Citation Nr: 1324257 Decision Date: 07/30/13 Archive Date: 08/07/13 DOCKET NO. 04-34 223 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for a heart condition/murmur, to include as secondary to service-connected posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1979 to April 1981. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a September 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which denied service connection for PTSD and found that new and material evidence had not been submitted to reopen the claim of entitlement to service connection for a heart condition/murmur. In October 2004, the Veteran withdrew his request for a Travel Board hearing. See 38 C.F.R. § 20.704(e) (2012). In its March 2007 decision, the Board, in relevant part, denied the Veteran's claim for service connection for PTSD and reopened his claim for service connection for a heart condition/murmur and denied it on the merits. In a March 2009 memorandum decision, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's March 2007 decision with respect to both issues, and remanded the claims for readjudication consistent with the Court's memorandum decision. In July 2010, the Board remanded both issues for additional development. The requested development was completed and in a December 2012 rating decision, the RO granted service connection for PTSD. As service connection has been granted for PTSD, that issue is no longer before the Board for further appellant consideration, however, the claim for service connection for a heart condition/murmur has since been returned to the Board for further appellate consideration. In light of the December 2012 grant of service connection for PTSD, the Board has rephrased the issue as listed on the title page to better reflect the issue on appeal. A review of the Veteran's Virtual VA electronic claims file shows that additional VA treatment records dating from 2006 to 2012 were associated with the electronic claims file in August and December 2012, prior to the issuance of the December 2012 supplemental statement of the case (SSOC). 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 Veteran contends that service connection is warranted for a heart condition/murmur. By way of history, as noted in the Board's March 2007 decision, a review of the record shows that the Veteran was in his usual state of good health without any indication of a heart condition/murmur until he sustained internal injuries during a motorcycle accident in June 1981, two months following his discharge from active service. The Veteran's March 1981 examination for separation from active service showed that a chest x-ray at that time was read as normal and physical examination of his heart was normal. The Veteran's service personnel records show that at the time of the June 1981 motorcycle accident, the Veteran was serving in the United States Navy Reserves, however, the accident did not occur during authorized travel to or from drill, active duty for training purposes (ACDUTRA), or inactive duty for training purposes (INACDUTRA). As to the June 1981 motorcycle accident, private inpatient treatment records from VVMC and LLUMC dated in June and July 1981 show that following surgical repair of splenic lacerations with splenectomy and repair of the diaphragm, the Veteran was found to be hypertensive in the upper extremities with blood pressures of 180 and only a systolic pressure of 110 in the lower extremities. He was also noted to have a cardiac murmur radiating to the back and a traumatic transaction of the aorta was suspected. Thoracic aortogram in July 1981 revealed a laceration of the proximal descending thoracic aorta with pseudoaneurysm formation. A left thoracotomy was performed and the aorta was found to be completely transected. A prosthetic graft was used to repair the thoracic aorta. In March 1982, the Veteran underwent examination to determine his fitness for continued military service. At that time, his chest was clear to percussion and auscultation and there was no gynecomastia. Cardiac examination revealed regular sinus rhythm without any murmurs or gallops. Chest x-ray was read as within normal limits. Treatment at that time included aspirin grains to prevent thrombosis of the aortic graft and no strenuous activity for the following 3 months, at which time he could begin ad lib activity. Diagnostic impression was brachial plexus nerve injury (complete transaction of the thoracic aorta and brachial plexus). The Medical Board opined that the Veteran was unfit for return to full duty in the Navy Reserves. Based on the foregoing, in the its March 2007 decision, the Board concluded that service connection for a heart condition/murmur was not warranted as there was no evidence showing that the claimed disability was incurred during or aggravated by service, rather, the evidence showed that the claimed disability was the result of intercurrent injury sustained during the 1981 motorcycle accident. In the March 2009 memorandum decision, however, the Court found that the Board erred in finding that the Veteran was not entitled to application of the 1 year presumption for service connection for cardiovascular disease, thus, a remand was required for readjudication of the claim on that basis. In this regard, it is significant to note that there are no further VA or private treatment records pertaining to a heart condition/murmur until the Veteran's involvement in a second motorcycle accident in August 1993. Private treatment records received from the Social Security Administration (SSA) show that a urine drug screen at that time was positive for methamphetamines. His heart rate was described as "mildly tachy - irregular rhythm." VA treatment records dating since 1995 show that ECG in January 1995 showed diagnostic assessments of moderate voltage criteria for left ventricular hypertrophy - may be normal variant, nonspecific ST abnormality, and an abnormal ECG. A January 1997 private treatment note showed diagnostic assessments of atypical chest pain of unknown etiology and ventricular arrhythmia. Thereafter, VA and private treatment records show that the Veteran has received treatment for heart palpitations, tachycardia, and atypical chest pain. As noted above, in a December 2012 decision, the RO granted entitlement to service connection for PTSD. In this regard, VA treatment records dated in 1998 note that the Veteran was found to have palpitations and it was questioned whether they were secondary to his use of Trazodone, which had been prescribed to assist with sleep. Tachycardia was also noted secondary to anger and stress from his truck being broken into. As service connection is now in effect for PTSD, the issue of whether the claimed heart condition/murmur disability is due to or aggravated by the Veteran's service-connected PTSD must be appropriately developed and adjudicated. In this regard, the Board observes that the Veteran has not been given appropriate notice regarding the evidence necessary to substantiate a claim for service connection on a secondary basis. Moreover, the Veteran has not been afforded a VA examination for diagnosis and medical opinion as to the nature and etiology of any current heart condition/murmur or cardiovascular disability. As there is medical evidence suggesting that the claimed heart condition/murmur may be aggravated by the Veteran's mental state and/or medication taken for treatment of his service-connected PTSD, a VA examination is warranted to determine whether the claimed disability is due to or aggravated by his service-connected PTSD. See Duenas v. Principi, 18 Vet. App. 512 (2004); McLendon v. Nicholson, 20 Vet App. 79 (2006). Given the need to remand the claim for additional development, the Veteran should be advised that there are no treatment records associated with the claims file dated during the year following his discharge from active service or until his August 1993 motorcycle accident. He should be requested to identify any treatment that he received for a heart condition/murmur and any cardiovascular disability dating since his discharge from service, to specifically include any treatment received dating from April 1981 to April 1982. Ongoing VA treatment records should also be obtained from the West Los Angeles VAMC since June 2013 and the Loma Linda VAMC since October 2012. Accordingly, the case is REMANDED for the following action: 1. Issue VCAA notice informing the Veteran of the evidence necessary to support a claim of entitlement to service connection on a secondary basis. 2. Contact the Veteran and afford him an opportunity to identify or submit any additional pertinent evidence in support of his claim for service connection for a heart condition/murmur, to include as secondary to service-connected PTSD. Of specific interest is any treatment received for the claimed disability dated during the 1 period following his discharge from active service in April 1981 and prior to his August 1993 motorcycle accident. Based on his response, if any, the RO/AMC must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless whether a response is received, relevant VA treatment records must be obtained from the West Los Angeles VAMC dating since June 2012 and the Loma Linda VAMC dating since October 2012. If the RO/AMC cannot locate such records, the RO/AMC must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO/AMC must then: (a) notify the Veteran and his representative, if any, of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The Veteran and his representative, if any, must then be given an opportunity to respond. 3. After the above development has been completed to the extent possible, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his claimed heart condition/murmur disability. The claims folder should be forwarded to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran, the pertinent details of which should be recited in the examination report. Following examination, interview of the Veteran, and review of the claims file, the examiner should identify all heart conditions/murmurs and cardiovascular disabilities diagnosed during examination and in treatment records dating from April 1981 to April 1982, and since the claim to reopen was received in November 2002. All necessary testing should be conducted, the results of which should be detailed in the examination report. With respect to each current heart condition/murmur and/or cardiovascular disorder identified, the examiner should provide an opinion as to whether it is at least as likely than not (i.e., probability of 50 percent or greater) that any such disability was either: (a) incurred within 1 year following the Veteran's discharge from active service or (b) caused or aggravated (permanently worsened beyond normal progression) by his service-connected PTSD. The examiner should provide a discussion of the complete rationale for any conclusion provided. If the examiner determines that he or she is unable to provide the requested opinion(s) without resort to speculation, he or she must provide a reasoned explanation for such conclusion, which includes appropriate references to pertinent evidence of record. 4. The Veteran is hereby notified that it is his responsibility to report for any examination, 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. 5. Readjudicate the claim on appeal, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative, if any, should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter 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). _________________________________________________ DAVID L. WIGHT 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).