Citation Nr: 1327987 Decision Date: 09/03/13 Archive Date: 09/10/13 DOCKET NO. 10-20 145 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for heart condition. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Laura E. Collins, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1985 to September 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In March 2013, the Veteran testified via video-conference hearing before the undersigned Veterans Law Judge. A transcript is associated with the claims file. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are potentially relevant to the issue on appeal. Thus, any future consideration of this appellant's case should take into account the existence of this electronic record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran if further action is required. REMAND The Veteran seeks service connection for a heart condition. For the reasons that follow, his claim must be remanded. VA's duty to assist includes a duty to provide a medical examination or to obtain a medical opinion where it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4) (2012). Further, the Board may order an examination when the record shows that the Veteran has a current disability, indicates that this disability may be associated with the Veteran's active service, and does not contain sufficient evidence for the Board to make a decision on the issue. 38 U.S.C.A. § 5103A(d)(2). If the record indicates that there may be a nexus between the current disability and any service related incident, then the Board may order an RO to have a claimant examined. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran has current cardiac diagnoses. Specifically, in June 2009 he reported a three-to four-month history of episodes characterized by tightness in the chest, chest pain, shortness of breath, pain in the right arm, and sweating. In July 2009 a myocardial perfusion scan showed ischemia of the inferior wall with apical extension and left ventricular ejection fraction (EF) of 61 percent. In August 2009 after an episode of chest pain he was diagnosed with unstable angina (myocardial infarction ruled out), nonobstructive CAD, dyslipidemia, and hypertension (HTN). In September 2010 he was hospitalized for chest pains and shortness of breath and had discharge diagnoses of non-ST segment elevation myocardial infarction, nonobstructive CAD, angina, and HTN. VA treatment records show that he continues to be followed for recurrent angina and CAD. Service treatment records (STRs) show that in a May 2006 pre-discharge physical, an echocardiogram showed EF of 70 to 75 percent, trace mitral insufficiency, hyperlipidemia, left atrial hypertrophy, and an estimated METS level of 7. The Veteran contends that his current cardiac diagnoses arose in service and are related to the May 2006 findings, as well as to elevated cholesterol and blood pressure in service. He notes that his EF has steadily worsened since service. The regulations at 38 C.F.R. § 3.159(c)(4) present a low threshold for the requirement that evidence indicate that the claimed disability may be associated with in-service injuries for the purposes of a VA examination. In this case, the Board finds that the medical evidence is sufficient to indicate that the current heart condition may be associated with in-service cardiac findings. The Board finds it appropriate to remand the claim to afford the Veteran an opportunity to undergo a VA examination to assess the current nature and etiology of his heart condition. Additionally, in a December 2012 statement and at his March 2013 hearing the Veteran and his representative indicated that there may be outstanding VA treatment records. The earliest VA treatment records in the claims file are dated August 16, 2007, but the Veteran indicated that he may have been treated for cardiac complaints earlier than that date. He reports that he has only been treated at the VA Medical Center (VAMC) in Oklahoma City and Lawton/Ft. Sill Outpatient Clinic. The most recent VA treatment records in the claims file are dated October 2012. Therefore on remand, any relevant VA treatment records from those facilities dated either prior to August 16, 2007 or after October 2012 should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain any relevant VA treatment records from the Oklahoma City VAMC and Lawton/Ft. Sill Outpatient Clinic dated prior to August 16, 2007 and after October 2012. 2. After associating any outstanding records with the claims file, schedule the Veteran for an appropriate VA examination to determine whether his heart condition is related to service. The claims file must be made available to and reviewed by the examiner, and such review should be noted in the report. All appropriate tests and studies should be conducted. The examiner should first identify the Veteran's current heart diagnoses. Then state whether it is at least as likely as not that any a) initially manifested in service; b) is causally related to or arose during service, particularly addressing the May 2006 findings; c) was manifested within one year of discharge from service (by September 2007); The examiner should also acknowledge and discuss the Veteran's statements as to the continuity of heart symptomatology since service. The examiner should describe all findings in detail and provide a complete rationale for all opinions offered. If the examiner is unable to provide the requested opinions without resort to speculation, the reasons for that should be explained, noting particularly whether it is the limits of medical knowledge that prevents providing the opinion or missing facts. If it is missing facts, the information that is necessary to provide a non-speculative opinion should be described to the extent possible. 3. Then, readjudicate the Veteran's claim. If action remains adverse, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. 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 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). _________________________________________________ MICHAEL E. KILCOYNE 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).