that he treated with inhalers and nebulizer.  The Veteran started the medication in 1999 or 2000.  Following examination, the examiner concluded that it was less likely than not that the obstructive sleep apnea was proximately due to or the result of the Veteran's service-connected disabilities. 
 In 2002, the Veteran had surgery to remove the nasal polyps.  In 2010 or 2011, the Veteran underwent a second nasal polypectomy along with uvuloplasty for sleep apnea.  The Veteran also had PTSD symptoms that affected sleep, including nightmares that would awake him and difficulty falling asleep due to anxiety.  The Veteran also reported symptoms of asthma with wheezing at night that he treated with inhalers and nebulizer.  The Veteran started the medication in 1999 or 2000.  Following examination, the examiner concluded that it was less likely than not that the obstructive sleep apnea was proximately due to or the result of the Veteran's service-connected disabilities.  The rationale was that the Veteran's mental health symptoms "can cause sleep disruption which does not indicate a connection or cause and effect relationship between each of the factors.  At the time of the 2002 sleep study, the Veteran was not taking PTSD medication and, "therefore, there is no pathophysiologic mechanism for PTSD to cause sleep apnea.  There is not support in the medical literature for PTSD itself to cause the sleep apnea.  Good medical science does not support a cause and effect relationship between two conditions just because they occur together.  A good example of support for this is the listed article in Chest 2013 which notes comorbid conditions of insomnia and sleep apnea are noted specifically identifying that these conditions often occur together but with no suggestion of a cause and effect relationship between the two conditions.  In the journal sleep.org there is speculation of a possible common link between the conditions but notes there are other studies which do not support this and there is no proposed mechanism for this in addition to multiple problems with their study.  There are examples of the current medical literature which supports that sleep apnea and PTSD often occur together in a given individual but there is no known common mechanism and no current support for a cause and effect relationship."  As to the asthma disability, "It is well documented in the medical literature and noted specifically in Up to Date, a well respected review journal, that 'poorly controlled asthma is often worse at night with nocturnal bronchospasm and cough inducing sleep fragmentation and paroxysmal dyspnea'.  In other words, the waking in the middle of the night with gasping is more likely a result of the veteran's asthma or upper airway conditions, and is not a typical feature of sleep apnea.  Therefore, Veteran's asthma can cause sleep disturbance but this does not mean it can cause the sleep apnea.  Again, current medical literature does not support a cause and effect association between sleep apnea and asthma and there is no proven pathophysiologic mechanism for asthma to cause sleep apnea.  I have reviewed the Sleep Study from [] and in critically evaluating the comments the medical provider made regarding the study results, it is noted the comment does not state the PTSD caused the Sleep Apnea.  The practitioner was reviewing the finding that the nasal CPAP did not improve the REM sleep which is atypical - meaning if the REM sleep disturbance is caused by the sleep apnea it would be expected to improve with CPAP.  Since it did not improve and the Veteran was noted to not be taking any drugs that 'cause this' - meaning affecting the REM sleep - that it 'is conceivable that [PTSD] may have some influence here'.  This is not a statement that [PTSD] caused the sleep apnea but a consideration that there may be a disruption of REM that is from PTSD rather than sleep apnea.  The practitioner goes on to say that i[t] could also just be related to interference with sleep due to the equipment.  In summary, the consideration was that there were comorbid factors others than sleep apnea causing abnormalities in REM sleep and not that they caused the sleep apnea itself.  The primary risk factors for obstructive sleep apnea include advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities.  In addition[] smoking, nasal congestion and family history play a role.  The Veteran is obese based on BMI calculation and had significant and severe craniofacial and upper airway soft tissue abnormalities with recurrent nasal polyps and requiring uvuloplasty and polyp removal.  It is likely these conditions are responsible for his sleep apnea diagnosis.  In summary, this Veteran has multiple medical and mental health conditions contributing to sleep disturbance.  There is not support for his comorbid conditions of PTSD or Asthma to Cause his sleep apnea."  The examiner cited to multiple articles and studies in support of the above conclusions.  As to aggravation, the examiner noted that the Veteran's PTSD medication started after his diagnosis of sleep apnea and that certain medication could cause insomnia and somnolence, so the medication could
 is obese based on BMI calculation and had significant and severe craniofacial and upper airway soft tissue abnormalities with recurrent nasal polyps and requiring uvuloplasty and polyp removal.  It is likely these conditions are responsible for his sleep apnea diagnosis.  In summary, this Veteran has multiple medical and mental health conditions contributing to sleep disturbance.  There is not support for his comorbid conditions of PTSD or Asthma to Cause his sleep apnea."  The examiner cited to multiple articles and studies in support of the above conclusions.  As to aggravation, the examiner noted that the Veteran's PTSD medication started after his diagnosis of sleep apnea and that certain medication could cause insomnia and somnolence, so the medication could theoretically contribute to the Veteran's overall sleep disturbance.  Medical literature suggested a possible link between sleep apnea and some medications affecting the central nervous system.  "However a definitive cause and effect relationship has not been established and it is not currently considered a known contributor.  However, this particular Veteran does not have evidence of worsening sleep disturbance since taking these medications.  Veteran does not have evidence of worsening of sleep apnea since taking these medications as his Epworth Sleepiness score remains normal.  In summary, the medical literature does not currently fully support an aggravating effect of some medication used for PTSD on Sleep Apnea and even if it did, this Veteran does not have evidence of aggravation of sleep apnea related to the medication for PTSD.  It has been established in the review above that there is not cause and effect relationship between PTSD itself and Sleep Apnea, therefore no mechanism for aggravation."  As to the asthma, there was no support for a cause and effect relationship between asthma and sleep apnea and, therefore, no mechanism for asthma to aggravate the sleep apnea.

A June 2016 letter from a private medical professional indicated that the Veteran "had extensive exposure to fire and smoke in Operation Desert Storm, triggering severe Asthma, PTSD, and obstructive sleep apnea, all leading to eventual multiple vessel coronary artery disease, myocardial infarction, and need for placement of stents."

A July 2016 letter from a fellow service member discussed in-service exposure to toxins and that the Veteran had in-service "heavy snoring and breathing problems."  

During the November 2024 Board hearing, the Veteran and his wife discussed how he had no sleep problems prior to his service in Southwest Asia.  Immediately after his deployment, the Veteran's wife noticed increased sleep problems, including gurgling in the chest, gasping, and stopping breathing.  

Thus, there are numerous lay reports of in-service onset of symptoms of heavy snoring and stopping breathing.  Multiple private medical opinions have linked the Veteran's current obstructive sleep apnea to his active service.  The opinions provided a rationale for the opinion provided and were based on an accurate factual basis.  In light of the foregoing, the Board will afford the Veteran the benefit of the doubt and concludes that entitlement to service connection is warranted.

 

 

MICHAEL LANE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. J. Houbeck, 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.