Citation Nr: 18153450 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-09 977 DATE: November 27, 2018 REMANDED Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for residuals of stroke is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1969 to June 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a heart disorder is remanded. The Veteran contends that his current heart disorders are due to in-service herbicide agent exposure. If a veteran was exposed to an herbicide agent during active service, the diseases set forth in 38 C.F.R. § 3.309(e) will be presumed to be related to such service if they become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6)(ii). The Veteran’s military personnel records demonstrate that he served in the Korean Demilitarized Zone (DMZ) in 1970 as part of the 1st Battalion, 31st Infantry Division, which is one of the units that VA guidance has identified as operating in or near the Korean DMZ during the qualified time period. 12/24/2013, Military. Accordingly, the Veteran is presumed to have been exposed to herbicide agents during service. See 38 C.F.R. § 3.307(a)(6)(iv). There is conflicting evidence as to whether the Veteran has ischemic heart disease (IHD) (including, but not limited to, acute, subacute, and old myocardial infarction), which is one of the diseases set forth in 38 C.F.R. § 3.309(e). Accordingly, a remand is required to determine whether the Veteran currently has (or has a history of ) IHD. Additionally, the Veteran contends that valvular heart disease and ascending aortic aneurysm are due to presumed in-service herbicide agent exposure. As valvular heart disease and ascending aortic aneurysm are not one of the diseases set forth in 38 C.F.R. § 3.309(e), a presumption based on in-service herbicide agent exposure is not warranted. However, the Board will consider whether there is evidence of actual direct causation due to herbicide agent exposure. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). December 2013 and January 2014 letters from the Veteran’s treating private physicians indicate that medical literature suggests there may be an association between aneurysm formation and herbicide agent exposure, thus indicating a potential nexus between a current heart disorder and service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (stating that “[t]his is a low threshold” for meeting the requirement to trigger VA’s duty to assist to provide an examination). However, the Board finds that those opinions do not provide a sufficient basis to grant service connection, as they do not identify the medical literature referenced, and the language used is speculative. See id. at 83; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Accordingly, the Agency of Original Jurisdiction (AOJ) should schedule the Veteran for an examination to clarify the current diagnoses of cardiac disease, and provide an opinion as to the nature and etiology of all diagnosed heart disorders.   2. Entitlement to service connection for residuals of stroke is remanded. The Veteran contends that his stroke and the ensuing residuals are due to treatment for his heart disorder. See, e.g., 07/16/2014, NOD. Accordingly, the Board finds that the claim of entitlement to service connection for residuals of stroke is inextricably intertwined with remanded claim of entitlement to service connection for a heart disorder, and will defer consideration of the matter. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (stating that two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records. 2. After completing directive #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed cardiac disorders. The clinician is to review the virtual file, including a copy of this Remand. The clinician is to address the following: (a.) Identify all heart disorders that are currently present (or present any time from November 21, 2012, to present). Specifically, state whether the Veteran has a history of myocardial infarction. If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. (b.) State whether any diagnosed heart disorder fits within the generally accepted medical definition of ischemic heart disease. The Board notes that VA regulations define IHD as including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina. (c.) Whether it is at least as likely as not (50 percent or greater probability) that any diagnosed heart disorder manifested during or is otherwise related to the Veteran’s period of active service, to include due to presumed herbicide agent exposure. (d.) Whether it is at least as likely as not (50 percent or greater probability) that cardiovascular-renal disease (i) manifested to a compensable degree within one year of June 29, 1971, or (ii) was noted during service with continuity of the same symptomatology since service. (Continued on the next page)   A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.A. Gelber, Associate Counsel