Citation Nr: 21072193 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-51 453 DATE: December 2, 2021 REMANDED Entitlement to service connection for a heart disorder, to include paroxysmal supraventricular tachycardia, as secondary to service-connected PTSD and service-connected sleep apnea is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 2004 to December 2005 and from April 2009 to May 2010. This matter was initially before the Board in June 2020, where it was remanded for additional development. Specifically, the Board found that new and material evidence was received to reopen his service connection claim. The Board also concluded that the Veteran should be afforded an additional VA examination for his heart disorder. The matter returned to the Board in September 2021, where it was again remanded. The Board concluded that the August 2020 VA examination was inadequate for adjudicative purposes. Entitlement to service connection for a heart disorder, to include paroxysmal supraventricular tachycardia, as secondary to service-connected PTSD and service-connected sleep apnea is remanded. At the outset, the Board finds there has not been substantial compliance with the Board's directives. Stegall v. West, 11 Vet. App. 268 (1998). The Board's September 2021 remand directives explicitly requested a medical opinion from a "cardiologist." The June 2021 VA opinion was rendered by Dr. T.D., "General Practice, Obstetrics and Gynecology." Additionally, while the examiner opined that it is less likely than not the Veteran's heart condition was caused and/or aggravated by his service-connected PTSD and sleep apnea "beyond its natural course," the examiner was requested to discuss whether the Veteran's service-connected PTSD and sleep apnea results in any additional functional impairment associated with the nonservice-connected disability, regardless of permanence. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019); Saunders v. Wilkie, 886 F.3d. 1356, 1363 (Fed. Cir. 2018); Garner v. Tran, U.S. App. Vet. Claims LEXIS 81 (Jan. 26, 2021). Therefore, the Board finds that the matter must be remanded to obtain a medical opinion consistent with the remand directives and court precedential opinions. The matters are REMANDED for the following action: 1. Forward the claims folder to a cardiologist for expert opinion on the Veteran's heart disorder. The claims file should be made available to and reviewed by the examiner. The AOJ should document for the record that the VA examiner is a cardiologist. The examiner should opine to the following: Whether it is at least as likely as not (50 percent or greater possibility) the Veteran's heart disorder, to include paroxysmal supraventricular tachycardia, had its onset in service or is etiologically related to service. The examiner should specifically explain why or why not the Veteran's description of chest pain and chest pressure which began after an RPG attack while he was serving in combat in Iraq represented the onset and/or initial manifestation of the paroxysmal supraventricular tachycardia. Whether it is at least as likely as not that the Veteran's heart disorder, to include paroxysmal supraventricular tachycardia, is (1) caused by the service-connected sleep apnea and/or service-connected PTSD, or (2) that the Veteran's service-connected sleep apnea and/or service-connected PTSD has caused additional functional impairment of the heart (e.g., a worsening of heart symptoms beyond those expected by the baseline level of disability, even if temporary). In providing an opinion, the examiner should consider the United States Court of Appeals for Veterans Claims case, which held that the term "aggravation" requires that a service-connected disability condition (PTSD and sleep apnea) causes a "functional increase in the severity" of the nonservice-connected disability (heart condition). Garner v. Tran, U.S. App. Vet. Claims LEXIS 81 (Jan. 26, 2021). The expert cardiologist should also note that the Veteran is deemed credible and should consider the Veteran's lay statements in rendering an opinion. In doing so, the examiner should consider the following: December 2020 private medical opinion from Dr. V.T., stating that "it is possible that the symptoms he experienced while in Iraq in 2004-2005 were related to this condition;" August 2020 VA opinion, where the examiner stated that obstructive sleep apnea "is associated with nocturnal cardiac arrhythmias" and "there may be a temporal relationship, with arrhythmias occurring more frequently after a respiratory event;" March 2020 testimony, reporting the Veteran's credible heart symptoms, including chest pain and chest pressure, which began after an RPG attack while he was serving in combat in Iraq; May 2020 statement from the Veteran's spouse, who is also a registered nurse, that the Veteran's symptomology consists of episodes of chest pain and periods of apnea; May 2017 letters from the Veteran's treating VA physicians indicating a diagnosis paroxysmal atrial tachycardia and noting the Veteran's statements that heart palpations began during service in 2005 after the Veteran underwent an RPG attack; and September 2017 VA examiner's statement that the etiology of the disorder cannot be determined without mere speculation, and apparently contradictory opinion that the disorder is not etiologically related to service. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In doing so, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Adeleke, T. 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.