Citation Nr: 18150921 Decision Date: 11/16/18 Archive Date: 11/15/18 DOCKET NO. 13-08 505 DATE: November 16, 2018 ORDER Entitlement to service connection for ischemia heart disease as due to service-connected type II diabetes mellitus (DM2) is granted. FINDING OF FACT The competent evidence of record is at least in equipoise as to whether the Veteran had coronary artery disease (CAD) at the time of his death. CONCLUSION OF LAW Affording the appellant all benefit of the doubt, the criteria for entitlement to service connection for CAD have been met. 38 U.S.C. §§ 1110, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The AOJ received the Veteran’s claim for ischemia heart disease (IHD) in May 2010. See 05/05/2010 21-4138. He died in May 2010, and the appellant was subsequently substituted in his stead as the surviving spouse. 1. Entitlement to service connection for ischemia heart disease Applicable Legal Standards A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Discussion The Veteran served in the Republic of Vietnam (RVN) during his active service. Hence, he was presumed to have been exposed to herbicide agents during that tour. See 38 C.F.R. § 3.307(a)(6) The appellant initially asserted that the Veteran was diagnosed with IHD prior to his death. See 05/05/2010 VA 21-4138; 06/19/2012 NOD. Prior to his death, the Veteran asserted that, in addition to his service-connected lung cancer and DM2, he had been diagnosed with small vessel ischemia and IHD, both due to his presumed exposure to herbicides agents. See 05/05/2010 Correspondence. After an abnormal CT scan, an April MRI of the brain was undertaken and based on that it was determined that the CT findings were most likely related to Leuko dystrophic changes, perhaps related to chronic small vessel ischemic disease. See 04/27/2010 Non-Government Facility, P. 122. The appellant and her representative essentially base their appeal on the aforementioned brain MRI and two EKGs. The first EKG was conducted during an April 2001 VA Agent Orange Protocol, which showed normal sinus rhythm with occasional premature ventricular complexes, possible inferior infarct, age undetermined. The accompanying physical examination revealed an occasional skipped beat and no bruits. The Veteran denied any complaints of chest pain. See 06/18/2012 Government Facility; 11/20/2013 Government Facility, P. 2. A May 2011 examination report reflects that a VA examiner reviewed the Veteran’s claims file and found no evidence that the Veteran was ever diagnosed with IHD. He opined that there were no other contributing causes to the Veteran’s death due to non-small cell carcinoma. See 05/12/2011 VA Examination. During the terminal stage of the Veteran’s cancer, his private provider referred him to a pain specialist for generalized pain. The specialist’s report reflects that the Veteran had a personal medical history (PMH) of CAD. No basis for that entry was noted. See 05/10/2010 Non-Government Facility, P. 5. In January 2018, the VA examiner who reviewed the claims file in 2011 reviewed it again. The examiner was asked to assess the 2001 EKG, April 2010 brain MRI, and the noted entry of the pain specialist. The VA examiner noted that the May 2010 VA examination was for DM2, and noted no evidence of heart involvement. Concerning the pain specialist’s notation, the VA examiner noted that the specialist’s Report of Systems found no complaints of chest pain, tightness, or palpitation. The VA examiner did not address the notation of PMH of CAD. See 01/24/2018 VA Examination. As concerns the April 2001 EKG, the VA examiner noted that the reasons for the interpretation were small q waves in leads II and aVF, and a Q wave in lead 3. The VA examiner noted agreement with the assessment of possible inferior infarct but this did not convince him that there was at least a 50 percent probability that it showed IHD. The examiner’s rationale was that the EKG variation was not uncommon, that there were no progress notes related to the EKG, and that several years later he could not find any evidence of diagnosed IHD. Id. at 2. Following a board hearing, additional evidence was received. A May 2010 EKG (the second of the earlier-mentioned 2) showed sinus tachycardia, and a May 1989 EKG was normal. 02/27/2018 Non-Government Facility, P. 29, 31. In September 2018, the Board requested that the Veterans Health Administration (VHA) designate a cardiologist to review the claims file and opine whether there was at least a 50 percent probability that the Veteran had IHD/CAD at the time of his death. The cardiologist reviewed the claims file and essentially agreed with the prior VA opinions that the medical evidence of record was not diagnostic for CAD. That fact notwithstanding, the cardiologist noted the fact that the Veteran had DM2 and opined that there was more than a 50 percent probability that the Veteran had some form of CAD, though to what extent was indeterminable. In so finding, the examiner reasoned that diabetes is considered a “CHD equivalent” based on the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. (Circulation. 2002; 106 (25): 3143.) (Quotes in original).  As noted earlier, service connection was in effect for DM2 as due to presumed exposure to herbicide agents. Hence, Wallin Element 2 is shown by the evidence of record. The VA cardiologist’s opinion provides sufficient evidence of Wallin Elements 1 and 3 to place the record in equipoise on a secondary basis in lieu of the asserted presumptive basis. 38 C.F.R. §§ 3.102, 3.310. Hence, the claim is allowed. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD W.T. Snyder