Citation Nr: 21063318 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 13-02 431 DATE: October 13, 2021 REMANDED Entitlement to service connection for sinus tachycardia is remanded. Entitlement to service connection for chronic bronchitis is remanded. Entitlement to service connection for asthma is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Air Force from January 1977 to May 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in April 2016. This case was previously before the Board in November 2016, April 2018, September 2020, and February 2021, when it was remanded for development. The case has been returned to the Board for further appellate review. 1. Entitlement to service connection for sinus tachycardia is remanded. Unfortunately, another remand is necessary in this case. The VA examiner who provided the July 2021 opinions in this case identified coronary artery disease (CAD), hypertrophic cardiomyopathy, and mitral valve disease as current cardiac disabilities. The examiner opined that none of these conditions manifested in sinus tachycardia, but rather the symptoms were shortness of breath and/or chest pain. The examiner did not offer any opinion regarding whether the sinus tachycardia noted in the private treatment records and in lay statements from the Veteran was a symptom of any of the Veteran's service-connected disabilities. The examiner also opined that no chronic diagnosis of sinus tachycardia is supported by the evidence of record. The examiner noted reports of palpitations and tachycardia on two occasions during service; the examiner also cited a progress note from the pulmonary clinic in 2015 documenting sinus tachycardia and concluding that this was a physiologic response to the Veteran's deconditioning. However, the examiner did not offer an opinion as to whether this indicated the tachycardia was a symptom of any service-connected disability, nor did the examiner discuss whether the persistence of the tachycardia from service to present had any medical significance. Further, the examiner's opinions regarding whether the identified cardiac disabilities were directly or secondarily related to service are inadequate. The examiner did not provide any rationale for the opinion that the cardiac conditions were not incurred in or caused by service beyond noting that they were all diagnosed at least 30 years after discharge. The secondary opinion was likewise inadequate. First, regarding whether any of the cardiac conditions were caused by the Veteran's service-connected respiratory disabilities, the examiner noted the known risk factors of CAD, cardiomyopathy, and mitral regurgitation, including obesity, but did not provide any explanation discussing the Veteran's particular circumstances and why the risk factors were more likely the cause than the service-connected pneumothorax or bullous emphysema. Further, the examiner did not discuss whether the service-connected respiratory disabilities could have caused or contributed to obesity as an intermediary step to causing the cardiac conditions. See Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). Finally, no explanation was offered regarding aggravation of any of the cardiac disabilities. For these reasons, the July 2021 VA opinions are inadequate, and another remand is necessary to obtain opinions addressing these aspects of the Veteran's claim. 2. Entitlement to service connection for chronic bronchitis is remanded. 3. Entitlement to service connection for asthma is remanded. The July 2021 VA examiner, when prompted to opine whether the Veteran has or had asthma and/or chronic bronchitis since July 2009, opined that the Veteran has a diagnosis of chronic obstructive pulmonary disease (COPD), which has subtypes that can include emphysema, chronic bronchitis, and chronic obstructive asthma. The examiner explained that patients can present with a spectrum of manifestations of COPD and related processes. The examiner opined that the Veteran has had consistent symptomatology of COPD throughout the pendency of this appeal, and its exacerbations have included flares of chronic bronchitis and asthma. The examiner opined that the Veteran's respiratory disabilities, including asthma, chronic bronchitis, and COPD, are not related to service because they were not diagnosed until after service and the respiratory complaints in the service treatment records, such as upper respiratory infections, hay fever, acute bronchitis, and sinusitis, all resolved without sequelae. The examiner opined that the current respiratory disabilities are a result of the history of cigarette smoking, elsewhere noting that the Veteran quit smoking around 1991-1992. The examiner did not provide any rationale for the conclusion that the COPD, asthma, and chronic bronchitis are more likely due to cigarette smoking than to the Veteran's in-service exposures, which include industrial cleansers. Finally, the examiner opined that the COPD was not caused or aggravated by the service-connected pneumothorax and bullous emphysema. The examiner noted only that cigarette smoking is the most important risk factor for COPD, but did not explain the significance, if any, of the Veteran quitting smoking around 1991-1992. Of note, the examiner did not discuss how the Veteran's service-connected bullous emphysema was related to the COPD, when elsewhere the examiner had noted that emphysema is a subtype of COPD. Further, the examiner supported the negative aggravation opinion only by stating that there is no evidence in the record the COPD was aggravated beyond its natural progression by the prior pneumothoraces or bullous emphysema. For these reasons, the opinions are inadequate, and the record continues to lack sufficient medical evidence to decide this claim. The matters are REMANDED for the following action: 1. Forward the claims file to a cardiologist or other appropriate clinician to determine whether any current heart condition manifesting in sinus tachycardia is related to the Veteran's military service. Following thorough review of the claims file, the examiner should identify all current cardiovascular conditions manifesting in sinus tachycardia since July 2009, when the Veteran first filed this claim for service connection. If no current cardiovascular condition manifesting in sinus tachycardia is identified, the examiner should opine whether the sinus tachycardia, both as noted in medical records and as reported by the Veteran in complaints of heart racing and palpitations, is a symptom of one or more of the Veteran's service-connected respiratory disabilities. For each cardiovascular condition identified, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran's active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that each cardiovascular condition is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran's service-connected respiratory disabilities, either individually or in combination. Please note, causation and aggravation are separate concepts and must be addressed independently. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the cardiovascular condition prior to aggravation by the service-connected disabilities. For each cardiovascular disorder currently found, the examiner should also provide opinions to the following: (a) Whether any of the Veteran's service-connected disabilities caused the Veteran to become obese, either individually or by the total combined effect of two or more service-connected disabilities (i.e., due to a lack of mobility or inability to exercise); (b) If so, whether the obesity was a substantial factor in causing the cardiovascular disability; and (c) Whether the cardiovascular disability would not have occurred but for the obesity. The examiner should specifically address the Veteran's private treatment records submitted in January 2010, documenting sinus tachycardia, and in June 2016, detailing heart surgery with bullectomy. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 2. Forward the claims file to a pulmonologist or other appropriate clinician to determine whether asthma, chronic bronchitis, and/or COPD is related to the Veteran's military service. Following review of the claims file, the examiner should opine whether the Veteran has or had asthma, chronic bronchitis, and/or COPD during the pendency of this appeal (since July 2009). If the examiner concludes the Veteran does not have any current diagnosis of asthma, chronic bronchitis, or COPD, the examiner must provide an opinion regarding whether the diagnoses in the record were made in error, resolved, or progressed to a different respiratory disability. Then, the examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the asthma, chronic bronchitis, COPD, and/or other respiratory disability began in or is otherwise caused by the Veteran's active service. In providing this opinion, the examiner should discuss the Veteran's reported in-service exposure to industrial cleaning solvents, as well as the respiratory complaints found in the service treatment records. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that each respiratory disability identified is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran's service-connected pneumothorax disability or giant bullous emphysema, either individually or in combination. Please note, causation and aggravation are separate concepts and must be addressed independently. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the asthma, chronic bronchitis, COPD, and/or other respiratory disability prior to aggravation by the service-connected disabilities. (Continued on the next page) The examiner MUST specifically address the Veteran's private and VA treatment records treating asthma and chronic bronchitis, including the private treatment records submitted in January 2010, as well as the Veteran's lay statements regarding symptoms since onset. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Josey, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.