Citation Nr: 21068168 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-24 090 DATE: November 9, 2021 REMANDED Entitlement to service connection for coronary artery disease, status post myocardial infarction is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1987 to February 1988 and from October 1990 to July 1991, to include service in the Southwest Theater of Operations during the Persian Gulf War. This case is before the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In that rating decision, in relevant part, the RO denied entitlement to service connection for a low back condition and entitlement to service connection for coronary artery disease. The Veteran timely appealed the March 2016 rating decision. In a December 2018 decision, in relevant part, the Board denied the claims of entitlement to service connection for a low back condition and coronary artery disease. The Veteran then appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2020 Memorandum Decision, the Court vacated and remanded the Board's December 2018 decision denying the claims of service connection for a low back condition and coronary artery disease. In a March 2021 decision, the Board remanded these claims to obtain addendum VA examinations. In a July 2021 rating decision, the RO granted entitlement to service connection for a low back disability; this claim is therefore no longer in appeals status. Entitlement to service connection for coronary artery disease, status post myocardial infarction The Veteran seeks service connection for coronary artery disease, which he contends is related to service. As noted above, in June 2020, CAVC vacated and remanded the Board's December 2018 decision denying the claim of service connection for coronary artery disease. Specifically, the Court noted that the Board did not provide an adequate statement of reasons and bases addressing the materiality of a heart murmur, noted in the Veteran's entrance examination, to the instant cardiac claim. Here, the Board notes that a Report of Medical Examination and a Report of Medical History, both dated July 1987, reflect a heart murmur present "since infancy." Additionally, a January 1991 service treatment record shows that the Veteran was treated for a "fast heartbeat." The treating clinician noted that the condition was probably secondary to Valsalva, with note of tachycardia. As noted in the March 2021 Board decision, the February 2016 VA examination failed to discuss the January 1991 indication of a heart murmur. The March 2021 Board directives instructed the VA examiner to provide direct, presumptive, and pre-existing etiological opinions. Pursuant to the March 2021 Board remand, addendum VA medical opinions were obtained. In April 2021, the VA examiner opined that "after review of medical records there is no documentation that supports that the [heart condition] occurred when the veteran was in service" and that it is "difficult to make the claim of aggravation as there was no report of chest pain while the veteran was in service." The examiner also opined that the heart conditions that "occurred after service is related to service as causes of the conditions can be due to varies causes." In a June 2021 VA addendum opinion, the examiner stated that it is less likely than not that the Veteran's coronary artery disease is due to the in-service report of fast heartbeat as there are multiple causes of such, including high cholesterol or genetics; the examiner additionally opined that it is less likely than not that the heart condition was aggravated by service as there was no report of chest pain while the Veteran was in service. In a July 2021 VA addendum opinion, the examiner stated that "it is noted that the veteran was seen for a heart condition on 1/29/91 which is within the time frame which makes the heart condition likely to have occurred while the veteran was in service." Due to the conflicting medical evidence mentioned above, another August 2021 VA medical opinion was sought. Therein, the examiner opined that there is no documentation that supports that the Veteran's heart condition is due to his time in service "as there is no evidence to support this claim." The examiner also opined that there is no documentation that supports the Veteran's heart condition as presumptively related to service. The examiner also stated, however, that while the Veteran was seen for a heart condition in January 1991, "which is within the time frame which makes the heart condition likely to have occurred while the Vet was in service . . . does not provide definitive information if this condition was something that could lead to [myocardial infarction or coronary artery disease]." Unfortunately, the Board must remand for another VA medical opinion from a cardiologist. Importantly, the medical opinions above fail to specifically consider the July 1987 notation of a heart murmur since infancy, as required by the Board remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Furthermore, the opinions discussed above circle around the relevant questions at hand and continue to contain conflicting medical conclusions. For example, the August 2021 VA examiner states that the January 1991 note of heart murmur is "within the time frame which makes the heart condition likely to have occurred while the Vet was in service," but still concludes that it is unrelated to service. This opinion is internally inconsistent and impossible to reconcile. Either the Veteran's heart disability is related to service, or it is not. The VA examiner's opinion regarding aggravation is also deficient. In its reasoning, the June 2021 VA medical opinion stated that the Veteran's heart disability was not aggravated as there was no report of chest pain while in service. While this may be true, the Veteran was seen in January 1991 for a fast heartbeat. The Board will ask the addendum examiner to opine whether the January 1991 treatment for a fast heartbeat is an indication that the Veteran's alleged pre-existing heart disability was aggravated during service. For these reasons, remand is necessary. The matters are REMANDED for the following action: Obtain a VA medical opinion from a cardiologist, or if one is not available, from another appropriate heart specialist. Another VA examination is left to the discretion of the examiner. After reviewing the claims file, to include a copy of this remand, the examiner must provide separate, well-reasoned opinions on the following: (a) Identify all currently diagnosed heart disabilities that have been present at any time during the appeal period. (b) Identify which heart disabilities, if any, clearly and unmistakably pre-existed service. The examiner must specifically discuss the Veteran's July 1987 notation of a heart murmur since infancy in rendering this opinion. (c) For the disabilities that pre-existed service, if any, opine whether any such disability was clearly and unmistakably NOT aggravated by service. The examiner must specifically discuss the January 1991 treatment for a fast heartbeat in this regard. (d) For any currently diagnosed heart disabilities that did not clearly and unmistakably preexist service, provide an opinion whether it is at least as likely as not that each such disability onset during service, manifested within one year after service separation, or is otherwise etiologically related to service. The examiner must consider and discuss the January 1991 record that the Veteran was treated for a fast heartbeat in this regard. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Finelli, Associate 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.