Citation Nr: 18148103 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-00 197A DATE: November 6, 2018 ORDER Entitlement to coronary artery disease, to include as due to herbicide exposure, is granted. REMANDED Entitlement to service connection for hypertension, including due to herbicide exposure and/or secondary to service-connected disability, type II, is remanded. Entitlement to service connection for a disability manifested by blood clots, including due to herbicide exposure and/or secondary to service-connected disability, is remanded. FINDINGS OF FACT 1. Based on the location and time of the Veteran’s service, he is presumed to have been exposed to an herbicide agent. 2. The Veteran has been diagnosed with coronary artery disease which has been manifested to 10 percent disabling. CONCLUSION OF LAW The criteria for service connection for coronary artery disease have been met. 38 U.S.C. §§ 1110, 5107(b), 7107(a)(2); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from March 1962 to June 1966. This case was most recently before the Board in September 2017 when the Board remanded it for further development (i.e. records, and VA examination and opinions). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Service Connection The Board notes that the issue of entitlement to service connection for coronary artery disease is not explicitly before the Board; however, the Veteran filed claims for service connection for hypertension and blood clots. Both conditions can reasonably be expected by a lay person to involve the cardiac system. Thus, based on the evidence of record, and given the holdings in DeLisio v. Shinseki, 25 Vet. App. 45 (2011), Clemons v. Shinseki, 23 Vet. App. 1 (2009), and Brokowski v. Shinseki, 23 Vet. App. 79 (2009), the Board finds that it may consider whether service connection for a heart disability is warranted. Entitlement to service connection for coronary artery disease VA regulations provide that ischemic heart disease (which includes coronary artery disease), is associated with exposure to an herbicide agent and may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307 (a)(6) are met. 38 C.F.R. § 3.309 (e). Ischemic heart disease shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(6)(ii). The Veteran’s service personnel records reflect that he served aboard the USS Finch from November 1964 to May 1966. The U.S.S. Finch (DER-328) is included on VA’s “Navy and Coast Guard Ships Associated with Service in Vietnam and Exposure to Herbicide Agents” list which notes it entered inland Qui Nhon Bay/Harbor during the Veteran’s service aboard the U.S.S. Finch (DEF-328) in January 1966. As such, the Veteran is presumed to have been exposed to an herbicide agent. VA clinical records associated with the claims file reflect that the Veteran has coronary artery disease, and has had three stents in total. Private records also associated with the claims file reflect that the Veteran is on medication for coronary artery disease, underwent drug-eluting stent placement in 2012, and underwent stenting in 2007. Thus, it can be reasonably assumed that his disability has been manifested to a degree of 10 percent or more. Based on the foregoing, the Board finds that service connection for coronary artery disease is warranted on a presumptive basis under 38 C.F.R. § 3.309(e). REASONS FOR REMANDS Entitlement to service connection for hypertension The Veteran contends that his hypertension is secondary to his service-connected diabetes mellitus and/or due to herbicide exposure. A December 2017 VA examiner opined that the Veteran’s hypertension was less likely than not due to, caused by, or aggravated by the Veteran’s service-connected diabetes mellitus, type II. The examiner’s rationale was based on no competent current medical literature that reveals diabetes causes hypertension nor any medical literature that reveals diabetes medications causes hypertension. The examiner also noted that many factors may contribute to hypertension, including being overweight or obese and older age. (The Veteran was diagnosed with hypertension when he was in his 60s, and he has been noted to be overweight and mildly obese (see April and June 2013 private records).) With regard to aggravation, the examiner concluded that the Veteran’s hypertension is less likely than not aggravated beyond its natural progression by his diabetes as his diabetes is well-controlled. The Board also notes that a December 2010 private record (Hendricks Regional Health) reflects that the Veteran’s diabetes has been complicated by hypertension, and not the other way around. The Board finds, however, that additional rationale with regard to hypertension and herbicide exposure, and hypertension and coronary artery disease, may be useful. In its September 2017 Remand, the Board directed that the clinician provide an opinion as to whether it is as likely as not that the Veteran’s hypertension is related to herbicide exposure. Rather than provide any rationale on a direct incurrence basis, the examiner simply noted that hypertension is not a disease which warrants presumptive service connection. In addition, now that the Veteran is in receipt of service connection for coronary artery disease, the clinician should provide an opinion as to whether his hypertension is caused by, or aggravated by, such. Entitlement to service connection for a disability manifested by blood clots The December 2017 VA examiner found that the Veteran’s blood clots were less likely than not (less than 50 percent probability) due to, caused by, or aggravated by the Veteran’s service connected diabetes mellitus, type II. The examiner provided a rationale that there is no current medical literature that reveals diabetes causes blood clots nor any medical literature that reveals diabetes medications cause blood clots. The examiner provided that medical literature provides many factors that may contribute to blood clots, including hypertension and heart conditions. As the Veteran is now in receipt of service connection for a heart disability, the Board finds that a supplemental opinion is warranted. In addition, as the issue of entitlement to service connection for hypertension is begin remanded, the issue of entitlement to service connection for a disability manifested by blood clots is inextricably intertwined with it. The matter is REMANDED for the following action: Obtain a supplemental opinion to the 2017 VA examination reports. The examiner should opine as to the following: a.) whether it is as likely as not (50 percent or more) that the Veteran’s hypertension is causally related to herbicide exposure (without regard to whether it is a disability which warrants presumptive service connection). b.) whether it is as likely as not (50 percent or more) that the Veteran’s hypertension is casually related to, or aggravated beyond its natural progression by his coronary artery disease. (Continued on the next page)   c.) whether it is as likely as not (50 percent or greater) that the Veteran’s post-phlebitic syndrome (or some other disability manifested by, or due to, blood clots) is casually related to, or aggravated beyond its natural progression, by, the Veteran’s i.) coronary artery disease, and/or ii.) hypertension. T. WISHARD Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. DEEMER, ASSOCIATE COUNSEL