Citation Nr: 21072133 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 16-58 085 DATE: December 2, 2021 REMANDED Entitlement to service connection for a disability manifesting as chest pain is remanded. Entitlement to service connection for a heart condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1996 to September 1999. These matters were previously before the Board in December 2018 and August 2021 when they were remanded for further development. For the reasons discussed below, there has not been substantial compliance with the prior remand directives and unfortunately another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998) Entitlement to service connection for a disability manifesting as chest pain and for a heart condition are remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that she is afforded every possible consideration. 38 U.S.C.§ 5103A; 38 C.F.R.§ 3.159. In addition, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, 11Vet. App.at 268. As previously noted, these matters were before the Board in August 2021. At the time the Board noted that in January 2020 the Veteran underwent a VA examination, and that the examiner noted that the Veteran had various cardiac conditions to include coronary artery disease, unstable angina, status post coronary artery stent placement, sinus bradycardia, atrioventricular block, first degree, pulmonic valve insufficiency, and tricuspid valve regurgitation. In addition, the examiner indicated that the Veteran's chest pain was possibly due to her unstable angina or anxiety but opined that the Veteran's heart conditions were not related to her service. The examiner noted that there were no cardiac symptoms or conditions during service and that the Veteran did not receive treatment for cardiac conditions until nearly 10 years after separation from service. The examiner also noted that, at the time of diagnosis and treatment for the cardiac conditions, the Veteran had several risk factors that contributed to the development of the cardiac conditions, including obesity, high blood pressure, and hyperlipidemia, and a 2017 medical article indicated that hypertension, high blood cholesterol levels, and obesity are risk factors for the development of coronary artery disease. The Board however found the opinion inadequate and in need of clarification. The Board required a medical determination as to whether the Veteran's chest pain was a separate and distinct disability or a symptom of one of her diagnosed heart conditions. In addition, the examiner failed to address the in-service treatment notes in 1997 where the Veteran was counseled on high cholesterol and diagnosed with obesity. Therefore, an addendum opinion was requested. In September 2021 the Veteran underwent an additional VA Heart Conditions examination with an accompanying disability benefits questionnaire (DBQ) as well as Medical Opinions. The examiner noted that the Veteran suffered from atherosclerotic cardiovascular disease, status post coronary artery stent placement, sinus bradycardia with 1st degree AV block, and left ventricular hypertrophy. The examiner noted that there was no longer evidence of unstable angina and no objective evidence to support the contention that cardiac conditions were caused by or related to depression or anxiety. Furthermore, the examiner found that the Veteran suffered from left ventricular hypertrophy and that fatigue, shortness of breath and exertional chest pain were all recognized symptoms of such. Finally, the examiner opined that the Veterans heart conditions were less likely than not related to service as the Veteran did not received treatment for any cardiac conditions or symptoms of cardiac conditions in service and was not diagnosed with a cardiac condition for at least 10 years following her discharge. Here, again, the Board must find the opinion inadequate as the examiner failed to substantially comply with the Board's prior remand directives. The examiner failed to discuss the 1997 in-service notations of high cholesterol and obesity, which are noted risk factors for cardiac conditions. In addition, the Veteran reported that her symptoms began in 1997 or 1998, which was noted on the September 2021 examination but not discussed by the examiner. Therefore, on remand an addendum opinion should be obtained that substantially and thoroughly addresses the Board's prior and current remand directives. Due to the amount of time which will pass on remand, updated treatment records should be obtained and associated with the record. The matters are REMANDED for the following action: 1. Obtain updated treatment records. 2. Return the Veteran's claims file to the September 2021 VA examiner (or another examiner if he or she is unavailable) for an addendum opinion regarding the Veteran's chest pain and heart conditions. The electronic claims file, including this remand, must be made available to the examiner for review. An examination should only be scheduled if the examiner deems one is necessary for providing the requested opinions. Following a review of the claims file, the examiner is asked to address the following: (a) Identify all current cardiac conditions and describe their manifestations. The examiner is asked to discuss prior examinations and diagnoses of record. (b) State whether the Veteran has a disability manifested by chest pain that is separate and distinct from her diagnosed cardiac conditions. (c) For all diagnosed cardiac conditions and/or disabilities manifested by chest pain, please opine as to whether it is at least as likely as not that such had its onset in or is otherwise related to the Veteran's active-duty service. In providing the requested opinion, the examiner MUST address the Veteran's in-service counseling on high cholesterol and obesity diagnosis in 1997 and the 2017 article previously referenced which indicates that obesity and high cholesterol are risk factors for developing coronary artery disease. In addition, the examiner MUST discuss the Veteran's contention that her symptoms began during service in either 1997 or 1998. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements. The rationale for any opinion offered should be provided. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Unger, 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.