Citation Nr: 19100167 Decision Date: 01/03/19 Archive Date: 01/02/19 DOCKET NO. 15-15 184 DATE: January 3, 2019 REMANDED Entitlement to service connection for a heart disorder, to include atrial fibrillation with atrial flutter, cardiomyopathy, congestive heart failure (CHF), heart block, etc., is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 to February 1971, to include service in the Republic of Vietnam. Entitlement to service connection for a heart disorder, to include atrial fibrillation with atrial flutter, cardiomyopathy, congestive heart failure (CHF), heart block, etc. is remanded. The Veteran seeks service connection for a heart disorder. He contends that it is related to service, to include exposure to herbicides or is secondary to his service-connected posttraumatic stress disorder (PTSD). Post-service private treatment records indicate that the Veteran has been diagnosed with chronic systolic congestive heart failure, nonischemic cardiomyopathy, atrial fibrillation, paroxysmal, heart block, and cardiac noncompaction. The Veteran was afforded VA examination in September 2011, and the examiner indicated that his hypertrophic obstructive cardiomyopathy is not caused by or the result of ischemic heart disease (IHD) or coronary artery disease (CAD). The examiner further noted that cardiomyopathy is caused by biventricular heart failure; and CHF is not caused by or the result of IHD, but the result of biventricular heart failure. In a VA examination in September 2011, the examiner noted the Veteran’s atrial fibrillation is not caused by or the result of IHD or CAD and said atrial fibrillation is an abnormality of the heart electrical conduction system and not affected by CAD unless there is right-sided heart ischemia. The Veteran’s myocardial infarctions (MIs) were in 1979, 1991 and 1996. If they had resulted in right-sided ischemia, the Veteran would have had atrial fibrillation immediately after the MI. The Veteran was most recently afforded VA examination in March 2015. The examiner diagnosed CHF, heart block, implanted cardiac pacemaker, and implanted automatic implantable cardioverter defibrillator. The examiner noted that the Veteran’s cardiomyopathy, heart failure, and left bundle block are from his Agent Orange exposure. She indicated that she did not have the Veteran’s records to review, but he did have both a pacemaker and implanted defibrillator, and there was no reported family history, the Veteran did not have atherosclerosis nor was he on antilipidemic medications. The examiner noted that the Veteran’s CHF qualified him for a heart condition within IHD; and she opined that his heart condition was at least as likely as not incurred in or caused by service, as CHF is considered one of the diagnoses under IHD, which is related to herbicide agent exposure. Additionally, the examiner provided a negative nexus opinion regarding the Veteran’s heart condition being caused by his service-connected PTSD. The Veteran provided a June 2015 opinion from Dr. D.P.M., which diagnosed chronic systolic congestive heart failure, nonischemic cardiomyopathy, atrial fibrillation, paroxysmal, and cardiac noncompaction. Dr. M. concluded that these conditions are as likely as not, or less likely as not related to his military service. The Veteran then provided articles to support his contention that his heart condition may be secondary to his service-connected PTSD. The Board notes that certain enumerated disorders such as ischemic heart disease, may be presumptively service-connected if the Veteran in Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii) (2017). However, congestive heart failure is not one of them. Also, as Dr. M. provided both a positive and negative nexus opinion, clarification is needed. And although the March 2015 VA examiner provided a negative opinion regarding secondary service connection, the opinion did not address aggravation. The Board needs an adequate opinion regarding secondary service connection. Additional medical opinion is warranted to determine whether the Veteran has ischemic heart disease, and if so, the relationship, if any, to service. When the medical evidence is inadequate, as it is here, new VA examination must be afforded to the Veteran. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matter is REMANDED for the following action: 1. Schedule the Veteran for a new VA heart examination. The claims file must be made available to, and reviewed by the examiner. The examiner is asked to provide answers to the following: Clarify the Veteran’s current heart disorder(s)? Does his heart disorder(s) qualify within the generally accepted medical definition of ischemic heart disease (IHD)? The examiner is specifically requested to review the file and determine whether the Veteran had ever incurred a myocardial infarction, as the medical evidence suggests a possible history of three myocardial infarctions. If so, the examiner is asked to opine as to whether any of the myocardial infarctions were related to or considered a part of ischemic heart disease or whether they are due to an intercurrent cause (note: some of the evidence suggests that the first such incident may have been related to cocaine use). Is it at least as likely as not (50 percent or greater probability) that the Veteran’s heart disorder(s) began in, or are otherwise the result of his military service, to include his presumed herbicide agent exposure? Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that any heart disorder was caused or aggravated beyond its natural progression by his service-connected PTSD? The opinion must address both causation and aggravation, as these are two separate inquiries. In offering any opinion, the examiner should consider the full record, to include the Veteran’s credible lay statements and articles submitted that supports his claim (See December 2018 Appellate Brief, page 2). The rationale for any opinion offered should be provided. 2. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD I. Warren, Associate Counsel