Citation Nr: 1800191 Decision Date: 01/03/18 Archive Date: 01/19/18 DOCKET NO. 13-08 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to service connection for a heart disability, to include ischemic heart disease (IHD). REPRESENTATION Appellant represented by: David Anaise, M.D., J.D. ATTORNEY FOR THE BOARD K. Hubers, Counsel INTRODUCTION The Veteran served on active duty from April 1964 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The RO in Reno, Nevada now has jurisdiction over the claim. In May 2017, the Board remanded this matter for further development, to include a VA examination, and readjudication. For the reasons discussed below, the matter must be remanded again. The Board has recharacterized the matter as a claim of entitlement to service connection for a heart disability, to include ischemic heart disease (IHD), for greater clarity and to ensure that the symptoms and disabling effects for which the Veteran seeks compensation are fully considered. See, e.g., See Clemons v. Shinseki, 23 Vet. App. 1, 9 (2009) (noting claims are typically based on lay assumptions, while the precise diagnosis is generally a medical question). The Veteran initially requested service connection for "heart disease" and submitted medical documentation of various conditions, including, but not limited to, severe bradycardia (due to vasovagal mechanism), sick sinus syndrome, hypertension, a heart block, in addition to possible IHD. See September 2011 VA Form 21-526 (claim for "heart disease due to Agent Orange"). Therefore, framing the claim as entitlement to service connection for a heart disability more accurately captures the scope of the Veteran's claim. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND In May 2017, the Board remanded the above listed matter for development including scheduling a VA examination by a cardiologist (with a finding that the 2011 and 2012 tests were too old to be the basis for a current opinion on the presence of IHD). The VA did submit the issue to a cardiologist who determined no current physical examination was necessary, though he also had the benefit of some 2016 test results. See October 2017 VA Examiner's Opinion (explaining why the test results from 2012 provided a sufficient basis for an opinion regarding whether the Veteran has a current disability consisting of IHD). Because the remand directed only testing that the examiner "finds necessary to diagnose or rule out IHD", the examination is adequate despite the lack of additional testing. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). However, the cardiologist was asked to "identify all heart conditions that have been present during the period of the claim." The cardiologist's opinion goes into detail regarding whether a diagnosis of IHD was warranted based on the tests that had already been performed, but did not discuss whether the Veteran had any diagnoses other than IHD. The record contains numerous diagnoses, including, but not limited to, severe bradycardia (due to vasovagal mechanism), sick sinus syndrome (September 2016 Private Treatment Record), hypertension (June 2011 Private Treatment Record), a heart block (same), among other conditions. See April 2016 VA Examination (severe bradycardia); March 2012 VA Examination (complete heart block, status post pacemaker placement); June 2011 Private Hospital Discharge Summary ("Final Diagnoses: 1. Heart block; 2. Syncope; 3. Arrythmic heart disease; 4. Hypertension."); May 2016 VA Examination Addendum (minimal coronary artery disease); but see October 2017 VA Examiner's Opinion ("no evidence of significant CAD" and ruling out IHD based on numerous test results). The October 2017 VA examiner's failure to identify and discuss these diagnoses renders the record incomplete. The Veteran is entitled to obtain an opinion discussing each of his diagnoses and whether they are related to the elevated blood pressure readings in service and/or to his exposure to herbicide agents. See Stegall, 11 Vet. App. at 271; 38 U.S.C. § 5103A(d)(2) (setting forth criteria for providing an examination to a veteran); McLendon v. Nicholson, 20 Vet.App. 79, 81-86 (2006). Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding, relevant VA medical records. 2. Only after obtaining the VA medical records and any other development deemed necessary, schedule the Veteran for VA examinations to address the nature and etiology of the Veteran's heart disabilities (to include hypertension). The entire claims file should be reviewed by the examiners. Any necessary testing should be accomplished. The examiners are advised it has been established that the Veteran was exposed to herbicide agents during his service in the Republic of Vietnam. After reviewing the record and performing any examination and/or testing of the Veteran deemed necessary, the examiner(s) should address the following: a. Identify each heart disability that the Veteran currently has or has had during the appeal period (September 2010 to the present). (The examiner should explain his reasoning if he disagrees with any diagnoses in the record and does not include them in the list of heart disabilities he identifies. The disabilities identified in the medical record include, but are not limited to: severe bradycardia (due to vasovagal mechanism), sick sinus syndrome, hypertension, heart block, syncope, arrythmic heart disease, and coronary artery disease.) b. For each heart disability identified in (a), does the heart disability fit within the definition of or is it a manifestation of ischemic heart disease? (For the purpose of this question, ischemic heart disease includes, but is 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. The term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease.) c. For each heart disability identified in (a), if the examiner has provided a negative answer to (b), is it at least as likely as not (50 percent probability or greater) that the heart disability was incurred in or otherwise related to the Veteran's military service, to include the documentation of elevated blood pressure and/or the Veteran's conceded exposure to herbicide agents during his service in the Republic of Vietnam? 3. After completing the above, and any other development deemed necessary, readjudicate, based on the entirety of the evidence, the Veteran's claim of entitlement to service connection for a heart disability, to include ischemic heart disease. If the benefits sought on appeal are not granted to the appellant's satisfaction, he and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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). _________________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2016).