ALEX ASTREN, Employee/Appellant, v. AD ART ADVERTISING, INC., and ACE USA, Employer-Insurer.
WORKERS= COMPENSATION COURT OF APPEALS
NOVEMBER 17, 2005
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including expert opinion, supported the compensation judge=s decision that the employee=s need for Plavix and Lipitor was related to the employee=s non-work-related coronary artery disease, rather than the employee=s work-related heart attack.
Determined by: Wilson, J., Rykken, J., and Stofferahn, J.
Compensation Judge: William R. Johnson
Attorneys: Howard S. Carp, Borkon, Ramstead, Mariani, Fishman & Carp, Minneapolis, MN, for the Appellant. Kathryn M. Perlinger, Eagan, MN, for the Respondent.
DEBRA A. WILSON, Judge
The employee appeals from the compensation judge=s decision that the employee=s 1980 work-related heart attack is not a substantial contributing cause of his need for the prescription medications Plavix and Lipitor. We affirm.
The employee was born in 1922 and began working for Ad Art Advertising, Inc. [the employer], a commercial printing company, in 1955, at some point becoming an owner of the business. On June 6, 1980, while making a delivery to a customer, the employee suffered a work-related myocardial infarction, or heart attack. Following the incident, the employee was diagnosed as having coronary artery disease, also referred to as coronary heart disease; prior to the incident, the employee had been diagnosed with both hypertension and adult-onset diabetes. Other factors relevant to the employee=s cardiac condition include a 40-year history of cigarette smoking, a family history of heart disease, and abnormal lipid levels, including high cholesterol. Following the work injury, the employee quit smoking. His treating physician eventually rated the employee as having a 25% permanent partial disability due to the 1980 heart attack.
In the years following the 1980 work injury, the employee was hospitalized many times for treatment and/or evaluation of chest pain and other potential cardiac symptoms. It appears that he suffered at least two more heart attacks, and he underwent numerous angiography and angioplasty procedures. Eventually, in 1993, he underwent quadruple cardiac bypass surgery, performed by Dr. Greg Anderson at Abbott Northwestern Hospital.
In April of 1998, the employee was admitted to Methodist Hospital for evaluation of left-sided weakness, and he was diagnosed as having suffered either a cerebral vascular accident (stroke) or a transient ischemic attack (TIA), apparently caused by carotid stenosis. During this hospitalization, a consulting specialist strongly recommended that the employee be placed on a drug such as Plavix, an Aanti-platelet@ agent administered to keep blood platelets from clumping or sticking together. Also at some point in 1998, the employee was prescribed Lipitor, a Astatin@ drug used to lower serum cholesterol levels.
In August of 1998, the employee underwent a right carotid endarterectomy to alleviate the carotid stenosis. By this point, the employee had also been diagnosed as having peripheral vascular disease and peripheral neuropathy, likely related to poorly-controlled diabetes. Medical records indicate that at least one physician characterized the employee as a Avasculopath.@ As Dr. Ronald Vessey later explained, the term was applied because the employee has Aatherosclerotic vascular disease more or less from head to toe.@
In 2003, the employee underwent additional surgery, cardiac pacemaker implantation, to control heart rhythm abnormalities. He has apparently not experienced any further cardiac events since undergoing this procedure. He continues to work for the employer on a part-time basis.
The matter came on for hearing on May 13, 2005, for resolution of the employee=s claim for payment of expenses for Lipitor and Plavix. Evidence submitted in connection with this claim included the employee=s extensive treatment records and the reports and deposition testimony of Dr. David Fine, one of the employee=s treating physicians, and Dr. Vessey, the employer and insurer=s independent examiner.
In a decision issued on June 13, 2005, the compensation judge denied the employee=s claim, concluding that the employee=s need for Lipitor and Plavix was not causally related to the 1980 work injury. The employee appeals.
STANDARD OF REVIEW
On appeal, the Workers' Compensation Court of Appeals must determine whether "the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted." Minn. Stat. ' 176.421, subd. 1 (2004). Substantial evidence supports the findings if, in the context of the entire record, "they are supported by evidence that a reasonable mind might accept as adequate." Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, "unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
It is undisputed that the employee=s 1980 work-related heart attack resulted in mild, but permanent, damage to the employee=s heart muscle, and that the employee had underlying, progressive coronary artery disease at the time of his heart attack. It is also undisputed that both Plavix and Lipitor are appropriate medications to treat the employee=s coronary artery disease. The only issue on appeal is whether the employee=s need for Lipitor and Plavix is causally related to the 1980 incident.
Medical experts differed on the issue of causation. Dr. Fine, one of the employee=s treating cardiologists, testified that the employee=s need for the two medications at issue was a substantial result of the 1980 work injury, A[b]ecause the initial  event was what brought [the employee] to the medical attention of the community as far as what his overall cardiovascular process was.@ Dr. Vessey, in contrast, testified that the employee=s 1980 heart attack was not a contributing factor to the employee=s need for Lipitor or Plavix, explaining that the drugs were used to treat the employee=s underlying, nonwork-related coronary artery disease. The compensation judge expressly accepted the opinion of Dr. Vessey and concluded that causation had not been established.
On appeal, the employee contends that the compensation judge erred in part by stressing the absence of ongoing symptoms related to the employee=s 1980 heart attack, and he argues, in essence, that the record establishes that the employee=s need for Plavix and Lipitor is a Amere sequel@ to the 1980 injury. Under the employee=s theory of the case, because the 1980 work injury caused permanent damage to the employee=s heart, and the Lipitor and Plavix were prescribed, in part, to prevent further damage of this kind by reducing the risk of further heart attacks, the medications should be held to be compensable. We are not persuaded by any of the employee=s arguments.
As previously noted, the work injury at issue resulted in permanent damage to the employee=s heart muscle. However, Dr. Fine acknowledged that neither Plavix nor Lipitor is used to treat damaged heart tissue; rather, those medications are used to treat the employee=s underlying coronary artery disease. It is important to note that Dr. Fine did not testify that the employee=s 1980 heart attack aggravated or accelerated the employee=s underlying coronary artery disease in any way, and Dr. Vessey expressly testified that the 1980 heart attack did not influence the course of the underlying disease process. As for the employee=s argument that the compensation judge erred by stressing the lack of ongoing symptoms related to the employee=s 1980 heart attack, we are persuaded that the judge was merely trying to call attention to the fact that the medications at issue were not prescribed to treat any residual effects of the heart attack itself.
We are also unconvinced by the employee=s attempt to analogize this case to Schutte v. Independent Sch. Dist. #281, slip op. (W.C.C.A. May 8, 2003), in which prophylactic treatment was held to be reasonable and necessary under the workers= compensation act. In Schutte, the prophylactic treatment - - testing and vaccinations - - was clearly related to the work injury itself, a human bite, as opposed to any nonwork-related underlying condition. Nor does the fact that the employee in the present case continued to work, thereby arguably exposing himself to the risk of another work-related heart attack, make preventative treatment for a nonwork-related condition compensable.
As a general rule, when an injury or condition is found to be work-related, every natural consequence that flows from the injury is compensable. See, e.g., Nelson v. American Lutheran Church, 420 N.W.2d 588, 590, 40 W.C.D. 849, 851 (Minn. 1988). At the same time, however, an employer and insurer are not responsible for medical treatment unless that treatment is reasonable and necessary to cure or relieve the employee from the effects of the injury. Minn. Stat. ' 176.135, subd. 1. Causation is a prerequisite to liability. In the case now before us, the employee=s preexisting coronary artery disease combined with work-related physical stress to produce a heart attack, resulting in damaged heart muscle, and all treatment necessitated by the employee=s heart attack is compensable. However, the medical evidence presented at hearing provides a clear basis for separating treatment necessitated by the employee=s work-related damaged heart muscle from treatment necessitated by the employee=s entirely nonwork-related underlying coronary artery disease, and we find no authority to support the employee=s contention that compensability should extend to a nonwork-related condition merely because that condition happened to be discovered during the course of treatment for a work injury. Because the medical evidence as a whole, and the opinion of Dr. Vessey in particular, support the compensation judge=s decision, we affirm his denial of medical expense benefits for Plavix and Lipitor.
 The insurer apparently initially denied liability for the injury, because the employee did not seek treatment for about two weeks. The employee was lifting a 70-pound box when the symptoms began.
 The employee did not become insulin-dependent until 1998.
 In the employee=s brothers, but not his parents.
 For many years prior to this hospital admission, the employee had been on aspirin therapy to try to achieve the same result.