Citation Nr: 21074265 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-00 038A DATE: December 14, 2021 REMANDED Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1972 to June 1994. This matter again comes before the Board of Veterans' Appeals (Board) on appeal from November 2015 and August 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this matter in January 2019 and June 2021. 1. Heart Disorder Regarding the Veteran's claim for a heart disorder, the Board acknowledges that the Veteran has asserted that his heart disorder is etiologically linked to service, or, alternatively, to his service-connected chronic obstructive pulmonary disease and obstructive sleep apnea. See January 2017 VA Form 9; January 2017 Correspondence from Veteran indicating a relationship between heart conditions and sleep apnea; March 2017 VA Form 21-4138; June 2020 VA Form 21-4138. To date, no opinion has been procured regarding this theory of entitlement. Consequently, the Board must remand this matter for a new opinion determining whether the Veteran's current diagnosed heart disability is causally related to his service-connected conditions. Regarding direct service connection, the Board notes that the August 2021 opinion found that the Veteran's service treatment records (STRs) found no underlying cardiac condition. However, a June 1993 evaluation found that the Veteran had "marked sinus bradycardia." Accordingly, the August 2021 opinion is based on an inaccurate factual premise and therefore is inadequate to determine this matter on the merits. Reonal v. Brown, 5 Vet. App. 458 (1993); Monzingo v. Shinseki, 26 Vet. App. 97 (2012). Therefore, an addendum opinion should be obtained. 2. Hypertension In the June 2021 remand, the Board requested an addendum opinion regarding the etiology of the Veteran's current hypertension. Specifically, the Board asked the clinician providing the opinion to address whether it was at least as likely as not that the Veteran's various reports of high blood pressure prior to separation represented the onset of his current hypertension, whether the in-service findings of elevated blood pressure were sufficient to identify hypertension, and whether the in-service elevated blood pressure readings were sufficient to establish that the Veteran's hypertension was chronic at the time. Although the clinician opined that the Veteran's current hypertension was less likely than not related to his active duty service, the clinician did not address the questions as to whether the in-service readings of elevated blood pressure were sufficient to identify hypertension or establish chronicity. A remand by the Board confers on claimants, as a matter of law, the right to compliance with the remand orders and on the VA a concomitant duty to ensure substantial compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). Because the clinician providing the August 2021 opinion did not respond to all of the Board's inquiries as noted in the June 2021 remand, the Board finds that an addendum opinion should be obtained. The matters are REMANDED for the following action: 1. Forward the claims file to an appropriate clinician who has not previously provided an opinion in this case to determine the nature and etiology of any heart condition(s) attributable to the Veteran throughout the appeal period. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. (a) The clinician should identify any and all heart condition(s) attributable to the Veteran throughout the appellate period. (b) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (probability of about 50 percent) that the Veteran's condition manifested during, or is the result of, his active service. (c) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (probability of about 50 percent) that the Veteran's condition was either (i) caused or (ii) aggravated by his service-connected disabilities, including, but not limited to, chronic obstructive pulmonary disease and/or obstructive sleep apnea. NOTE: With respect to the question concerning aggravation, the clinician is advised that aggravation under 38 C.F.R. § 3.310(b) does not require "permanent worsening" of the nonservice-connected disability. If aggravation is found, the clinician should attempt to identify the baseline level of severity of disability prior to such aggravation. In formulating his or her opinion(s), the clinician should consider and address all competent medical and lay evidence of record, including, but not limited to: (i) The Veteran's service treatment records, including various in-service complaints of dizziness, palpitations, chest pain, and shortness of breath; chest imaging reports; and the June 1993 record diagnosing the Veteran with marked sinus bradycardia; (ii) The Veteran's post-service VA and private medical records; (iii) The Veteran's competent lay statements regarding his first-hand in-service experiences and the onset and continuity of his symptomatology; and (iv) Information from the Mayo Clinic submitted in January 2017 indicating a relationship between heart conditions and obstructive sleep apnea. If the clinician finds that the Veteran's heart condition(s) is/are less likely than not due to his active service and/or less likely than not caused and/or aggravated by his service-connected disabilities, the clinician should discuss what other factor(s) caused the disorder(s). In other words, the clinician should ascertain the most likely etiology of the Veteran's heart condition(s). The clinician must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. 2. Forward the claims file to an appropriate clinician to determine the nature and etiology of the Veteran's hypertension. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. (a) The clinician should opine as to whether it is at least as likely as not (probability of about 50 percent) that the Veteran's in-service elevated blood pressure readings are sufficient to identify hypertension. (b) The clinician should opine as to whether it is at least as likely as not (probability of about 50 percent) that the Veteran's in-service elevated blood pressure readings were sufficient to establish that hypertension was chronic at the time. (c) The clinician should opine as to whether it is at least as likely as not (probability of about 50 percent) that the Veteran's hypertension manifested during, or is the result of, his active service. In formulating his or her opinion(s), the clinician should consider and address the competent medical and lay evidence of record, including, but not limited to: (i) The Veteran's service treatment records, to include all blood pressure readings; (ii) The Veteran's post-service VA and private medical records; and (iii) The Veteran's competent lay statements regarding his first-hand in-service experiences and the onset and continuity of his symptomatology. If the clinician determines that the Veteran's hypertension is less likely than not due to his active service, the clinician should discuss what other factor(s) caused the disorder. In other words, the clinician should ascertain the most likely etiology of the Veteran's hypertension. The clinician must provide a comprehensive report that provides a complete rationale for all opinions and conclusions reached. 3. After completing the foregoing development, the RO should readjudicate the issues on appeal. If the above-sought benefits remain denied, the RO should issue a Supplemental Statement of the Case (SSOC) to the Veteran and his representative. An appropriate period of time should be allowed for response before returning the appeal to the Board. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoffman 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.