Citation Nr: 1335095 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 11-25 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for ischemic heart disease (IHD). REPRESENTATION Veteran represented by: David L. Huffman, Attorney at Law ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to August 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claim. A review of the Virtual VA claims file does not reveal any additional documents pertinent to the present appeal. In August 2013, the Board requested an expert medical opinion from a cardiologist with the Veterans Health Administration (VHA). See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901 (2013). The VHA expert provided an opinion in October 2013. As the claim may be fully resolved in favor of the Veteran, the Board will issue a decision rather than wait an additional time to provide the Veteran and his attorney a copy of the VHA opinion followed by an opportunity for presenting additional evidence and/or argument in support of the claim. FINDINGS OF FACT 1. The Veteran is presumed to have been exposed to herbicides coincident with his service aboard the U.S.S. Iwo Jima during the Vietnam Era. 2. Resolving all doubt in his favor, the Veteran has ischemic heart disease, diagnosed as coronary artery disease, which is presumed to be a result of exposure to herbicides. CONCLUSION OF LAW The criteria for entitlement to service connection for ischemic heart disease, diagnosed as coronary artery disease, have been met. 38 U.S.C.A. §§ 1110, 1112, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.307(a)(6)(iii), 3.309(e) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION As the Board's decision to grant service connection for ischemic heart disease, diagnosed as coronary artery disease, herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 and the implementing regulations. The Veteran claims entitlement to service connection for ischemic heart disease as a result of exposure to herbicides. Service connection is established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during periods of active service. 38 U.S.C.A. § 1110. In general, service connection requires 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has acknowledged that the Veteran was exposed to herbicides coincident with his service aboard the U.S.S. Iwo Jima during the Vietnam Era. In this regard, VA regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period from January 9, 1962, to 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. 38 U.S.C.A. § 1116 ; 38 C.F.R. § 3.307(a)(6)(iii). VA regulations further provide that presumptive service connection is warranted for ischemic heart disease (including, but 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) due to herbicide exposure. Therefore, the crux of the issue before the Board is whether the Veteran has a current diagnosis of ischemic heart disease during the appeal period, i.e., since July 2010. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). By way of background, in March 2001, the Veteran was hospitalized with complaints of chest pain. It was noted that his enzymes, ECGs, and chest x-rays were all negative. The ECG was noted to have shown no sign of acute ischemic changes. The discharge diagnosis was chest pain, noncardiac. The Veteran underwent a pharmacological stress test using Cardiolite imaging protocol five days later in March 2001. A perfusion study was interpreted as showing a medium-sized inferior and inferolateral defect with nearly complete redistribution consistent with a small area of nontransmural infarction and stress-induced ischemia in the same coronary territory. Another perfusion test was performed in September 2001, the results of which were also interpreted as showing a previous infarction and superimposed stress-induced ischemia. A December 2001 private cardiology consultation noted that these stress Cardiolite tests showed small areas of inferior and inferolateral ischemia. The Veteran was suspected as having underlying coronary artery disease which had not been medically treated in the past. Also in December 2001, the Veteran was hospitalized for chest pressure with a flushed feeling. The discharge diagnosis was atypical chest pain. Other diagnoses included possible history of coronary artery disease, status post abnormal stress echo which showed an inferior wall infarct and stress-induced ischemia, hyperlipidemia, hypertension, and anxiety and panic disorder. In March 2004, the Veteran reported to the emergency room with complaints of left-sided chest pain. Following a physical examination and a negative chest X-ray, chest wall pain was diagnosed. In July 2007, the Veteran was admitted to the hospital with complaints of heart palpitations. Diagnostically, the Veteran had a normal hemogram, cardiac profile, and magnesium. It was noted that an EKG showed normal sinus rhythm with no ischemic changes. Provisional diagnoses included palpitations, anxiety disorder, and premature ventricular contractions. In June 2011, the Veteran was admitted to the hospital for treatment of atypical chest pain and atypical angina. It was noted that he had been previously admitted in 2001 and had a negative cardiac workup. An ECG revealed sinus rhythm at a heart rate of 60 beats per minute and was essentially normal with the exception of some mild relative bradycardia. A chest X-ray revealed clear lung fields and normal cardiac silhouette. The physician noted that prior nuclear stress perfusion scan in the distant past (2001) revealed an inferior abnormality, though diaphragmatic attenuation was also present decreasing the specificity of the finding and ultimately further workup was not pursued. The impression was bradycardia. A July 2011 VA examination report first stated that it was at least as likely as not that the Veteran had a diagnosis of ischemic heart disease, but then stated that it was equivocal whether there was a diagnosis of ischemic heart disease. It was explained that, while the prior Cardiolite stress testing was suggestive of ischemia in the inferior and inferolateral region, there were no follow-up studies conducted to confirm the diagnosis. Following an echocardiogram, the examiner submitted an addendum opinion in January 2012 stating that there was no confirmed diagnosis of ischemic heart disease. Given this conflicting evidence regarding whether the Veteran, in fact, has ischemic heart disease, the Board obtained an expert opinion from a VHA cardiologist in October 2013. The cardiologist discussed all pertinent evidence of record and found that the outpatient testing in 2001 (reported above) revealed findings consistent with coronary artery disease involving the inferior and inferolateral regions of the left ventricle. It was noted that there was a possible progression from ischemia to infarct shown between the testing conducted in March and September 2001. The examiner next noted that the Veteran's "normal" echocardiogram results with no apparent wall motion abnormalities did not rule out the presence of coronary artery disease, as wall motion on echocardiography could appear normal even with severe blockages of coronary arteries due to collateral flow. It was further noted that the echocardiogram could not be considered 100 percent accurate as it was described as technically difficult with recommendation to obtain further imaging. As such, based on findings that include multiple risk factors and two abnormal nuclear scans consistent with ischemic coronary heart disease, the VA cardiologist concluded that it was at least as likely as not that the Veteran has a diagnosis of ischemic heart disease since he filed his claim in July 2010. The Board finds that the evidence is, at the very least, in equipoise as to the question of whether the Veteran manifests ischemic heart disease. In this regard, sophisticated imaging tests have been interpreted as showing a history of infarction with stress-induced ischemia in the inferior and inferolateral regions of the heart. Private cardiologists have interpreted these results as demonstrating underlying coronary artery disease. The VHA cardiologist in October 2013 found that, based upon these imaging tests, it was appropriate to conclude that the Veteran manifested coronary artery disease. In contrast, the 2011/2012 VA examiner has stated that a diagnosis of ischemic heart disease has not been "confirmed." However, the VA examiner did not provide any reasoning why the Cardiolite testing results are insufficient. Additionally, the VHA examiner in 2013 provided persuasive reasoning why the echocardiogram results relied upon by the VA examiner also do not provide a definitive answer ruling out the presence of an underlying coronary artery disease. In light of the opinions of the private cardiologists and the VHA cardiologist, which are based upon two separate imaging results of the heart, the Board resolves all doubt in favor of the Veteran and finds that he manifests ischemic heart disease, diagnosed as coronary artery disease, which is presumed to be a result of exposure to herbicides. The claim, therefore, is granted on a presumptive basis under 38 C.F.R. § 3.309(e). ORDER Service connection for ischemic heart disease, diagnosed as coronary artery disease, is granted. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs