Citation Nr: 18139892 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 15-25 304 DATE: October 1, 2018 REMANDED Service connection for cardiovascular disease is remanded. Entitlement to entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran, who served on active duty from October 2006 to October 2010, to include service in Iraq during the Gulf War, appeals the May 2014 decision that denied these claims. In April 2018, the Veteran and his sister testified during a Board hearing before the undersigned Veterans Law Judge (VLJ). Here, the undersigned clarified the issues on appeal and made inquiry as to the existence of outstanding evidence. In addition, the appeal was left open for 90 days for the Veteran to obtain additional evidence. The Veteran submitted a medical report in August 2018. 1. Service connection for cardiovascular disease The Veteran testified his heart disease began in service, and that the manifestations were misdiagnosed as related to a broken collarbone. He also theorizes that prolonged exposure to burn pits and environmental hazards in Iraq contributed to the development of his current heart disease. His sister, a registered nurse and veteran paramedic, agreed that the personnel dealing with the Veteran would not have initially suspected or medically explored the theory that an outwardly healthy young man would have a severe heart problem. The Veteran indicated at the hearing that he would reach out to his treating cardiologist to obtain a medical opinion supporting his theory. The July 2018 ischemic heart disease disability benefits questionnaire (DBQ) completed by a non-VA physician did not contain an opinion as to the etiology of the current end stage congestive heart failure which places the Veteran in need of a heart transplant. While the examiner noted a medical history that suggests he may support the theory that there were manifestations of heart disease in service that were misdiagnosed as attributable to other causes, he falls short of providing any opinion. The Board cannot make a fully-informed decision on this issue because no examiner has opined whether the current heart disease, which was noted from May 2012 in VA treatment records, is related to his service which ended approximately 18 months prior. Also, the Veteran’s claim that the heart disease is a manifestation of undiagnosed illness should be addressed given his service in Southwest Asia during the Gulf War. Under the circumstances, the Board finds that a VA exmaiantion is warranted. 2. TDIU The TDIU claim is based on the heart disability. Because a decision on the issue being remanded could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the current cardiovascular disease. The examiner should address the Veteran’s theory, as set forth in the testimony both he and his sister provided at the hearing, that the current heart disease initially manifested in service and was misdiagnosed. It is noted that the Veteran’s sister has reported that she is a registered nurse and former in-service paramedic. Both the Veteran and his sister are considered reliable historians. The examiner must opine whether the current heart disease is at least as likely as not related to a service including the treatment for chest pain pointed out by the Veteran. The examiner should also opine whether it at least as likely as not that any heart disease began during active service or manifested within the presumptive period after discharge from service. The examiner should also opine whether current heart disease is at least as likely as not related to contaminants the Veteran was likely exposed to during his Gulf War service in Southwest Asia.   After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of TDIU. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Rippel, Counsel