Citation Nr: 1805543 Decision Date: 01/29/18 Archive Date: 02/07/18 DOCKET NO. 14-23 850 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for a heart disorder, claimed as chest pain radiating down the left arm and left jaw, cardiac syndrome, and palpitations. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD N. Sangster, Counsel INTRODUCTION The Veteran served on active duty from November 2003 to November 2011. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an September 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran had a hearing before the undersigned in January 2017. A copy of the transcript is of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran's claim must be remanded for further medical commentary to resolve the conflicting evidence of record. Of record is a June 2011 (in-service) medical opinion from Dr. M.W.C. He diagnosed the Veteran had Cardiac Syndrome X. Dr. M.W.C. stated that the Veteran had symptoms very consistent with angina pectoris except for the prolonged discomfort lasting now for several months and was typical in character and worse with activity or exertion. He observed that it radiated to the Veteran's left arm and left jaw. He opined that the Veteran's symptoms did fit Cardiac Syndrome X. He explained that Cardiac Syndrome X is a syndrome of microvascular dysfunction possibly secondary to endothelial dysfunction, which does result in angina, but with a good clinical outcome and no increase in the risk of myocardial infarction. Contrary to the June 2011 private opinion, a November 2011 (first month post service) VA examiner determined that there was no diagnosis at that time because although the Veteran had symptoms, there was no objective evidence of diagnosable disease or pathology. The examiner noted the Veteran's reports that he had chest pain during the April 2009 physical training test. She observed that the Veteran was sent to the ER, but no diagnosis was made. In addition, the examiner noted that the Veteran had chest pain on several other occasions while on active duty but pointed out that an October 2011 CT angiogram was normal. She further observed that the Veteran had a private cardiologist, who had diagnosed him with Cardiac Syndrome X. The examiner, however, stated that she did not have access to Dr. M.W.C.'s records. An April 2014 VA examiner concluded that the Veteran had palpitations which were being treated with propranolol. However, the examiner found that the Veteran did not have Cardiac Syndrome X. Also, the Board notes that the Veteran is a Persian Gulf War Veteran. VA regulations provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses to a Persian Gulf War Veteran who exhibits objective indications of a qualifying chronic disability if that disability (i) became manifest either during active service in the Southwest Asia theater of operations, or (ii) to a degree of 10 percent or more not later than December 31, 2016, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). For VA purposes, a qualifying chronic disability presently means a chronic disability resulting from any of the following (or any combination of the following): (A) An undiagnosed illness; or (B) A medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders. If, however, signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be established under the specific provisions applicable to Persian Gulf Veterans. See VAOPGCPREC 8-98 at paragraphs 4-5 (Aug. 3, 1998). However, service connection may still be established if otherwise warranted under VA law. Lastly, the RO has been unable to obtain all of the Veteran's service treatment records (STRs). Specifically, the record indicates that his STRs prior to October 2006 have been deemed unavailable. Since this appeal is being remanded, additional efforts should be made to obtain the Veteran's STRs prior to October 2006. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain the Veteran's service treatment records, dated prior to October 2006. If these records remain unavailable, a notation of such should be made in the claims file. 2. Make arrangements to update the Veteran's complete VA treatment records, dated from March 2014 forward. 3. Make arrangements to obtain the Veteran's complete treatment records from the Texas Medical Clinic. 4. Upon receipt of all additional records, schedule the Veteran for the appropriate VA examination to determine the nature and etiology of his chest pain radiating down the left arm and left jaw, cardiac syndrome, and palpitations. The claims file must be provided to the examiner for review in conjunction with the examination and the examiner must indicate that it was reviewed. The examiner should elicit a full history from the Veteran. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. All pertinent symptomatology and all clinical findings should be reported in detail. The examiner should identify all current cardiac/heart disorders found to be present, to include any disorder manifested by palpitations, Cardiac Syndrome X, etc. Then, the examiner should provide opinions on the following: (a) Is it at least as likely as not (50% or greater probability) that any current diagnosed cardiac/heart disorder had its clinical onset during active service or is related to any incident of service, to include the various complaints in service and/or any environmental exposures experienced by the Veteran during service in Southwest Asia. (b) If the Veteran's chest pain, palpitations, and associated symptoms cannot be attributed to a known clinical diagnosis, the examiner should provide an opinion as to whether the condition or conditions is/are manifestations of an undiagnosed illness. If there are any objective indications of chest pain and/or palpitations that cannot be attributed to any organic or psychological cause, the examiner should so state. The examiner should identify any abnormal symptoms, abnormal physical findings, and abnormal laboratory test results that cannot be attributed to a known clinical diagnosis. (c) Alternatively, if any or all of these signs or symptoms can be diagnosed, but are without conclusive pathophysiology or etiology, the examiner should opine as to whether they are manifestations of a chronic multisymptom illness, i.e., a diagnosed illness without conclusive pathology or etiology characterized by overlapping symptoms and signs with features that are out of proportion to the physical findings and inconsistent demonstration of laboratory abnormalities. The examiner must adequately explain the rationale for all opinions and conclusions reached. 5. Finally, readjudicate the claim on appeal. If the claim continues to be denied, send the Veteran and his representative a supplemental statement of the case and give them an opportunity to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of this claim. 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. §§ 5109B, 7112 (West 2014). _________________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 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) (2017).