Citation Nr: 18151353 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-40 174 DATE: November 16, 2018 REMANDED Entitlement to service connection for heart disability, to include as due to herbicide exposure, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from January 1970 to January 1973. He served in the Republic of Vietnam from February 1971 to January 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a January 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In the Veteran's August 2016 substantive appeal (via a VA form 9), he requested a hearing before the Board; however, in September 2016 written correspondence, he withdrew his request for a hearing. In keeping with the evidence on file, the Board has expanded the scope of the Veteran’s service-connection claim, which had been stated as one for coronary atherosclerosis/myocardial infarction, to encompass any heart disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009); Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009) (citing Clemons and 38 C.F.R. §§ 3.159(c)(3)). 1. Entitlement to service connection for heart disability, to include as due to herbicide exposure, is remanded. The Board finds that a remand of this claim is needed to clarify whether the Veteran has a heart disease for which he could be entitled to presumptive service connection because of exposure to herbicide agents during service in Vietnam or whether service connection on a direct basis is warranted. If a veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases such as ischemic heart disease shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). Ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasms) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. However, 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. Note (2), 38 C.F.R. § 3.309 (e). In this regard, a July 2013 VA nuclear stress test revealed an impression of an abnormal myocardial perfusion study, with a fixed defect along the inferior and inferoseptal walls concerning for prior myocardial infarct. No inducible ischemia is noted. VA medical records from May 2014 reflect that the Veteran was assessed with coronary artery disease (CAD). An October 2014 VA DBQ was received from the Veteran’s VA physician noting that the Veteran was diagnosed with CAD in July 2013. However, in December 2014, the Veteran was afforded a VA examination which included diagnostic testing, such as echocardiogram. The VA examiner at that time diagnosed the Veteran with cardiomyopathy and did not find that the Veteran had CAD. Subsequent VA medical records note that the Veteran’s active problems include coronary atherosclerosis, but not CAD. In light of the conflicting evidence above, the Board finds that further medical opinion is needed to clarify whether the Veteran has carried a diagnosis of CAD at any point during the course of this appeal; and if the Veteran did not have current ischemic heart disease, to determine whether it is at least as likely as not that any diagnosed heart condition is related to the Veteran's period of active service, including exposure to herbicides. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The matter is REMANDED for the following actions: 1. Obtain and associate with the file any outstanding VA treatment records. 2. Schedule the Veteran for a new VA examination, with a VA cardiologist, to determine the nature and etiology of all diagnosed heart disabilities. The entire claims file should be reviewed by the examiner. All indicated tests and studies should be performed. (a.) Identify all diagnosed heart disabilities during the appeal period, to include addressing whether the Veteran has a diagnosis of ischemic heart disease and/or residuals of a myocardial infarction. In providing this opinion, the examiner is requested to reconcile the conflicting diagnosis of record as noted above. (b.) The examiner should opine whether it is at least as likely as not (50 percent probability or greater) that any diagnosed heart disability (other than ischemic heart disease) is at least as likely as not (50 percent probability or greater) related to active service, to include the Veteran’s presumed exposure to herbicides in Vietnam. The examiner is asked to provide a clear rationale for all opinions. The mere fact that a presumption has not been established for the particular disability at issue is not dispositive of the issue of nexus. Consideration must still be given to the exposure. If the examiner cannot form the requested opinions without resorting to speculation, the reasoning and findings supporting that conclusion must be clearly set forth. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Pitts, Associate Counsel