Citation Nr: 21073960 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 17-26 926 DATE: December 13, 2021 REMANDED Entitlement to service connection for ischemic heart disease (IHD), to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served in the United States Army from October 1974 to October 1977. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Veteran requested a Board hearing. In December 2017, the Veteran requested to withdraw his request for a hearing. As such, the Veteran's hearing request is considered withdrawn. See 38 C.F.R. § 20.704. The issues of entitlement to service connection for IHD, hypertension, and a heart murmur were before the Board in September 2020, at which time the Board remanded the issues for further development. In June 2021, the Board issued a decision granting service connection for hypertension and a heart murmur and remanding the issue of entitlement to service connection for IHD for additional development. This matter was again remanded in August 2021 for further development. The matter returns for appellate consideration. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c). Although the Board regrets the delay, another remand is warranted before an appellate decision can be rendered in this matter. 1. Entitlement to service connection for IHD, to include as secondary to service-connected disabilities, is remanded. The Veteran contends that his IHD is caused by his use of non-steroidal anti-inflammatory drugs (NSAIDs) to treat his service-connected left knee disability and/or his service-connected heart murmur and hypertension. Pursuant to the August 2021 Board remand, an opinion was requested addressing whether the Veteran's IHD was caused or aggravated by his service-connected heart murmur and/or hypertension. An October 2021 VA addendum opinion was obtained. The examiner concluded that the Veteran's IHD was not caused by his heart murmur or hypertension because medical literature did not support a causal relationship between these conditions. Furthermore, the examiner indicated that while hypertension is a risk factor for IHD, it does not cause it. In addition, the examiner concluded that IHD was not aggravated beyond its normal progression by the heart murmur or hypertension because there is no compelling medical evidence to support such conclusion and that medical literature did not support the same. The Board finds the October 2021 VA opinion is inadequate. The examiner failed to provide an adequate rationale in support of the conclusions. Without an opinion that sufficiently provides a rationale for its conclusion, the Board cannot make a fully informed decision on the issue of entitlement to service connection for IHD. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) ("a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor's opinion"). Furthermore, while the examiner suggested that there is no causal relationship between IHD and service-connected heart murmur and hypertension, the medical evidence demonstrates otherwise. First, the June 2021 VA examiner explained that coronary artery disease is a condition that occurs when major blood vessels of the heart become damaged or diseased, often by cholesterol plaques and inflammation in the coronary arteries, resulting in decreased blood flow to the heart. The examiner noted that plaque buildup and/or inflammation in the coronary arteries can be caused by smoking, high blood pressure, high cholesterol, diabetes, obesity, an unhealthy diet, or not being physically active. See June 2021 VA examination report. Second, the March 2014 private opinion from Dr.G.H. also suggested that medications taken by the Veteran for cholesterol, diabetes, hypertension, and other heart issues contribute to a higher risk for major heart incident, stroke, and other related medical problems at "any time." Moreover, the incorrect standard for aggravation. The Board emphasizes that any amount of aggravation is sufficient to establish secondary service connection, so even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). As such, another addendum opinion is warranted, preferably a licensed cardiologist, to better assess the nature and etiology of the Veteran's IHD. The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from a licensed cardiologist to determine the nature and etiology of the Veteran's IHD. The claims folder and a copy of this remand in its entirety must be provided to the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements; the examiner must indicate on the report that such review was undertaken. The examiner is asked to determine the following: a) Is it at least as likely as not that the Veteran's IHD was proximately caused or aggravated by the service-connected heart murmur, to include medications taken therein? b) Is it at least as likely as not that the Veteran's IHD was proximately caused or aggravated by the service-connected hypertension, to include medications taken therein? The examiner is advised that secondary service connection does not require "permanent" worsening of the condition being claimed by the service-connected disability and requires considering whether there has been any worsening, no matter how incremental, so even if not above and beyond the condition's natural progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). The examiner must provide separate findings and rationales relating to causation and aggravation. The examiner must consider the June 2021 VA examiner's findings regarding a causal relationship between coronary artery disease and high blood pressure. The examiner must also consider the March 2014 private opinion from Dr.G.H. suggesting a causal relationship between medications taken by the Veteran for cholesterol, diabetes, hypertension, and other heart issues resulting in major heart incident, stroke, and other medical issues. The examiner must provide a rationale in support of all opinions provided. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 2. Then, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, provide the Veteran a supplemental statement of the case and allow an appropriate period for response. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Asfaw, 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.