Citation Nr: 1621965 Decision Date: 06/01/16 Archive Date: 06/13/16 DOCKET NO. 06-21 317 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a heart disability, to include angina, congestive heart failure, coronary artery disease (CAD) and hypertensive heart disease and hypertension. 2. Entitlement to service connection for an acquired psychiatric disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran had active military service from August 1957 to July 1959. This case comes before the Board of Veterans' Appeals (Board) on appeal from December 2005 and October 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board denied the appeal pertaining to service connection for heart disability, along with a separate claim for service connection for respiratory disability in November 2008. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In September 2009, the Court granted a joint motion for partial remand (JMR) of the Veteran and the Secretary of Veterans Affairs (the Parties), vacated the November 2008 Board decision as to the heart and respiratory issues, and remanded those issues to the Board for action consistent with the terms of the JMR. The Board remanded the heart and respiratory issues to the AOJ for additional development in December 2009 and in October 2011. In a January 2013 decision, the Board again denied the appeal as to the heart and respiratory issues. The Veteran appealed that decision to the Court. In June 2014, the Board remanded the separate issue of entitlement to service connection for a psychiatric disorder to the AOJ for further development. Later in June 2014, the Court issued a Memorandum Decision in which it vacated the January 2013 Board decision as to the heart and respiratory denials and remanded those issues to the Board for further development and readjudication. In so doing, the Court determined that there had not been compliance with the Board's October 2011 Remand instructions. The Board subsequently remanded the claims in December 2014 for further development In a September 2015 decision, the Board granted service connection for a lung condition and again remanded the claims for service connection for heart disability and psychiatric disability for further development. In an April 2016 statement, the Veteran appeared to raise a claim for service connection for neurological disability due to lead exposure during service (but this is not clear). This claim is not currently on appeal before the Board and is referred to the agency of original jurisdiction (AOJ) for any appropriate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Board apologies for the many delays in the full adjudication of the Veteran's case. The issue of service connection for an acquired psychiatric disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's hypertension is reasonably shown to have been aggravated by lead exposure during service. 2. The Veteran has been diagnosed with mild hypertensive heart disease during the appeal period, which has been attributed to his hypertension. 2. The Veteran is not shown to have any other chronic heart disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2015). 2. The criteria for entitlement to service connection for hypertensive heart disease have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2015). 2. The criteria for entitlement to service connection for heart disability other than hypertensive heart disease, including coronary artery disease, congestive heart failure and heart disability manifested by angina, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Analysis: service connection for heart disability Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. §3.303. Service connection nonetheless may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain listed, chronic disabilities, including ischemic heart disease and hypertension are presumed to have been incurred in service if they become manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A disability which is proximately due to or the result of a service- connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The standard of proof to be applied in decisions on claims for Veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 3.102. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). As reflected in his September 2004 claim and in numerous subsequent written statements, the Veteran essentially contends that he has a heart disability due to direct contact with paint fumes while assigned to a paint locker in service from August 1957 to July 1959, more than one-half century years ago. Specifically, the Veteran has contended that he was extensively exposed to lead through paint fumes, chips, and dust while in charge of a paint locker aboard a seafaring vessel during his active service, where his duties included opening and mixing cans of paint, and that such lead exposure resulted in current heart disability. Service treatment records reflect no complaints or treatment related to any heart problems. The July 1959 separation examination reflects a normal clinical evaluation of the heart, lungs and chest, with no heart problems noted. The Veteran's blood pressure at that time was measured as 118/54, and chest X-rays at the time were noted to be negative. The Veteran's service personnel records, including his DD Form 214 (Report of Transfer or Discharge) reflect that the Veteran served one year, eight months, and 25 days on foreign or sea service, but reflect no noted military occupational specialty. A January 2001 private treatment record reflects that the Veteran presented for possible Alzheimer's disease. His past medical history was noted to include hypothyroidism, rosacea, asthma, arthritis, and being hit by motor vehicles at age seven. The earliest indication in the medical record potentially suggestive of heart disability is contained in private treatment records from July 2001 related to surgery to repair a right medial meniscus tear. July 11, 2001 chest X-rays revealed normal heart size with ecstatic calcified aorta but no mediastinal mass or adenopathy and no pleural disease. However, the Veteran did experience an episode of postoperative respiratory failure following the surgery. Following this, the Veteran denied any hypertension or history of heart disease. His blood pressure was noted to be 130/80. The diagnoses at that time were postoperative respiratory failure, suspected to be a side effect of anesthetics, and underlying chronic obstructive pulmonary disease (COPD). July 13, 2001, chest X-rays revealed a larger heart size, and it was noted that there might be mild failure with bibasilar infiltrates; the impression was endotracheal tube with prominent heart size and suggestion of mild failure with bibasilar infiltrates. A July 15 chest X-ray indicated that the Veteran's respiratory failure- related pathology had improved A September 10, 2003, private treatment record reflects that the Veteran was seen for a cardiac evaluation after having shortness of breath and having "apparently" been diagnosed with congestive heart failure in the past. It was noted that a couple of years previously, during knee surgery, he had sustained a cardiac arrest but was not aware of a cardiac work-up in the past. He also reported chest tightness and fluttering on a daily basis. He reported a past medical history that was positive for angina, congestive heart failure, and pulmonary edema. His cardiac risk factors were noted to be hypertension or diabetes, and smoking for 24 years but quitting 24 years previously.. After evaluation, the Veteran was assessed as having symptoms compatible with left-sided heart failure with angina symptomatology, palpitations, long history of smoking, family history of coronary artery disease and a history of hypertension and diabetes. September 15, 2003 heart testing revealed negative stress electrocardiogram (EKG) for ischemia, although the testing was noted to be less specific due to abnormal baseline EKG; negative stress-gated myocardial perfusion study for ischemia; and moderate global left ventricular systolic dysfunction with a regional variation. Echocardiogram showed normal left ventricular function with a mild diastolic relaxation abnormality. At a September 17, 2003 follow-up visit, his treating physician reviewed the results of the testing and rendered a diagnostic impression of cardiomyopathy possibly from multi-vessel coronary artery disease while noting that the Veteran had no scintigraphic evidence of ischemia on his nuclear stress test. With the Veteran's smoking history, hypertension, diabetes and symptoms, he was scheduled for a right and left heart catheterization and started on medication, including 81mg of aspirin per day. On September 22, 2003, the Veteran underwent right and left heart catheterization, selective coronary angiography, and left ventriculography. Following the procedures, the impression was trivial coronary artery disease; possible catheter-induced spasm of the proximal right coronary artery versus atherosclerotic plaquing; mild pulmonary hypertension; and possible symptomatology based on sleep apnea. An October 2003 private treatment record reflects that the Veteran was seen after his cardiac catheterization. The examining physician noted that the catheterization appeared to indicate that the Veteran had hypertensive heart disease and mild pulmonary hypertension; that the pulmonary hypertension was possibly due to sleep apnea; and that he was experiencing coughing possibly due to taking an ACE inhibitor. An April 2004 VA primary clinic note reflects that the Veteran sought to establish treatment at a VA Medical Center. After evaluation, the diagnoses included hypertension, controlled. An April 2004 private treatment record indicates that the Veteran was seen for shortness of breath; that he had been diagnosed with COPD and wheezing, and that he had been told in 2001 that he had congestive heart failure. The examining physician stated that most of the Veteran's shortness of breath was probably pulmonary in origin, but that he could have had some underlying heart failure. In a statement received in connection with his June 2006 substantive appeal, the Veteran summarized articles relating to the effects of lead exposure, which stated that lead components are found in paint; human exposure occurs when dust and fumes are inhaled; lead entering the respiratory system is released to the blood and distributed through the body; more than 90 percent of the total body burden of lead is accumulated in the bones where it is stored for decades, 30 years or more; and lead in the bones may be released to the blood and reexposed to organ systems long after the initial environmental exposure. The articles noted by the Veteran further stated that the most important aspects of lead toxicity were its effects on the central nervous system, which may be irreversible, but that lead affected all organs and functions of the body to varying degrees, and that the frequency and severity of symptoms among exposed workers depended on the level of exposure. The Veteran also asserted that chronic high exposure to lead is associated with an increased incidence of hypertension and heart disease and that he suffered from these diseases. The articles noted by the Veteran also indicated that it was not possible for the body to rid itself of all the lead that had entered it, as lead will remain stored in the bones for decades beyond the initial exposure period. Further, the articles indicated that some of the medical effects of lead poising that had been observed in adults included easy fatigability, dizziness, rapid heartbeat, and hypertension and the Veteran asserted that he suffered from these conditions. Moreover, the Veteran asserted that although his service treatment records did not indicate treatment for lead poisoning symptoms, he did not know at the time that he was in charge of the paint locker that his breathing problems were the result of lead-based paint exposure, and did not seek military medical help but rather sought over-the counter assistance such as breathing assistance devices and various medications. In a statement received in June 2007, the Veteran again asserted that his breathing problems due to inhalation of lead-based paint fumes had an immediate onset, but that he self-treated for such breathing problems. At a May 2005 private cardiac risk stratification consultation, it was noted that surgery had been recommended for the Veteran's bimalleolar ankle fracture. It was also noted that the Veteran had a past history of severe COPD and mild right heart failure. The Veteran denied any current symptomatology or any symptoms prior to his admission to the hospital. However, because he was determined to have moderate risk factors, he was scheduled for an adenosine nuclear heart study (i.e. myocardial perfusion stress scan). A May 2005 private myocardial perfusion stress scan produced a diagnostic impression of normal adenosine myocardial perfusion stress scan without evidence of stress-induced ischemia or scarring. The Veteran subsequently underwent the ankle surgery. The procedure was completed without complications and the Veteran's postoperative course was uncomplicated. A June 2005 private echocardiogram produced diagnostic impressions of ejection fraction of 69 percent, left ventricular diastolic dysfunction with borderline left ventricular hypertrophy, preserved normal systolic wall motion, normal valve morphology and function and right ventricular systolic pressure calculated as 28mmHg. The Veteran submitted a letter from Dr. Kumar, dated in July 2006, reflecting that it was Dr. Kumar's understanding that the Veteran was in charge of a paint locker for a seafaring vessel on active military duty, and that on reviewing the Veteran's medical records and the Veteran's research into the possible medical conditions associated with lead poisoning and exposure to lead, it was Dr. Kumar's opinion that some of his medical conditions might be related to exposure from lead-based paints. The Veteran also submitted a statement from his service comrade, J.L., received in December 2008, asserting that when J.L. was in the Navy, he had to do a lot of painting about the ship, and had to go to the paint locker to check paint out and back in again when he needed it. J.L. stated that most of the time the Veteran was in the locker logging the paint in and out, and that sometimes when he would be in there, the Veteran would be coughing and gagging because the smell and fumes were very strong. The report of a January 2007 VA examination reflects that the Veteran reported serving from 1958 to 1960 aboard a ship, where he was in charge of the paint locker. He reported that he could not breathe well, that he could only walk a block or two before becoming short of breath, and that he had started to get short of breath about three or four years previously. He reported that in 2003 he was diagnosed with obstructive sleep apnea. The Veteran reported smoking half a pack of cigarettes a day for about 10 years but quitting in 1974. The VA examiner diagnosed COPD; obesity; obstructive sleep apnea; well-controlled hypertension; questionably controlled diabetes mellitus; shortness of breath most likely secondary to COPD; and rule out congestive heart failure. Chest X-rays revealed a normal cardiomediastinal silhouette with normal pulmonary vasculature, no infiltrates and effusion, and right diaphragmatic eventration, stable since April 2004. February 2007 private stress electrocardiogram and echocardiograms produced overall diagnostic impressions of normal stress electrocardiogram and normal stress echocardiogram. Post-exercise, there was a normal increase in left ventricular systolic function without evidence of new focal wall motion abnormalities. In a subsequent February 2007 letter, a private cardiologist, Dr. B, indicated that the stress echocardiogram was normal. It was Dr. B's impression that the Veteran had hypertension and diabetes and was significantly overweight. An April 2007 private transesophageal echocardiogram produced an interpretation summary of intact interatrial septum with no evidence for an atrial septal defect, mild atherosclerotic plaques in the descending aorta and no thrombus detected in the left atrial appendage. Left ventricular systolic function was normal. Doppler transmittal flow pattern did show impaired relaxation. In an April 2007 follow-up letter, Dr. B noted that while the transesophageal echocardiogram did show some atherosclerosis of the aorta, there was no evidence of patent formaen ovale, intracardiac tumor, masses or thrombi. Dr. B recommended adding Plavix to the Veteran's current medication regimen. In a February 2008 follow up letter, Dr. B indicated that a physical examination of the Veteran was mostly unremarkable except for obesity and ventral hernias. The diagnostic impressions were hypertension, hypercholesterolemia, obstructive lung disease and diabetes. A July 2008 private echocardiogram produced diagnostic conclusions of normal left ventricular systolic function with an ejection fraction of 60 to 64 percent; impaired left ventricular relaxation consistent with left ventricular diastolic dysfunction; normal stress electrocardiogram; and normal stress echocardiogram. A subsequent November 2009 letter from Dr. B also showed these diagnoses, along with chest pain and cough. A September 2009 private primary care progress note shows a pertinent diagnosis of hypertension. A November 2009 private stress electrocardiogram and echocardiogram produced diagnostic conclusions of normal global left ventricular systolic function with an ejection fraction of 60 to 64 percent; negative stress electrocardiogram; and negative stress echocardiogram. The left ventricle size was normal and Doppler transmittal flow pattern showed impaired relaxation. In January 2010, the Veteran was seen for a pre-operative visit, as he planned on undergoing genitourinary surgery soon. It was noted that the previous November 2009 stress echocardiogram was normal and that his current EKG was normal. The report of a May 2010 VA examination reflects that the Veteran had a previous history of smoking estimated at 24 years, but that he quit in 1979, and that the service treatment records did not show any physical complaints during the time he was in service. It was noted that the Veteran had a long history of progressive shortness of breath; that following arthroscopic surgery of the right knee in approximately 2000, he had sudden desaturation and respiratory arrest occurring in the recovery room, was reintubated, and taken to the intensive care unit at this time; and that there was documentation that his wife stated that he had had a long history of lung disease and dyspnea on exertion. It was also noted that his emphysema was well-established by the year 2000-2001, by his history; that he had a cardiac workup in 2003 with heart catheterization and echocardiogram; and that he was evaluated for left heart failure and found to have had mild cardiomyopathy. Additionally, it was noted that the heart catheterization showed trivial non-obstructive CAD and mild pulmonary hypertension. It was further noted that the Veteran was diagnosed with obstructive sleep apnea in May 1995 and that his cardiologist felt that his mild pulmonary hypertension was related to such sleep apnea. The VA examiner noted that the Veteran claimed that his heart problems were related to inhaling fumes from lead paint in service, but that the Veteran had never had any history of lead toxicity, never had lead levels measured and never exhibited neurological signs of lead toxicity, and therefore that it was only speculation that any of his cardiac conditions could be related to lead exposure. The examiner stated that the service treatment records were silent for any health complaints and specifically neurological complaints. The pertinent diagnoses were acute respiratory failure following surgery in July 2001 without any recurrence; mild pulmonary hypertension secondary to COPD; mild right ventricular dysfunction; no current evidence of congestive heart failure, with chest X-ray currently and three years previously showing normal cardiac silhouette; non-obstructive CAD showing on cardiac catheterization but of no clinical significance, as it was not ischemic and likely related to inherited genetic factors; history of cigarette smoking; essential hypertension; hypertensive heart disease not found; and some congestive heart failure in the past likely related to essential hypertension. The examiner opined that the Veteran's main problem was his progressive COPD and emphysema, which was related to his cigarette smoking, and that physical examination did not indicate cardiac failure or pulmonary edema. The examiner further stated there was no evidence that exposure to lead paint fumes in service had any effect on his current health conditions, and that any assertion of lead paint fumes related to current heart disease was pure speculation. At the time, chest X-rays revealed lungs clear and heart size normal, with no congestive heart failure or pleural effusion. In a March 2011 addendum to the May 2010 VA examination report, the VA examiner indicated that according to the record, cardiac testing done by a cardiologist subsequent to the Veteran's July 2001 respiratory failure did not determine that the Veteran had angina pectoris or congestive heart failure. Indeed, the coronary angiogram performed in 2003 showed tiny amounts of cholesterol plaque in some of the coronary vessels but no evidence of ischemia or past injury to the heart. The examiner noted that while congestive heart failure was listed as a past medical condition in an early clinical note, the condition had never been diagnosed by Dallas VA physicians in the previous five years. Also, echocardiograms performed by the Veteran's private cardiologist did not determine that he had left ventricular failure, the most common cause of congestive heart failure. Thus, it was unlikely that the Veteran had congestive heart failure. The examiner also explained that the Veteran was found to have mild secondary pulmonary hypertension or high pressure within the vessels of the lungs, which may accompany severe obstructive sleep apnea and could also be seen in severe COPD. The examiner also indicated that the Veteran had been diagnosed by his private cardiologist with mild right-sided congestive heart failure where there is peripheral edema or swelling of the legs but no buildup of fluid in the lungs. Additionally, he noted that this condition was commonly referred to as right-sided heart failure or cor pulmonale. The examiner found that this condition was likely due to the Veteran's sleep apnea. The examiner noted the trivial coronary artery disease that was discovered during the 2003 coronary angiogram. The examiner indicated that the angiogram did not show any significant narrowing of the vessels, nor of any ischemia. Similarly, the Veteran's electrocardiograms and stress echocardiograms has not shown any evidence of ischemia. The examiner noted that trivial coronary artery disease is an asymptomatic condition and may or may not lead to later ischemic heart disease. The examiner further explained that hypertensive heart disease is a condition caused by hypertension, characterized by left ventricular hypertrophy, and that pulmonary hypertension develops in the lung circulation, usually as a secondary disorder to either extensive scarring in the lungs or constriction of the lung arteries, brought on by hypoxia, as in obstructive sleep apnea. Additionally, the examiner noted that pulmonary hypertension can become symptomatic when it is severe enough to cause right heart failure and that it was likely that the Veteran had a mild version of this disorder as evidenced by the echocardiogram and cardiac eventration in 2004 and 2005. The examiner further stated that, as the Veteran completed his service in 1959, it was highly unlikely that any of his heart disorder had its onset while he was on active duty and would not have been caused by his military service. The examiner stated that regarding Dr. Kumar's letter suggesting that exposure to lead paint would have caused the Veteran's disabilities, this appeared to a wildly speculative claim with no documentation was offered, and that it could be stated with reasonably certainty that lead poisoning was not a cause of the Veteran's medical problems. The examiner stated that chronic lead poisoning could lead to neuropathy with weakness in certain muscles, as well as anemia, but that the Veteran had not been documented to have these. The Veteran was afforded another VA examination in November 2011. The report of the examination reflects that the Veteran had been noted to have CAD, hypertensive heart disease, and cardiomyopathy beginning in 2003, but that none of the Veteran's heart conditions qualified as ischemic heart disease. He also had the diagnosis of pulmonary hypertension, with a diagnosis date of 2003. It was noted that the Veteran had a history of prior tobacco use, with about 24 pack years until 1979. November 2011 X-rays revealed normal chest in appearance. The examiner noted that the Veteran had a normal chest X-ray in April 1959 and July 1959. The examiner further noted that several years following discharge from the military the Veteran had a "knee condition" for which a progress note in June 2001 notes that X-ray of the knee was unremarkable, with no findings of lead on film of the knee, and no mention of dense metaphyseal lines. The examiner noted that in adults, 94 percent of absorbed lead is deposited in the bones and teeth, and that the estimated half-life of lead in bone was 20 to 30 years. The examiner therefore found that there was no evidence suggesting lead toxicity in the Veteran. Regarding the Veteran's claimed pulmonary edema and pulmonary hypertension, the examiner stated that pulmonary edema was typically a result of congestion of fluid from circulation in the lungs and typically resulted from acute left-sided heart failure, and the examiner was unable to locate any findings or documentation of left heart failure or documentation of pulmonary edema in the Veteran's medical records. The examiner noted that in September 2003, the Veteran underwent an echocardiogram with findings of normal left ventricle systolic function with a mild diastolic relaxation abnormality, and that the Veteran underwent the coronary catheterization September 2003, which documented normal left ventricular ejection fraction, with no indication of left heart failure. The Veteran was found to have trivial CAD and mild pulmonary hypertension, but his symptomatology at the time was felt to be secondary to sleep apnea. The examiner also noted that there could be many causes of pulmonary hypertension such as left heart disease, lung diseases or hypoxemia, embolic or other diseases or familial, but that the likely etiology of mild pulmonary hypertension in the Veteran, as his cardiologist suggested, was from his sleep disordered breathing and chronic hypoxia from his obstructive sleep apnea. Regarding the Veteran's claimed angina, CAD and congestive heart failure, the examiner stated that angina was defined as chest pain caused by ischemia or inefficient oxygen delivery to the cardiac muscle. The examiner stated that the records did not show that the Veteran had significant CAD to cause obstruction or ischemia to the heart, and it was not likely that the Veteran's subjective history of chest pain was related to lack of oxygen delivery to the heart muscle as this was not demonstrated on the Veteran's coronary catheterization. The examiner also noted that the Veteran underwent a nuclear stress test in 2003, and there was no scintigraphic evidence of ischemia at that time. Thus, the examiner concluded that there was no evidence documenting significant CAD or angina secondary to ischemia in the Veteran. The examiner further stated that congestive heart failure occurred when there was congestion of fluid in the lungs and general circulation, which typically caused generalized edema but especially to the lower extremities ranging from trace to pitting edema. The examiner explained that there were numerous causes of congestive heart failure, but the examiner could not find evidence documenting clinically significant congestive heart failure in the Veteran's claims file. The examiner stated that CAD developed over many years and was caused by cholesterol-containing deposits or plaque build-up in the coronary arteries, and that risk factors for CAD included older age, male gender, family history, smoking, hypertension, high cholesterol, diabetes, obesity, sedentary lifestyle, and high stress. The examiner stated that the Veteran's mild CAD was more likely related to his multiple risk factors than military service. The examiner further stated that significant congestive heart failure in the Veteran had not been documented and was therefore not related to military service. Regarding the Veteran' s claimed hypertensive heart disease, the examiner stated that such disease occurs due to the complication of longstanding hypertension or high blood pressure, as the workload of the heart was increased manifold and over a long period of time the heart muscle thickens and becomes less compliant. The examiner stated that the Veteran's cardiac echocardiogram documented diastolic dysfunction, which was decline in performance of one or both ventricles of the heart during the time or phase of a diastole, and that hypertensive heart disease was a direct result of longstanding hypertension. The examiner stated that the Veteran had mild hypertensive heart disease that was not likely caused by military service and instead was more likely a direct result of his longstanding hypertension. The examiner further stated that while the Veteran had claimed respiratory and cardiovascular problems secondary to lead toxicity, and while lead toxicity may lead to multi-symptom conditions, typically lead toxicity caused the greatest impact on the neurologic system, and lead toxicity in adults would generally involve complaints of headache, abdominal pain, memory loss, mood disorder, decline in mental function, seizures, loss of consciousness, decreased appetite, anorexia, pain, numbness, or tingling of the extremities or generalized fatigue or malaise. The examiner noted that she could not locate any reported neurological complaints in the service treatment records; there were no measurements or serosal measurement serum lead levels to reference the Veteran's service treatment records or in the Veteran's claims file during his military service, following discharge, around the time of onset of his cardiovascular or respiratory problems, or following diagnosis of such conditions. The only pertinent evidence found by examiner was an unremarkable knee X-ray that did not mention any lead lines or indication of lead toxicity in the Veteran. The examiner further stated that she had reviewed multiple credible sources of literature regarding lead toxicity in adults but could not find any credible literature that documented a clear link to the cardiovascular conditions claimed by the Veteran at a time period several years later and in the absence of any documented complaints or evidence of neurologic manifestations of lead toxicity, and could not find any credible literature to substantiate lead toxicity as the etiology of the cardiovascular conditions claimed by the Veteran. June 2012 private treatment records show that the Veteran required reconstructive bladder surgery. Because of a notation of a past history of CAD, he required clearance from cardiology prior to surgery. The Veteran was evaluated with serial contrast echocardiography x3 and myocardial infarction was ruled out. The interpretative summary of the echocardiography showed a Doppler flow pattern suggestive of impaired left ventricular relaxation, ejection fraction of 70 to 74 percent, trace tricuspid regurgitation and sinus tachycardia. The Veteran was cleared for surgery and underwent the procedure on June 11, 2012. In an October 2013 follow-up letter, Dr. Kumar opined, in pertinent part, that the Veteran's assignment to the paint locker during service was the direct and proximate cause of his hypertension. In the June 2014 decision, the Court noted that the Board's October 2011 remand instructed the VA examiner to complete all necessary testing, to include testing for lead exposure, if applicable. However, the November 2011 VA examiner chose to provide an in-depth analysis of typical situations and maladies associated with lead poisoning without discussing whether lead testing was actually necessary. The Court also found that the examiner had implicitly recognized that the Veteran may still be affected by lead toxicity and that this recognition indicated that lead testing was actually necessary. Thus, a remand was required for the Veteran to be provided with all necessary testing, to include testing for lead exposure. At a February 2015 VA examination, the examining physician noted that a stress echocardiogram had been ordered and thus far, the Veteran did not have any confirmed heart disease. The examiner also noted that testing had indicated an elevated blood lead level. Additionally, the examiner opined that it was at least as likely as not that the Veteran's hypertension had been aggravated by the high level of lead in his circulatory system. At a January 2016 follow-up VA examination, the examiner found that the Veteran did not have ischemic heart disease; had not had a myocardial infarction; did not have congestive heart failure; and did not have any heart valve conditions, infectious heart diseases or pericardial adhesions. The examiner noted that an EKG and that a stress echocardiogram had been performed in April 2015. The EKG was normal and the echocardiogram showed an ejection fraction of 50% with normal wall motion and normal wall thickness. Also, the echocardiogram stress test showed a normal response to dobutamine stress without inducible wall motion abnormalities and did not show ischemia, with the test being terminated when the Veteran met his target heart rate. Additionally, the examiner noted that the September 2003 coronary artery angiogram had shown trivial coronary artery disease. The VA examiner concluded that the Veteran did not have any current, chronic heart disease. She noted that the current echocardiogram did not indicate the presence of any current congestive heart failure and as noted, the examiner also concluded on the basis of the testing that the Veteran did not have any ischemic heart disease. In an April 2016 letter, the Veteran indicated that Dr. S and Dr. B, both cardiologists, had diagnosed him with congestive heart failure. He noted that as a result of this diagnosis, he was put on Plavix. The Veteran also indicated that shortly after he began receiving VA follow-up care, he was taken off Plavix and prescribed 81mg of aspirin. Then, the previous year, this prescription was changed to 325mg, without any explanation. The Veteran indicated that as a result of the new prescription, he experienced extreme bruising on the visible parts of his body and he also began to bleed profusely from even the smallest wound. Consequently, he was taken off the 325mgs of aspirin and was re-prescribed the 81mg. Moreover, the Veteran indicated that VA had not performed any tests to substantiate the denial it had issued him in regard to congestive heart failure. As noted above, the undersigned has reviewed this case is some detail (not simply the evidence cited, but all evidence in this case). The above-summarized evidence reasonably shows that the Veteran was exposed to lead during service. It also shows that he currently has hypertension. Additionally, the February 2015 VA examiner opined that the current hypertension has at least as likely as not been aggravated by the Veteran's elevated lead blood level (noted in February 2015). There is no opinion of record to the contrary (i.e. an opinion indicating that the Veteran's hypertension has not been aggravated by the elevated lead blood level noted in February 2015). Also, there is no indication from the record that the Veteran had any significant pre or post-service lead exposure. Accordingly, while there is significant evidence against this claim, resolving any reasonable doubt in the Veteran's favor, an award of service connection for hypertension is warranted. 38 C.F.R. §§ 3.102, 3.303, 3.310. Also, although the more recent VA examinations indicate that the Veteran does not have any underlying heart disease disability, the November 2011 VA examiner did diagnose the Veteran as having mild hypertensive heart disease characterized by impaired diastolic function and that this disease was likely caused by his hypertension. Consequently, given that hypertension is now service-connected and resolving any reasonable doubt in the Veteran's favor, service connection for hypertensive heart disease is also warranted. 38 C.F.R. §§ 3.102, 3.303, 3.310. The Veteran was also diagnosed with possible coronary artery disease (CAD) during the September 2003 angiogram. However, at that time the CAD was noted to be trivial. Also, the subsequent sporadic notations in the Veteran's medical records of CAD appear to be based on this initial September 2003 finding of "trivial CAD." Additionally, the subsequent VA examiners, while noting this finding, generally have indicated its trivial, not clinically significant and non-obstructive nature. The November 2011 VA examiner did characterize the Veteran as having "mild CAD" but this appears to only be based on the earlier September 2003 finding. Also, the examiner specifically concluded that the record contained no evidence documenting that the Veteran had "significant CAD." Moreover, after reviewing the record, including the September 2003 angiogram finding and conducting detailed testing, including the stress echocardiogram, the January 2016 VA examiner specifically found that the Veteran did not have ischemic heart disease or coronary artery disease. Further, there is no medical evidence of record tending to indicate that the findings indicative of CAD (e.g. arterial placquing), whether characterized as trivial, non-clinical, insignificant or mild, has resulted in any underlying impairment. Accordingly, considering the sporadic notations of CAD in the record and the November 2011 VA examiner's characterization of mild CAD in the context of the broader record, the weight of the evidence is against a finding that the Veteran has had anything more than trivial, not clinically significant coronary artery disease, which does not qualify as a current disability for VA compensation purposes. 38 C.F.R. § 3.303, 4.1. Accordingly, service connection for coronary artery disease and/or ischemic heart disease is not warranted. Similarly, it is not show that the Veteran has any chronic disability manifested by congestive heart failure, with the earlier VA examiners generally finding that he either did not have congestive heart failure or did not have any significant congestive heart failure and with the January 2016 VA examiner specifically finding that the congestive heart failure was not shown. The Veteran was shown to have an acute incident of respiratory failure in 2001 and there are some notations in the Veteran's medical records of a history of congestive heart failure, apparently based on this event. However, the May2010 VA examiner, in his March 2011 addendum, specifically noted that the cardiac testing done after the Veteran's 2001 surgery did not determine that the Veteran had angina pectoris or congestive heart failure; that the coronary angiogram performed in 2003 showing no evidence of ischemia or past injury to the heart; that while congestive heart failure was listed as a past medical condition in an early clinical note, the condition had never been diagnosed by Dallas VA physicians in the previous five years; and that echocardiograms performed by the Veteran's private cardiologist had not determined that he had left ventricular failure, the most common cause of congestive heart failure. Thus, it was unlikely that the Veteran had congestive heart failure. Further, although there are limited notations of congestive heart failure, in the Veteran's medical records under either "medical history" or "medical problem list", there is no medical evidence of record, dated since September 2003, either from VA or a private source, showing any independent, objective findings or diagnoses of congestive heart failure. Moreover, the January 2016 VA examiner also specifically concluded that the Veteran did not have congestive heart failure. The Veteran has argued that he was prescribed Plavix for heart failure. However, the medical evidence indicates that while he was prescribed this medicine by a private treating physician, there is no indication that it was prescribed to treat congestive heart failure. Rather it appears to have been prescribed as a preventative measure to protect against potential stroke. The May 2010 VA examiner, in the March 2011 addendum did indicate that the Veteran was found to have mild secondary pulmonary hypertension and also indicated that the Veteran had been diagnosed by his private cardiologist with mild right-sided congestive heart failure where there is peripheral edema or swelling of the legs but no buildup of fluid in the lungs. Regarding this latter notation, review of the medical records does not reveal that the Veteran has been found by objective testing to have chronic right sided congestive heart failure, even of the moderate variety. Rather, as noted by the November 2011 VA examiner, the Veteran has been found to have pulmonary hypertension but this symptomatology has been found to result from his sleep apnea, a disability, which is not service-connected and not currently on appeal before the Board. (Thus, even if the Veteran were shown to have mild chronic right sided heart failure, the weight of the evidence is in favor of it resulting from sleep apnea and against it being related to service, including lead exposure therein). Consequently, in sum the weight of the medical evidence is also against a finding that the Veteran has a current, chronic disability manifested by congestive heart failure. Accordingly, service connection for such a disability is not warranted. (Although service connection for pulmonary hypertension, is not technically on appeal, the weight of the evidence is similarly against a finding that this disability is related to service, including lead exposure therein, as it has instead been found likely to result from the non-service connected sleep apnea). Further, as noted by the May 2010 examiner, in the March 2011 addendum, angina is defined as chest pain caused by ischemia or inefficient oxygen delivery to the cardiac muscle. However, the May 2010 examiner indicated that the Veteran's medical records did not show that the Veteran had significant CAD to cause obstruction or ischemia to the heart, and it was not likely that the Veteran's subjective history of chest pain was related to lack of oxygen delivery to the heart muscle as this was not demonstrated on the Veteran's coronary catheterization. This examiner also noted that the nuclear stress test in 2003 showed no scintigraphic evidence of ischemia at that time and thus concluded that angina secondary to ischemia in the Veteran had not been shown. This finding is generally consistent with the other medical findings of record, which simply do not establish any significant ischemia that would result in angina. Accordingly, the weight of the evidence is against a finding that the Veteran has any heart disability manifested by angina. Accordingly, the Board does not have a basis for awarding service connection for heart disability manifested by angina. The Board is cognizant that Dr. Kumar has generally opined that a relationship likely exists between lead exposure and current heart conditions. However, this physician has not provided any significantly probative evidence that the Veteran currently has a disabling level of coronary artery disease, chronic congestive heart failure or heart disability manifested by angina or any other heart disability, aside from hypertensive heart disease. Moreover, although the Veteran has affirmatively asserted that he does have current cardiac disability, including these conditions, as a layperson, without any demonstrated expertise in diagnosing such disabilities, his assertions may not be afforded significant probative value. Thus, in sum, the weight of the evidence is against a finding that the veteran has any of these heart disabilities. Moreover, although echocardiograms have at times shown some apparent abnormalities such as cardiomyopathy, impaired ventricular relaxation and diastolic dysfunction (while for the most part being interpreted as normal studies), the evidence does not establish that these findings are indicative of any other type of chronic, disabling heart disease, aside from the Veteran's now service-connected hypertensive heart disease. In the absence of proof of current disability, there can be no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Alemany, 9 Vet. App. 518 (1996). Accordingly, the Board has no basis for awarding service connection for any claimed heart disabilities other than hypertension and hypertensive heart disease. 38 C.F.R. § 3.303, 3.310; Brammer, 3 Vet. App. 223 (1992); Alemany, 9 Vet. App. 518 (1996). The Board notes that should the Veteran be given a confirmed diagnosis of a disabling level of these other claimed conditions in the future, he may be able to reopen his claims. II. Due Process VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, VA provided adequate notice in letters sent to the Veteran in April 2004, September 2005 and October 2010. VA has a duty to assist a claimant in the development of a claim. This duty includes assisting the claimant in the procurement relevant treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records, VA medical treatment records, identified private medical records, private medical opinions, and a lay statement from the Veteran's service comrade have been obtained. While the Veteran, in a July 2011 statement, asserted that crucial medical records were destroyed in a fire, he has not identified what records were destroyed or how such records were crucial, and there is no other indication in the claims file that any pertinent medical records have been destroyed. Also, the Veteran was provided VA examinations and opinions in January 2007, May 2010, November 2011, February 2015 and January 2016. In particular, the February 2015 and January 2016 VA examinations were appropriately responsive to the Court's requirement that Veteran be provided with all necessary testing, to include testing for lead exposure. In this regard, specific testing was performed to measure lead levels and detailed heart testing was also performed to determine the nature and extent of any heart disability that was present. Reasoned medical opinions based on consideration of the test results, physical examinations and review of the claims file were also provided. Accordingly, the examinations were adequate because, together, they provided sufficient information to decide the appeal. 38 C.F.R. § 3.159(c)(4) (2012); Barr v Nicholson, 21 Vet. App. 303 (2007). In a November 2012 informal hearing presentation from the Veteran's representative, the Veteran alleged that his November 2011 VA examination, and his VA examinations in general, had been inadequate. The Veteran asserts that the November 2011 VA examination report failed to discuss the positive private opinions in a substantive fashion, that the examiner's reasoning was incomplete, as the examiner stated that she reviewed multiple credible sources of literature regarding lead toxicity in adults, but did not list these resources, and that the opinion was written by a physician's assistant. However, as discussed above, the November 2011 VA examiner substantively and fully addressed and discussed the private opinions of Dr. Kumar, and the Veteran has not identified any aspect of Dr. Kumar's opinions that was not addressed or fully discussed in the November 2012 examination report. Also, as noted above, the literature discussed by the November 2011 VA examiner is consistent with the medical evidence submitted by the Veteran himself regarding the nature of lead-based exposure and toxicity, and the Veteran has provided no evidence that the examiner did not review the appropriate literature regarding lead toxicity in adults in formulating her opinions. See Ashley v. Derwinski, 2 Vet. App. 307 (1992) (it is presumed that government officials have properly discharged their official duties, and clear evidence to the contrary is required to rebut this "presumption of regularity"). Further, the additional examinations and opinions provided in February 2015 and January 2016 added additional detail and clarity to the medical opinions of record. Moreover, although the Veteran is not being granted service connection for certain heart disabilities (i.e. coronary artery disease, chronic congestive heart failure and disability manifested by angina), these denials are based on the weight of the evidence indicating that he does not have any of these chronic disabilities, as explained above. Once again, should future medical evidence establish that he does have a current, disabling level of coronary artery disease, chronic congestive heart failure or a heart condition manifested by angina, he may be able to reopen these claims. Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). In this case, the Veteran has indicated no such records and all pertinent records have been obtained. There is no indication of additional existing evidence that is necessary for a fair adjudication of the claims that are the subject of this appeal. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist. ORDER Service connection for hypertension is granted. Service connection for hypertensive heart disease is granted. Service connection for heart disability other than hypertensive heart disease, to include coronary artery disease, chronic congestive heart failure and disability manifested by angina, is denied. REMAND In the September 2015 remand, the Board instructed the AOJ to arrange for a VA psychiatric examination and for the examiner to provide an opinion concerning whether any current psychiatric disability had its onset in service or is otherwise causally related to service, to include lead exposure. The Veteran was afforded a VA psychological evaluation in January 2016. However, the psychologist concluded that it was out of her scope of knowledge to comment on a potential relationship between lead exposure and mental health symptoms. A review of the history of the Veterans Court's determination in this case may be advantageous to the RO/AMC. A remand by the Board confers on the appellant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, as the January 2016 VA examiner's opinion did not satisfy the remand instructions, a further remand is necessary so that a further medical opinion can be provided, which does appropriately address the likelihood of a relationship between the Veteran's current psychiatric disability and his lead exposure in service. Prior to arranging for the examination, the AOJ should secure copies of complete records of VA treatment or evaluation for psychiatric disability dated since March 2016. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Secure copies of complete records of VA treatment or evaluation for psychiatric disability dated since March 2016. 2. Arrange for a supplemental psychiatric/mental health opinion by an appropriate VA medical professional, other than the January 2016 VA psychologist, concerning the likelihood that the Veteran's current psychiatric disability is related to his lead exposure during service. The Veteran's claims file must be reviewed by the medical professional in conjunction with the examination. This review should include the service treatment records, any pertinent post-service medical records, the report of the January 2016 VA psychological evaluation, the reports of VA heart disease examinations from February 2015 and January 2016, with particular attention to the lead level testing that was performed, and any other information in the claims file deemed pertinent. The medical professional should assume that the Veteran was exposed to lead during service in his role staffing the paint locker and opening and mixing cans of paint aboard ship during service in the late 1950s. The medical professional should also review any medical literature deemed pertinent concerning a relationship between lead exposure and the development of subsequent psychiatric disability. The medical professional should then provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that any current psychiatric disability is related to the Veteran's exposure to lead during service. The medical professional should provide a specific rationale for the opinion provided. If the medical professional feels that a new examination is necessary prior to providing the above-requested opinion, one should be provided. 3. Review the supplemental opinion to ensure that it is in complete compliance with the remand instructions. If not, take appropriate corrective action. 4. This is a complex case from the Veteran's Court. Readjudicate the claim. If it remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. No action is required of the appellant until he is notified. The appellant 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 2014). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs