Citation Nr: 1129656 Decision Date: 08/10/11 Archive Date: 08/23/11 DOCKET NO. 06-06 120 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a cardiac disorder to include heart arrhythmia and valvular disorder, claimed as secondary to PTSD or as due to herbicide (Agent Orange) exposure. 2. Entitlement to service connection for hypertension, claimed as secondary to PTSD or as due to herbicide exposure. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Bosely, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1961 to January 1964 and from October 1968 to December 1971. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In a February 2009 rating decision, the RO denied service connection for hypertension and valvular heart disease, which are the remaining issues now on appeal. These issues are within the scope of the Veteran's original claim of service connection for a cardiovascular disorder, which was adjudicated in the December 2004 rating decision. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 86-88 (2009); see also Percy v. Shinseki, 23 Vet. App. 37, 45 (2009). The two issues are listed separately on the title page above in light of the Board's determination that the claim of service connection for hypertension requires distinct factual development. See Tyrues v. Shinseki, 23 Vet. App. 166 (2009) ("VA has the power to bifurcate a single claim and adjudicate different theories separately."). In October 2009 the Veteran testified before the undersigned Acting Veterans Law Judge in a hearing conducted at the RO. A transcript of that hearing is of record. In May 2010, the Board remanded the matter to the RO for additional evidentiary development. The case has now been returned to the Board for further appellate action. In a May 2011 rating decision, the RO granted service connection for (1) coronary artery disease, coronary artery bypass; and (2) cerebrovascular accident. The Veteran did not file a second notice of disagreement (NOD) disagreeing with either the schedular rating or effective date assigned by the RO for either disability. Thus, those issues are no longer before the Board. See 38 C.F.R. §§ 20.200, 20.201, 20.302; Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (explaining that where a claim of service connection is granted during the pendency of an appeal, a second NOD must thereafter be timely filed to initiate appellate review concerning the compensation level or the effective date assigned for the disability). The issue of service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. As the Veteran served in the Republic of Vietnam during the Veteran era, his exposure to herbicides is presumed. 2. The weight of the more probative evidence demonstrates that a cardiac disorder involving heart arrhythmia and a valvular disorder manifested by mitral regurgitation is not due to herbicide exposure and is not aggravated by, proximately due to, or the result of a service-connected disability. CONCLUSION OF LAW A cardiac disorder involving heart arrhythmia and a valvular disorder manifested by mitral regurgitation was not incurred in or aggravated by active service, to include aggravated by, proximately due to, or the result of a service-connected disability; nor may it be presumed to have been incurred in service, to include as a result of exposure to herbicide agents. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.313 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in July 2008 that fully addressed all notice elements. The letter provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, the letter informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. Although a document fully meeting the VCAA's notice requirements was not provided to the Veteran before the rating decision on appeal, the claim was fully developed and then readjudicated most recently in a May 2011 supplemental statement of the case (SSOC), which was issued after all required notice was provided. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, the Veteran's statements in support of the claim are of record, including testimony provided at an October 2009 hearing before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board recognizes that a May 2010 VA examination reflects outstanding treatment records involving a surgery in 2009 for a pacemaker replacement. Throughout the course of appeal, the Veteran has identified and submitted records, including private medical records, pertinent to his appeal. Yet, he did not submit, identify, or provide authorization for VA to obtain on his behalf the records relating to the pacemaker replacement. To the contrary, he filed an SSOC response in May 2011 indicating that he had no additional evidence regarding his appeal, and he requested that the Board proceed with adjudication of his claim. Moreover, although cited in the May 2010 VA examination report, the VA examiner did not indicate that the records were necessary to render an opinion. See Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010). Thus, the Board finds that remanding the claim to attempt to obtain the outstanding records is not required as it would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). As indicated, the Veteran was afforded a VA examination in May 2010 to determine whether his claimed disorder is due to Agent Orange exposure or secondary to PTSD. The Board finds that the VA examination is adequate because, as shown below, it was based upon adequate review of the pertinent medical history. Although records relating to a pacemaker replacement surgery in 2009 were not available, the VA examiner noted this history. The VA examiner did not indicate that the actual records were necessary to render a decision. The VA examiner otherwise considered the Veteran's lay assertions and current complaints, and described the claimed cardiac disorder in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). The Board accordingly finds no reason to remand for further examination. Accordingly, all reasonable efforts have been undertaken by VA with respect to the instant appeal, and no further development is required under these circumstances. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board also finds that there was substantial compliance with the May 2010 remand directives. A remand by the Board confers upon the claimant, as a matter of law, the right to substantial compliance with a remand order. See Stegall v. West, 11 Vet. App. 268 (1998); see D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (finding substantial compliance where an opinion was provided by a neurologist as opposed to the internal medicine specialist requested by the Board); Dyment v. West, 13 Vet. App. 141 (1999). Specifically in this case, the Board directed the AMC/RO to afford the Veteran an examination by a physician with sufficient expertise to determine the etiology of his current cardiac disorder, who was then asked to provide an opinion as to whether there is a 50 percent or better probability that the Veteran has a cardiac disorder that was either (1) caused or (2) permanently worsened to any degree by his service-connected PTSD. Upon remand, as indicated, an adequate VA examination was performed in May 2010. Thereafter, the AMC/RO readjudicated the matter in a May 2011 SSOC, as directed by the Board. For these reasons, the Board finds that there was substantial compliance with the May 2010 remand directives. Accordingly, no further remand is necessary. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries, 22 Vet. App. at 104-05. II. Analysis The Veteran contends that service connection is warranted for a cardiac disorder manifested by heart arrhythmia and valvular disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (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. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Also, certain chronic diseases, including cardiovascular-renal disease, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d 1372, 1376-77. The Board's duty is to assess the credibility and weight of the evidence. See Dalton v. Nicholson, 21 Vet. App. 23, 36 (2007); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In the present case, the evidence of record on appeal, including a May 2010 VA examination, establishes diagnoses of mitral regurgitation and atrial fibrillation (with pacemaker) during the pendency of the appeal. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran does not contend, and the evidence does not indicate, that these disorders were diagnosed during service, within one year of his December 1971 discharge from active duty, or for many years thereafter. See 38 C.F.R. §§ 3.303, 3.304, 3.307; see also Mingo v. Derwinski, 2 Vet. App. 51, 53 (1992) (Evidence of a present condition is generally not relevant to a claim for service connection, absent some competent linkage to service.). Furthermore, although the Veteran had National Guard service after his discharge from active duty, there is no indication that a claimed disorder worsened during a period of active duty for training or that any worsening was caused by any such period of active duty for training. See Smith v. Shinseki, 24 Vet. App. 40 (2010). Rather, the evidence presents two alternative theories of entitlement in support of the Veteran's claim. First, the record raises the issue of service connection for mitral regurgitation and atrial fibrillation (with pacemaker) disorders as due to Agent Orange exposure. Second, the Veteran's main contention is that these disorders are secondary to PTSD. The Board must adjudicate all theories of entitlement reasonably raised by the record, including a liberal reading of a Veteran's statements. See Robinson v. Peake, 21 Vet. App. 545, 552-553 (2008). For sake of clarity, the Board will address each theory separately. Agent Orange Exposure A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 C.F.R. §§ 3.307(a)(6)(iii); see also VAOPGCPREC 7-93. The VA General Counsel has determined that the regulatory definition, which permits certain personnel not actually stationed within the borders of Vietnam to be considered to have served in that Republic, requires that an individual actually have been present within the boundaries of the country. Specifically, the General Counsel has concluded that in order to establish qualifying "service in Vietnam" a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Service on a deep water vessel in waters off the shore of the Republic of Vietnam, without proof of actual duty or visitation in the Republic of Vietnam, does not constitute "service in the Republic of Vietnam" for the purposes of 38 U.S.C.A. § 101(29)(A) (establishing that the term "Vietnam era" means the period beginning on February 28, 1961 and ending on May 7, 1975 in the case of a veteran who served in the Republic of Vietnam during that period). See VAOPGCPREC 27-97. In short, a veteran must have been physically present on the landmass or inland waters of the Republic of Vietnam at some point during his service in order to establish qualifying service in Vietnam. See Haas v. Peake, 525 F.3d 1168, 1197 (2008), cert. denied 129 S.Ct. 1002 (2009). The Secretary of Veterans Affairs has also determined that there is a presumptive positive association between exposure to herbicides and certain medical disorders, which are listed in 38 C.F.R. § 3.309(e). The Secretary of Veterans Affairs has determined, on the other hand, that there is no presumptive positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See 75 Fed. Reg. 81332 (2010); 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41, 442-449 and 61 Fed. Reg. 57, 586-89 (1996); Notice, 64 Fed. Reg. 59, 232-243 (Nov. 2, 1999). Effective August 31, 2010, ischemic heart disease is a disorder for which service connection may be granted on a presumptive basis for veterans exposed to Agent Orange during service. Ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. The term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. See 38 C.F.R. § 3.309(e); 75 Fed. Reg. 53202. In this case, it is not in dispute that the Veteran had service during the Republic of Vietnam during the Vietnam era. Thus, he is presumed to have been exposed to Agent Orange during service. See 38 C.F.R. § 3.307. Mitral regurgitation and atrial fibrillation (with pacemaker), however, are not diseases listed in 38 C.F.R. § 3.309(e), for which service connection may be presumed as due to Agent Orange exposure. Further, the evidence does not indicate that either disorder qualifies within the generally accepted medical definition of ischemic heart disease. Thus, service connection is not warranted on a presumptive basis for either disorder. See 38 C.F.R. § 3.307. Notwithstanding the presumptive provisions, service connection for claimed residuals of exposure to herbicides also may be established by showing that a disorder resulting in disability is, in fact, causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155, 162-64 (1997); Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994)(citing 38 U.S.C.A. §§ 1113 and 1116, and 38 C.F.R. § 3.303). On this issue, the Veteran was afforded a VA examination in May 2010. The VA examiner reviewed the Veteran's history, noting the pertinent evidence. The VA examiner also noted that records from the University of Michigan concerning a pacemaker were not available. Based on the examination results, the examiner opined that there is no evidence that Agent Orange caused or aggravate valvular disease. Atrial fibrillation and subsequent pacemaker implantation, according to the VA examiner, were most probably due to the left atrial enlargement caused by mitral regurgitation. Upon review, the Board finds that the May 2010 VA examiner's opinion is the most probative evidence addressing whether mitral regurgitation or atrial fibrillation may be due to Agent Orange exposure. First, the VA examiner accurately reviewed the pertinent history. Although treatment records related to a pacemaker implantation were not available, these records were not necessary to decide the claim, as discussed in more detail above. Further, the VA examiner provided a clear opinion with supporting rationale. Thus, it is highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the VA examiner's opinion is uncontroverted by any remaining evidence of record. The Veteran underwent VA examinations in September 2005, February 2008, and February 2009. These VA examinations, however, do not contain probative opinions addressing whether a claimed heart disorder is due to Agent Orange exposure. See id.; see also Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010). ) The Veteran has not offered his own opinion relating a claimed cardiac disorder to Agent Orange exposure. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. For these reasons, an award of service connection for mitral regurgitation and atrial fibrillation as due to presumed Agent Orange exposure is not warranted. Secondary Service Connection The Veteran's main contention is that his mitral regurgitation and atrial fibrillation are aggravated by PTSD. Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability, which includes the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). (The Board notes that VA amended its regulation pertaining to secondary service connection, effective from October 10, 2006. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation; specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the Veteran's appeal was already pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects).) In the present case, the Veteran is service-connected for PTSD. Thus, the remaining question is whether mitral regurgitation and atrial fibrillation were caused or aggravated by the PTSD. See 38 C.F.R. § 3.310. On this question, the record includes an August 2003 statement from a private (non-VA) cardiologist, who wrote that the Veteran's coronary disease may well have been exacerbated by his very stressful military service. The Board notes that this opinion, in isolation, appears favorable to the Veteran's claim. An overall reading of the cardiologist's August 2003 statement, however, makes clear that he was discussing CAD (for which service connection is already in effect) and not a heart arrhythmia or valvular disorder. Thus, the August 2003 statement is not relevant in the instant appeal. The record also shows that the Veteran underwent two VA examinations with the same examiner, first in February 2008 and again in February 2009. In the February 2008 VA examination report, the VA examiner concluded that no opinion could be reached without resort to mere speculation without echocardiogram (ECHO) results, which were not available. Then, in February 2009, after reviewing recent ECHO results, the VA examiner opined that there is no direct relationship of PTSD to valvular heart disease, and PTSD "would contribute less than 50 percent to" valvular disease in light of the Veteran's "more overriding risk factors of dyslipidemia, hypertension, and being male." The Board notes that the VA examiner's February 2009 opinion is not clear. On the one hand, it can be read to support the Veteran's claim as it appears to indicate that PTSD aggravated ("contributed" to) in some degree to valvular disease. Service connection may be warranted without regard to the degree of aggravation caused by the service-connected disability. See 38 C.F.R. § 3.310 (prior to October 2006). Nonetheless, it is not clear that this was the VA examiner's intended meaning. The RO requested the examiner to indicate whether there is a "50/50 probability" that a disorder was, for instance, "most likely," "at least as likely as not," or "less likely" than not caused or aggravated by PTSD. In light of this background, the February 2009 VA examiner's opinion could also be understood to mean that there is less than a 50 percent possibility that PTSD aggravated ("contributed" to) valvular disease. Overall, the Board finds that this lack of clarity renders the February 2009 VA examiner's opinion nonprobative. Thus, it neither weighs in favor of or against the claim. See Nieves-Rodriguez, 22 Vet. App. at 304. As discussed above, the Veteran underwent another VA examination in May 2010. Pertinent to the Veteran's secondary service connection theory of entitlement, the VA examiner opined that there is no evidence that PTSD caused or aggravated valvular disease. Likewise, according to the VA examiner, atrial fibrillation and subsequent pacemaker implantation were most probably due to the left atrial enlargement caused by mitral regurgitation. The VA examiner also commented that the Veteran had mitral regurgitation unrelated to CAD or any coronary risk factors, which probably accounted for most of his disability. The mitral regurgitation resulted in left atrium enlargement which "is the probable cause of his atrial fibrillation." The Board finds the VA examiner's opinion highly probative as he was accurately informed by the pertinent history of the case, and because he provided a clear opinion with supporting rationale. See Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran has also offered his opinion indicating that his mitral regurgitation and arrhythmia have been aggravated by PTSD. At his October 2009 Board hearing he testified that PTSD "certainly" aggravated his heart disease. Although credible, this question of causation and aggravation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. In conclusion, the Board finds that the preponderance of the most probative evidence of record, which consists of the May 2010 VA examination, weighs against the claim of service connection for heart arrhythmia and a valvular disorder manifested by mitral regurgitation. Accordingly, the claim is denied. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. 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 claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for a cardiac disorder involving heart arrhythmia and a valvular disorder manifested by mitral regurgitation is denied. REMAND Upon review, the Board finds that further development is necessary on the claim of service connection for hypertension. In particular, the Board finds that a new VA examination is necessary. Previously, the Veteran underwent pertinent VA examinations in February 2008 and February 2009. Although the VA examiner provided an opinion regarding the Veteran's hypertension, that opinion does not address with sufficient clarity the question of whether hypertension is caused by or permanently worsened by his service-connected PTSD. In fact the VA examination report appears to be internally inconsistent in this regard. The evidence of record also includes a January 2005 statement from a private (non-VA) cardiologist. Although the primary focus of the cardiologist's statement relates coronary artery disease (CAD), the cardiologist also commented that "It is well know and accepted that stress, the associated levels of stress related hormones, and the effects of stress on the blood pressure are all prime contributors to" CAD (emphasis added). The highlighted statement indicates that stress may have an effect on the Veteran's blood pressure. Thus, a VA examination is necessary to clarify whether the Veteran's hypertension is caused or aggravated by PTSD. The Board finds that there is also a preliminary question concerning whether the Veteran's hypertension is due to Agent Orange exposure, which also should be addressed. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board again notes that the provisions of 38 C.F.R. § 3.310, which concern secondary service connection, were amended during the course of the Veteran's appeal, effective October 10, 2006, in order to conform VA's regulation to the Court's decision in Allen v. Brown, 7 Vet. App. 439, 448 (1995). In that decision the Court held that the term "disability" as used in 38 U.S.C.A. § 1110 referred to impairment of earning capacity, and that such definition mandated that any additional impairment (emphasis supplied) of earning capacity resulting from an already service-connected condition shall be compensated. Under the revised regulation, the rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 CFR Part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310(b) (2007-2009). However, this requirement was not contained in prior versions of the regulation. See 38 C.F.R. § 3.310 (2006). Therefore, in deciding the claim, the originating agency should apply the former version of the regulation. Accordingly, the issue is REMANDED for the following action: 1. After completing any initial development deemed warranted based upon a review of the entire record, to include associating any pertinent outstanding records with the claims folder, the RO should arrange for the Veteran to undergo an appropriate VA examination with a physician. The entire claims file, including a copy of this remand, must be made available to the examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions, and undertake any indicated studies and diagnostic tests. Then, cased upon the examination results and the review of the claims folder, the examiner should provide an opinion as to the following: (a) Is it at least as likely as not (i.e., there is a 50 percent or better probability) that the Veteran's hypertension is due to herbicide (Agent Orange) exposure during service? (b) Is it at least as likely as not (i.e., there is a 50 percent or better probability) that the Veteran's hypertension was either (1) caused or (2) permanently worsened to any degree by his PTSD. In making these determinations, the examiner is asked to address all medical opinions of record addressing these issues, including a February 2009 VA examination and a January 2005 private cardiologist's letter. The examiner is also requested to discuss the Veteran's own assertions regarding his symptomatology. The examiner is requested to prepare a printed (typewritten) report setting forth all examination findings, along with a complete rationale for all opinions and conclusions reached. It is imperative that the examiner offer a detailed analysis for all conclusions and opinions reached supported by specific references to the Veteran's claims file, including the in-service and post-service medical records, and the Veteran's lay assertions. 2. After completing the requested actions, and any additional notification and/or development warranted by the record, the RO should readjudicate the remanded claim in light of all pertinent evidence and legal authority and addressing all relevant theories of entitlement. If any benefit sought on appeal remains denied, the RO should furnish to the Veteran and his representative, if any, an appropriate Supplemental Statement of the Case (SSOC) that includes clear reasons and bases for all determinations, and affords the appropriate time period to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs