Citation Nr: 21065976 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 19-07 830 DATE: October 28, 2021 REMANDED Entitlement to service connection for bradycardia as secondary to atrial fibrillation and unspecified anxiety disorder is remanded. Entitlement to service connection for an automatic implantable cardioverter defibrillator (AICD) pacemaker as secondary to atrial fibrillation, unspecified anxiety disorder, and bradycardia is remanded. Entitlement to a temporary total convalescence rating pursuant to 38 C.F.R. § 4.30 following surgery for AICD pacemaker is remanded. Entitlement to a compensable rating for atrial fibrillation is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1968 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) from an April 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran filed a Notice of Disagreement (NOD) in April 2017. A Statement of the Case (SOC) was issued in January 2019. The Veteran filed a VA Form-9 in March 2019 and appeared before the undersigned Veterans Law Judge in January 2021 for an optional Board hearing. The Board notes that the Veteran has indicated that he should be awarded service connection for bradycardia and that bradycardia may have resulted in the need for the AICD. See May 2020 statement submitted by representative. As such, the Board finds that a claim for service connection for bradycardia has been reasonably raised by the record and the issue has been added to the appeal. DeLisio v. Shinseki, 25 Vet. App. 45, 53 (2011). 1. Entitlement to service connection for bradycardia as secondary to atrial fibrillation and unspecified anxiety disorder The Veteran contends that he has bradycardia as a result of his service-connected atrial fibrillation, to include the medications taken for such disability. The evidence of record includes a September 2010 letter from a private physician indicating that the Veteran has "physical symptoms related to his anxiety," to include an "irregular heart beat." A May 2011 private opinion notes that the Veteran's "cardiac condition was significantly exacerbated by his depression and anxiety." As the Veteran is service connected for an anxiety disorder, the Board finds that an additional secondary theory of entitlement has been raised by the record and the issue on appeal has been amended accordingly. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for bradycardia because no VA examiner has opined whether this is secondary to his service-connected anxiety disorder. Additionally, the Board notes that the Veteran was provided with a VA heart conditions examination in December 2011 where he was noted to have hypertensive heart disease and atrial fibrillation. The Veteran was noted to take Acebutolol daily for his heart conditions. Private treatment records from November 2015 indicate that the Veteran was "having bradycardic episodes," with the examining physician noting that the Veteran would "have to stop the acebutolol." The private physician noted that if the Veteran's low heart rate persisted, he would be considered for a pacemaker. The Veteran was provided with a VA heart conditions examination again in March 2016 where the VA examiner found that the Veteran's "bradycardia was 'most likely exacerbated by medication'" per the Veteran's private cardiology treatment in November 2015, noted above. However, the examiner did not set a baseline level of severity of the bradycardia. See 38 C.F.R. § 3.310. Finally, the Board notes that the record suggests that the Veteran may be in receipt of disability benefits from the Social Security Administration. However, the claims file does not contain a decision to grant or deny SSA benefits or the medical records upon which that determination was based. Nor does it appear that an attempt has made to obtain them. VA has a duty to obtain SSA records when they may be relevant to a claim. The possibility that SSA records could contain evidence relevant to the appellant's claim cannot be foreclosed absent a review of those records. Quartuccio v. Principi, 16 Vet. App. 183, 188 (2002). Therefore, the Board finds that an attempt should be made to obtain any available SSA records. 38 C.F.R. § 3.159(c)(2). 2. Entitlement to service connection for an AICD pacemaker as secondary to atrial fibrillation and bradycardia The Veteran contends that he has an AICD pacemaker as a result of his service-connected atrial fibrillation, to include the medications taken for such disability. The Veteran also contends that his AICD pacemaker is secondary to his bradycardia. Private treatment records from November 2015 indicate that the Veteran was "having bradycardic episodes," with the examining physician noting that the Veteran would "have to stop the acebutolol." The private physician noted that if the Veteran's low heart rate persisted, he would be considered for a pacemaker. The Veteran was provided with a VA heart conditions examination in March 2016 where the VA examiner opined that a "nexus cannot be established for a pacemaker implant secondary to his SC atrial fibrillation," as "the pacemaker was more likely than not placed for his bradycardia (low heart rate)." At a March 2017 VA heart conditions examination, the same VA examiner that provided the examination report in March 2016 provided an opinion that the Veteran's pacemaker was less likely than not proximately due to his atrial fibrillation because "the Veteran's pacemaker was placed because he had symptomatic bradycardia which is known as sick sinus syndrome." The VA examiner noted the November 2015 private opinion finding that the Veteran's pacemaker is due to his arrhythmias, but found that since office notes did not accompany the cardiologist's statements, there appeared to be conflicting statements regarding the cause of the Veteran's pacemaker implant. The examiner then concluded by stating that it is more often than not that a pacemaker is placed for symptomatic bradycardia. The Board acknowledges the March 2016 private opinion indicating that the Veteran's pacemaker implant was secondary to his atrial fibrillation and sick sinus syndrome. However, as this opinion was not supported by a rationale, it cannot be used as the basis to award service connection in this case. 3. Entitlement to a temporary total convalescence rating pursuant to 38 C.F.R. § 4.30 following surgery for AICD pacemaker The Board finds that adjudication of the issue of entitlement to a temporary total convalescence rating pursuant to 38 C.F.R. § 4.30 following surgery for an AICD pacemaker is inextricably intertwined with the Veteran's claim for service connection for bradycardia and an AICD pacemaker requiring remand action below. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Therefore, the Board finds that the action requested below must be completed prior to appellate consideration of the issue of entitlement to a temporary total convalescence rating. 4. Entitlement to a compensable rating for atrial fibrillation The Veteran contends that his service-connected atrial fibrillation is more severe than what is represented by a noncompensable rating. The Veteran was most recently provided with a VA heart conditions examination in March 2017 where he was noted to have intermittent atrial fibrillation with zero episodes in the past 12 months. An exercise stress test was not performed as the VA examiner found that exercise stress testing was not required as part of the Veteran's current treatment plan and the test was not without significant risk. In April 2017, the Veteran submitted a statement from his spouse indicating that the Veteran's cardiac disability has worsened over the years. Additionally, in February 2021, the Veteran submitted private treatment records including pacemaker interrogation summaries and echocardiogram reports from August 2017 and August 2020. Accordingly, the Board finds that the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his atrial fibrillation. 38 C.F.R. § 3.159(c)(4). The examination report must consider the private treatment records submitted in February 2021 and discuss whether they show increased episodes of paroxysmal atrial fibrillation or other supraventricular tachycardia in the last 12 months. The matters are REMANDED for the following action: 1. Obtain a copy of any decision to grant or deny SSA benefits to the Veteran and the records upon which that decision was based and associate them with the claims file. If the search for such records has negative results, the claims file must be properly documented as to the unavailability of those records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected heart disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. If the examiner determines that contemporaneous exercise stress testing and/or an echocardiogram is not necessary or medically contraindicated, he or she should provide an explanation. The examiner should provide an opinion on the following: a) Is it at least as likely as not that the Veteran's bradycardia was caused by his service-connected anxiety disorder? b) If not, is it at least as likely as not that the Veteran's bradycardia was aggravated by his service-connected anxiety disorder? In so opining, the examiner should consider the i) September 2010 letter from a private physician indicating that the Veteran has "physical symptoms related to his anxiety," to include an "irregular heart beat," and ii) a May 2011 private opinion noting that the Veteran's "cardiac condition was significantly exacerbated by his depression and anxiety." c) Is it at least as likely as not that the Veteran's bradycardia was caused by his service-connected atrial fibrillation, to include medications taken for such? d) If not, is it at least as likely as not that the Veteran's bradycardia was aggravated by his service-connected atrial fibrillation, to include medications taken for such? In so opining, the examiner should consider: i) the private treatment records from November 2015 indicating that the Veteran was "having bradycardic episodes," and would "have to stop the acebutolol," and ii) the articles in May 2020 indicating a connection between atrial fibrillation, beta blockers, and bradycardia. e) Is it at least as likely as not that the Veteran's AICD pacemaker was implanted due to his service-connected atrial fibrillation, to include medications taken for such? f) If not, is it at least as likely as not that the Veteran's AICD pacemaker was aggravated by his service-connected atrial fibrillation, to include medications taken for such? g) If service connection is warranted for bradycardia, is it at least as likely as not that the Veteran's AICD pacemaker was caused by his bradycardia? h) If service connection is warranted for bradycardia, is it at least as likely as not that the Veteran's AICD pacemaker was aggravated by his bradycardia? In so opining, the examiner should consider: i) the private treatment records from November 2015 indicating that if the Veteran's low heart rate (bradycardia) persisted, he would be considered for a pacemaker, ii) the March 2016 VA examiner noting that the Veteran's pacemaker "was more likely than not placed for his bradycardia (low heart rate)," and iii) the articles in May 2020 indicating a connection between atrial fibrillation, beta blockers, bradycardia, and pacemaker implantation. Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. A fully articulated rationale for each opinion requested must be set forth in the medical report. The examiner must discuss the particulars of this Veteran's medical history and the relevant medical science applicable to this case, which may reasonably make clear the medical guidance in the study of this case. 3. After the development requested has been completed and the requested opinion has been obtained, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morrad, 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.