Citation Nr: 1323790 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 07-10 003A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for a cardiovascular disorder, to include paroxysmal atrial fibrillation, including as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Holtz, Associate Counsel INTRODUCTION The Veteran had active duty service from October 1965 to August 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which, in pertinent part, denied entitlement to service connection for heart disease. The Veteran testified at a videoconference hearing in January 2013; a transcript of that hearing is associated with the Veteran's Virtual VA record. The Board has reviewed relevant records in the Virtual VA paperless claims processing system in conjunction with this remand. The matter was previously before the Board in April 2013, at which time the Board reopened the claim of entitlement to service connection for paroxysmal atrial fibrillation based on a finding that the Veteran had presented new and material evidence. The Board remanded the claim to obtain records and to seek an addendum opinion. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Board remanded the Veteran's claim for service connection in April 2013 to obtain private treatment records, and, if there was evidence of treatment for paroxysmal atrial fibrillation during the period of the appeal, to seek an addendum opinion concerning the relationship between the Veteran's paroxysmal atrial fibrillation and posttraumatic stress disorder. In June 2013, following the most recent supplemental statement of the case, VA received treatment records from Northeast Methodist Hospital. Per those records, the Veteran was admitted for treatment for a transient ischemic attack in May 2009. The May 2009 treating provider noted a history of paroxysmal atrial fibrillation in the distant past. According to the report, the day prior to his admission, the Veteran developed a sudden onset of discoordination, weakness, and numbness of his left lower extremity. Testing performed during his treatment, including a bilateral carotid Doppler ultrasound and an echocardiogram, provided normal results; the echocardiogram results indicated a normal sinus rhythm. Upon discharge, the Veteran was assigned multiple diagnoses including transient right hemispheric dysfunction consistent with transient ischemic attack, paroxysmal atrial fibrillation (though remained in sinus rhythm throughout his hospital stay), and posttraumatic stress disorder. The records obtained, which indicate a current diagnosis of paroxysmal atrial fibrillation, sufficiently satisfy the prerequisite to obtaining an addendum medical opinion. Moreover, on further consideration of the decision by the United States Court of Appeals for Veterans Claims in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board finds that the issue presented pertains to all diagnosed cardiovascular disorders, not just paroxysmal atrial fibrillation. Hence, an additional opinion is in order. Accordingly, the case is REMANDED for the following action: 1. Obtain a medical opinion from the September 2012 examiner, or another qualified medical professional, addressing whether it is at least as likely as not that paroxysmal atrial fibrillation, or any other identified cardiovascular disorder, is caused or aggravated by his PTSD. The medical professional who provides the requested opinion should review the claims file, this remand, and the Veteran's Virtual VA electronic file. The ensuing report should indicate that he or she performed the requested review. The medical professional should address the following issues: (i) Is it at least as likely as not that paroxysmal atrial fibrillation disability, or any other identified cardiovascular disorder, was caused by or is aggravated (chronically worsened beyond the natural progression of the disease) by his service-connected PTSD? (ii) If the paroxysmal atrial fibrillation disability, or any other identified cardiovascular disorder, was not caused by, but is aggravated by, posttraumatic stress disorder, the examiner should identify the baseline level of severity of any diagnosed cardiovascular disorder prior to the onset of aggravation, and the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. If some of the increase in severity of any diagnosed cardiovascular disorder is due to the natural progress of the disease process, the medical professional should identify the degree of increase in severity due to natural progression. The medical professional providing the requested addendum must explain the rationale for any and all opinions expressed. If the questions cannot be answered without resorting to speculation, then he or she should provide a detailed medical explanation as to why causation is unknowable. If the medical professional determines that the addendum requested cannot be provided without a new examination, then the RO/AMC should arrange such an examination. 2. The Veteran is to be notified that it is his responsibility to report for any scheduled examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. After the development requested has been completed, the RO/AMC should review the examination report to ensure that it is in complete compliance with the directives of this remand. The RO/AMC must ensure that the examiner documented his or her consideration of Virtual VA. If the report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 4. Then, readjudicate the claim. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before the claims folder is returned to the Board for further appellate action. The appellant 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. 2012). _________________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).