Citation Nr: 1401167 Decision Date: 01/10/14 Archive Date: 01/23/14 DOCKET NO. 10-13 762A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for a heart disorder. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from October 1, 1974, to October 31, 1974. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, which denied the claim. The Veteran presented testimony at a videoconference hearing before the undersigned Veterans Law Judge in March 2012. A transcript is of record. The record before the Board consists of paper claims files and an electronic file known as Virtual VA. 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 seeks service connection for a heart disorder. He has specifically claimed a pin hole in his heart that has opened up. See February 2009 VA Form 21-526. The Veteran asserts that this pin hole was discovered in 1974 during service. See March 2009 VA Form 21-4138. He contends that he had no problems prior to service. See June 2009 VA Form 21-4138; March 2012 hearing transcript. Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. The application of the presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48 (2012). There were no cardiovascular defects, infirmities or disorders noted at the time of the Veteran's entry into active duty. See September 1974 reports of medical history and examination. The Veteran was seen by cardiology on October 4, 1974, with complaint of chest pain and dyspnea on exertion (DOE). A history of acute rheumatic fever (ARF) was noted. See clinical record. The Veteran underwent an electrocardiogram (EKG) on October 6, 1974, which was within normal limits. When seen by internal medicine on October 7, 1974, the Veteran reported exercise intolerance from early childhood and possible ARF in the fourth grade was noted, though the details of the illness were not clear. The Veteran reported developing chest pain and DOE during physical training. Following physical examination and review of the EKG, the impression was dysplastic pulmonary valve, symptomatic. The examiner suspected it was congenital rather than secondary to ARF. See clinical record. A medical board was conducted on October 24, 1974; following physical examination, the impression was dysplastic pulmonic valve. It was determined that this existed prior to the Veteran's entry into service and that it had not been aggravated by service. It was also noted that this was a nonacceptable defect and that the medical board recommended separation from service. See also Medical Board Report Cover Sheet; Medical Board Statement of Patient. Service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole establishes that the familial conditions in question were incurred or aggravated during service. VAOPGCPREC 82-90 (July 18, 1990); see also VAOGC 8-88 (Sept. 29, 1988) (reissued as VAOPGCPREC 67-90 (July 18, 1990) (noting that diseases of hereditary origin can be incurred or aggravated in service if their symptomatology did not manifest itself until after entry on duty and reasoning that the mere genetic or other familial predisposition to develop the symptoms, even if the individual is almost certain to develop the condition at some time in his or her lifetime, does not constitute having the disease). With regard to congenital or developmental defects, service connection may not be granted for a defect but may be granted for disability which is shown to have resulted from a defect which was subject to a superimposed disease or injury during service. VAOPGCPREC 82-90 (July 18, 1990). The Board finds that a medical examination is needed in this case given the in-service findings and the post-service medical evidence of record, which reveals that the Veteran has been diagnosed with coronary artery disease (CAD) with reversible ischemia. See 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Recent VA treatment records should also be obtained. A specific request for a March 10, 2009, stress test conducted at Hickory Cardiology Associates and noted to have been scanned into VistA Imaging should also be made. In addition to the foregoing, review of the VA treatment records reveals that the Veteran appears to have filed a claim with the Social Security Administration (SSA). The medical and legal documents pertaining to the Veteran's application for SSA benefits have not been associated with the claims folder. The possibility that SSA records could contain evidence relevant to the claim cannot be foreclosed absent a review of those records. Quartuccio v. Principi, 16 Vet. App. 183, 188 (2002). On remand, efforts should be made to obtain these records. 38 C.F.R. § 3.159(c)(2) (2013). The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2013). Accordingly, the case is REMANDED for the following action: 1. Request the March 10, 2009, stress test conducted at Hickory Cardiology Associates, which was noted to have been scanned into VistA Imaging. 2. Obtain the Veteran's treatment records from the Salisbury VA Medical Center, dated since June 2009. 3. Request all medical and legal documents pertaining to the Veteran's application(s) for SSA disability benefits. If no records can be found, indicate whether the records do not exist and whether further efforts to obtain the records would be futile. 4. Schedule the Veteran for a VA examination of his heart, preferably by a cardiologist. The claims file and any pertinent evidence in Virtual VA that is not contained in the claims file must be made available to and reviewed by the examiner. All necessary tests should be conducted. a. The examiner should identify all current disorders of the heart. b. For each diagnosis, and for the previously-diagnosed dysplastic pulmonary valve and coronary artery disease with reversible ischemia, the examiner should indicate whether it had its onset prior to service, during military service in October 1974, or after service. c. For any disorder (to include the previously-diagnosed dysplastic pulmonary valve and coronary artery disease with reversible ischemia) that had its onset prior to active service, the examiner should indicate whether it is a congenital or developmental defect versus disease. i. If any pre-service disorder (to include the previously-diagnosed dysplastic pulmonary valve and coronary artery disease with reversible ischemia) is a disease rather than a defect, the examiner should provide an opinion as to whether there is any factual evidence which supports a conclusion that it underwent an identifiable permanent increase in severity during military service that was beyond its natural progression. ii. If any pre-service disorder (to include the previously-diagnosed dysplastic pulmonary valve and coronary artery disease with reversible ischemia) is a congenital or developmental defect, the examiner should provide an opinion as to whether it was subject to a superimposed disease or injury during service, and if so, describe the resultant disability. d. For any disorder (to include the previously-diagnosed dysplastic pulmonary valve and coronary artery disease with reversible ischemia) that had its onset after active service, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the disorder is related to any in-service disease, event, or injury, including the findings made in the October 1974 service treatment records. A rationale for any opinion expressed should be provided. 5. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 6. Finally, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, if in order. The appellant 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 U.S. 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). _________________________________________________ KATHLEEN K. GALLAGHER 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) (2013).