Citation Nr: 1808382 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 13-00 054A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a heart disorder, including coronary artery disease. 2. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Suzie Gaston, Counsel INTRODUCTION The Veteran served on active duty from March 26, 1978 to July 21, 1978, from September 24, 2005 to October 24, 2005, and from July 9, 2006 to July 31, 2006, with additional service in the Army National Guard of Alabama. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from a November 2010 rating decision, by the Montgomery, Alabama, Regional Office (RO), which denied the Veteran's claims of entitlement to service connection for coronary artery disease, and service connection for hypertension. He perfected a timely appeal to that decision. The issue of entitlement to service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's coronary artery disease preexisted his July 2006 period of active duty and was aggravated by his active duty. CONCLUSION OF LAW The criteria to establish service connection (aggravation) for coronary artery disease have been met. 38 U.S.C. §§ 101, 1110 1153, (2012); 38 C.F.R. §§ 3.303, 3.306 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that service connection is warranted for his heart disability, diagnosed as coronary artery disease. The Veteran maintains that he was found fit for military when he was activated on active duty in July 2006; however, shortly after that he started having chest pain and was taken to the hospital where he underwent stent replacement due to 80 percent blockage. The Veteran argues that his heart condition was aggravated by military service. Historically, the service treatment records (STRs) for the period from March 26, 1978 to July 21, 1978, were negative for any complaints or findings of a heart condition. Of record is a statement of medical examination, dated in October 1995, indicating that the Veteran had chest pain while working on annual training; he was hospitalized for one day to be sure it was not heart pain. It was noted that follow up stress test was normal. A report of medical examination for retention, dated in February 1997 was negative for any complaints or findings of heart disease; clinical evaluation of the heart was normal and a chest x-ray was normal. Blood pressure reading was 118/80. Of record is a private treatment report from Cardiology Consultants, dated in November 2001, indicating that the Veteran had a history of known coronary artery disease with a previous angioplasty of the LAD in June 1999. Arteriograms in August of 2000 had shown this to be open. It was noted that the Veteran had had recurring problems with chest pain, which came on suddenly. He stated that it was a severe pain which came on suddenly and lasted for 30 minutes or so. Treadmill test was negative. The pertinent diagnoses were history of chest pain, NOS; history of edema; history of short of breath; status post PTCA/Stent; status post myocardial infarction; history of leg pain; heart disease, coronary artery disease-native vessel; history of cough; and heart disease-ischemia, myocardial, chronic. Of record is a medical statement from Dr. Willam A. Hill, Jr., dated in January 2003, indicating that he followed the Veteran for cardiac care. Dr. Hill noted that the Veteran had heart catheterization studies done in June 2002 which were normal; therefore, from a cardiac standpoint, he was cleared for deployment. A medical examination report, dated in February 2003 was negative for any complaints or findings of a heart disease; clinical evaluation of the heart was normal. Blood pressure reading was 145/90 and 116/74. A memorandum, dated in April 2003, recommended that the Veteran be medically disqualified for deployment due to uncontrolled hypertension and cardiac stents. An annual medical certificate, dated in August 2005, indicates that the Veteran did not currently have any medical problems; he did not have any medical problems since his last periodic physical examination. The Veteran was found to be fully fit and was cleared for deployment. An order dated in June 2006 documents that the Veteran was ordered to active duty for a period not to exceed 545 days for the purpose of OPN IRAQI FREEDOM. On July 13, 2006, the Veteran was evaluated for mobilization. It was noted that the Veteran had a medical problem that required further evaluation prior to completing the mobilization process. Status post cardiac stent in 1999, and required current medical clearance to mobilize. Pre-deployment health assessment on July 13, 2006, the Veteran indicated that he had a heart stent in 1999, and he was currently on medication. Following his evaluation, it was determined that the Veteran was deployable per Dr. Slater. This amounts to a finding on an examination report of preexisting heart condition. On a chronological record of medical care, dated July 13, 2006, the Veteran answered yes to the question of which he had a heart or vessel condition. He indicated that he had a heart condition, high blood pressure and high cholesterol. Of record is a hospital report from Franciscan Skemp Healthcare medical center, indicating that the Veteran was admitted to the hospital on July 24, 2006 with complaints of chest pain. It was noted that the Veteran was deployed at Fort McCoy to be transferred to Kuwait for deployment. He had ran about a mile that morning when he noticed chest discomfort which was across his chest radiating to his neck; there was no associated significant shortness of breath, but he did have some diaphoresis. He did not take nitroglycerin. The pain subsided in an hour s time period. It was noted that his past history included placement of a stent in 1999; the Veteran indicated that his symptoms were reminiscent of his previous chest pain. The pertinent diagnosis was coronary heart disease, possibly acute coronary syndrome and unstable angina. At the time of discharge he is still doing quite well denies any chest pain at all. An order, dated July 31, 2006, indicated that the Veteran was released from active duty not by reason of physical disability. The soldier was released from active duty for contingency operation Iraqi Freedom and for demobilization of forces from a contingency operation. Of record is a treatment note from the cardiology consultants, dated in August 2006, indicating that the Veteran had a history of known coronary disease. He was doing a physical test when he developed chest pain. He subsequently had arteriograms done in LaCrosse, Michigan, which showed an 80 percent stenosis in the mid left anterior descending, which was treated with balloon angioplasty and stenting. He has had no chest pain, shortness of breath or dyspnea since that time. The impression was negative graded exercise test. Among the records is a memorandum, dated November 28, 2006, indicating that the Veteran was deployed with the 186th CSE; but, while at the MOB station he developed chest pain and subsequently had arteriograms done at Lacrosse Michigan Hospital. He was then referred back to this unit. After he returned home, he suffered a stroke which has left him unable to perform his MOS duties. In sum, the record shows that the Veteran was taken to Franciscan Skemp Healthcare Medical Center, after experiencing chest pain while on active duty; he was discharged the next day. Medical evidence of record shows that that the Veteran continues to have a chronic heart condition. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010 In this case, the Veteran's preexisting heart condition was noted on examination at entrance into active service. For conditions noted on examination at entrance into active service there is no presumption of soundness. 38 U.S.C.A. § 1111. Rather, the question is whether the preexisting injury or disease was aggravated by military service. 38 U.S.C.A. § 1153; Wagner v. Principi,370 F.3d 1089 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active military service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153. Regulation implementing § 1153 provides that clear and unmistakable evidence (obvious and manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b). This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Id. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestation of the disability prior to, during and subsequent to service. Id. The Veteran was afforded a VA examination in October 2010. He reported that, while training for deployment to Iraq he began experiencing chest pain with radiation to left arm accompanied by vomiting. He was taken to LaCrosse Hospital in Wisconsin where he underwent stent placement due to 80 percent blockage. He complained of irregular heart rate along with chest pain takes nitroglycerin approx 1X weekly for chest pain. Following a physical examination, the examiner reported a diagnosis of coronary artery disease. The examiner opined that the Veteran's current coronary artery disease is less likely as not permanently aggravated by military service beyond the natural progression. The examiner explained that 80 percent stenosis is considered progressive or occurred over time a one-time incident of running is not causal to this condition; therefore, stenosis or CAD was not aggravated beyond normal progression due to military service. The examiner further explained that coronary heart disease is usually caused by a condition called atherosclerosis which occurs when fatty material and a substance called plaque buildup on the walls of arteries. This causes them to get narrow. As the coronary arteries narrow blood flow to the heart can slow down or stop. This can cause chest pain (stable angina) shortness of breath heart attack and other symptoms. It is clear from the medical evidence that the Veteran's preexisting heart disease underwent an increase in disability during his 2006 period of active duty. Neither the examiner's opinion, nor any other evidence of record, is clear and unmistakable evidence that the increase was due to the natural progress of the disease. At most, the examiner's opinion is that it is at least as likely as not that his period of service did not cause the condition. The opinion does not rise to the level of clear and unmistakable evidence that his increase in disability was due to the natural progress of the disease. As the presumption of aggravation has not been rebutted, the appeal must be granted. ORDER Service connection (aggravation) for coronary artery disease is granted. REMAND A Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012). Such conditions must be noted on examination reports. The record does not show that the hypertension was noted on any examination report at entrance into service. The Veteran was afforded a VA examination in October 2010 for evaluation of his heart condition. During the examination, it was noted that he was currently taking medication for hypertension. However, the examiner failed to provide an opinion on whether the Veteran's hypertension was related to his active service. Once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the Board finds that an additional examination with an opinion regarding the nature of the Veteran's hypertension is necessary. Accordingly, the case is REMANDED for the following actions: 1. Ensure that the Veteran is scheduled for a VA examination with regard to his hypertension claim. The examiner must review the evidence in the claims folder, including a complete copy of this REMAND, and acknowledge such review in the examination report. All necessary tests should be conducted. The examiner is requested to provide medical opinions as to the following; each opinion must be supported by a complete rationale: (a) Has the Veteran had hypertension at any time since he filed his claim in November 2009? (b) If the Veteran has had hypertension at any time since he filed his claim in November 2009, is there clear and unmistakable medical evidence that his hypertension preexisted his entrance into active service in September 2005 or in July 2006. The examiner must provide a clear explanation with reference to medical evidence in the claims file if the examiner concludes that there is clear and unmistakable evidence of such preexistence. (c) If it is opined that clear and unmistakable evidence of record establishes that hypertension preexisted service, the examiner must also provide an opinion as to whether clear and unmistakable evidence of record establishes that the pre-existing hypertension was NOT aggravated by service, and, if so, specify the evidence upon which this opinion is based. Thorough rationale must be provided for the opinion offered, to include whether any increase identified was due to the natural progression of the disease. (d) Did hypertension manifest during the Veteran's period of active service from September 2005 to October 2005 or in July 2006? The examiner must support any conclusion with an explanation. (e) If the Veteran currently has hypertension, is it at least as likely as not that it is related to any hypertension that existed during his September 2005 to October 2005 period of active service or during his July 2006 period of active service. The examiner must support any conclusion with an explanation. 2. After completing the above development, and any other development deemed necessary, readjudicate the Veteran's claim of entitlement to service connection for hypertension. If the benefit sought on appeal is not granted, furnish to the Veteran and his representative a supplemental statement of the case (SSOC), allow an appropriate opportunity to respond, and then return the appeal to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B , 7112 (2012). ____________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs