Citation Nr: 1323977 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-27 905 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for coronary artery disease (CAD), to include on a direct basis and secondary to the service-connected diabetes mellitus. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. Finn, Counsel INTRODUCTION The Veteran served on active duty from May 17, 1994 to September 16, 1994, from April 30, 2001 to September 14, 2001, and from April 15, 2002 to December 16, 2002 and from January 21, 2003 to January 20, 2004, during the Gulf War Era. This matter comes before the Board of Veterans' Appeal (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. A review of the Veteran's electronic ("Virtual VA") paperless claims file does not reflect additional treatment records. Virtual VA is a highly secured electronic repository used to store and review every document involved in the claims process. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran if he has received any VA, non-VA, or other medical treatment that is not evidenced by the current record. Provide the Veteran with the necessary authorizations for the release of any non-VA treatment records not currently on file. Obtain these records and associate them with the claims folder. If the records are not obtainable (or none exist), the Veteran should be notified and the record clearly documented. 2. After the above has been completed, the RO/AMC should arrange for the claims folder to be reviewed by the examiner who prepared the October 2010 VA examination report (or a suitable substitute if that examiner is unavailable), for the purpose of preparing an addendum that addresses whether the Veteran's CAD or any heart disability is related to or had its onset in service and/or related to his period of active service. The following considerations will govern the examination: a. The claims folder, and a copy of this remand, must be available to the examiner for review in conjunction with writing of the addendum opinion and/or examination if deemed necessary. If another examination is provided, the examiner MUST take a complete history from the Veteran as to the onset, nature, and progression of symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran regarding his CAD, the examiner must state this, with a fully reasoned explanation. All appropriate tests and studies should be accomplished. b. The examiner is advised: * The Veteran asserts that he first experienced chest pain during service while in Iraq. He stated that he had further chest pain and numbness in both arms in December 2005. * STRs reflect work-up for an abnormal EKG and two complaints of chest pain. * A July 1974 Report of Medical History reflects no complaints of heart trouble, shortness of breath, or chest pain. * A March 1980 Report of Medical Examination reflects a normal heart upon clinical evaluation. The March 1980 Report of Medical History reflects no complaints of heart trouble, shortness of breath, or chest pain. * A September 1984 Report of Medical Examination reflects a normal heart upon clinical evaluation. A September 1984 Report of Medical History reflects no complaints of heart trouble, shortness of breath, or chest pain. * A May 1988 Report of Medical Examination reflects normal heart. A May 1988 Report of Medical History reflects no complaints of heart trouble, shortness of breath, or chest pain. * In a January 1992 Report of Medical Examination, the Veteran had a normal heart upon clinical evaluation. A January 1992 Report of Medical History reflects no complaints of heart trouble. * An April 1997 Report of Medical Examination reflects abnormal heart upon clinical evaluation. In an April 1997 Report of Medical History, the Veteran reported high blood pressure. He was placed on medication. * In an April 1997 Physical Profile, it was noted that an EKG showed evidence of long standing high blood pressure. * An April 2003 echocardiograph report reflected the following: 1) no significant aortic valve insufficiency by Doppler; 2) no significant aortic valve stenosis by Doppler; 3) minimal mitral valve regurgitation by Doppler; 4) no significant mitral valve stenosis by Doppler; 5) no significant tricuspid valve regurgitation by Doppler; 6) no significant tricuspid valve regurgitation by Doppler; 7) mild concentric left ventricular hypertrophy; 8) left ventricular ejection fraction approximately 70 percent; and 9) normal Doppler study. An April 2003 STR noted uncontrolled hypertension, heart murmur (awaiting echo result), dyslipidemia, and abnormal EKG/ECG. * The Veteran complained of chest pain in April 2003. * In a May 2003 STR, it was noted that the Veteran desired to be deployed with his unit to Kuwait. It was determined that the Veteran would discontinue Zocor medication and restart the treatment upon his return. * A January 2006 VA treatment record diagnosed the Veteran, in part, with CAD and hyperlipidemia. * An April 2007 VA treatment record noted that the Veteran had a "CAD-stent x 1 RCA last week of 12/05." * A December 2005 EKG Report noted sinus mechanis rate of 60; PVC; and ST-T abnormalities, probably coronary insufficiency. * The December 2005 radiology report of the chest was negative. The Veteran had a non-ST elevated myocardial infarction in December 2005. * A February 2006 treatment record noted, in part, that the Veteran had severe CAD of the RCA and codominant left circumflex system. * A January 2008 VA examination noted a history of a heart murmur in April of 2003 and asymptomatic mitral regurgitation. He suffered a heart attack in December 2005 and at that time had 90 percent stenosis of the right coronary artery and total occluded distal circumflex. The Veteran had a stent placed in the right coronary artery and coronary angioplasty. * In a June 2007 Post-Deployment Health Reassessment, the Veteran complained, in part, of chest pain or pressure, difficulty breathing, dizziness, fainting, and light headedness. * An October 2010 VA examination diagnosed the Veteran, in part, with CAD, status post-angioplasty with stent placement. He stated, in part, that due to the longevity of the essential hypertension, it was his medical opinion this played a major role in the development of CAD. * A June 2011 VA examiner noted that the Veteran's electrocardiogram showed sinus bradycardia. c. After a review of the examination findings and the entire evidence of record, the examiner must answer the following questions: (i) Does the Veteran currently have a heart disability, to include CAD? Please list all heart disabilities. If so, did any heart disability, to include CAD have its onset in service, or within one year after discharge from service in January 20, 2004? In the alternative, is the Veteran's CAD or any other heart disability related to his period of active service. An explanation must be provided for any opinion or conclusion expressed. 3. After completion of the above and any other development deemed necessary, the RO should review and re-adjudicate the issue on appeal. If any such action does not resolve each claim to the Veteran's satisfaction, the RO must provide the Veteran and his representative, if any, a supplemental statement of the case (SSOC) and an appropriate period of time should be allowed for response. Thereafter, the case should be returned to this Board for appellate review. 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. 2012). _________________________________________________ Vito A. Clementi 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).