Citation Nr: 21075574 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 17-57 410 DATE: December 20, 2021 ORDER Entitlement to service connection for myocardial infarction, to include as due to herbicide exposure, is granted. REMANDED Entitlement to service connection for cardiomyopathy, to include as secondary to myocardial infarction and/or herbicide exposure is remanded. Entitlement to service connection for ventricular arrhythmia, to include as secondary to myocardial infarction and/or herbicide exposure is remanded. Entitlement to service connection for heart block, to include as secondary to myocardial infarction and/or herbicide exposure is remanded. FINDING OF FACT The Veteran's myocardial infarction is presumptively associated with his exposure to herbicide agents during his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for myocardial infarction, to include herbicide exposure have been met. 38 U.S.C. §§ 1110, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(e). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from March 1969 to October 1970, including service in Vietnam from September 8, 1969 to October 15, 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in this decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Service Connection Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection can also be established based on herbicide agent exposure. 38 C.F.R. § 3.307(a)(6). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed during such service to an herbicide agent containing dioxin, such as Agent Orange, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). If the veteran is presumed to have been exposed to herbicide agents, the veteran is entitled to a presumption of service connection for certain disorders, to include ischemic heart disease. See 38 C.F.R. § 3.309(e). As defined by 38 C.F.R. § 3.309(e), ischemic heart disease includes, but is not limited to: acute, sub-acute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable, and Prinzmetal's angina. 38 C.F.R. § 3.309(e). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). 1. Entitlement to service connection for myocardial infarction, to include herbicide exposure The Veteran contends that his cardiovascular disabilities including a myocardial infarction are due to herbicide agent exposure, specifically Agent Orange. The Veteran contends that he was never examined by the VA for his cardiovascular conditions, but instead examiners only reviewed some of his records in making their determinations. See August 2021 Correspondence. There are two issues to determine if service connection is warranted in this claim on a presumptive basis: whether the Veteran was directly exposed to designated herbicide agents and whether the Veteran has an enumerated disease associated with designated herbicide exposure. The Veteran's personnel records demonstrate that he served in Vietnam between September 1969 to October 1970. Therefore, the evidence of record reflects that during the Veteran's active service, he was in the Republic of Vietnam during the Vietnam era, and thus herbicide exposure is presumed. In January 2016, a VA examiner reviewed the Veteran's medical records. The examiner indicated that the Veteran was diagnosed with ventricular arrhythmia, heart block, and cardiomyopathy. The examiner noted that none of the Veteran's heart conditions qualify within the generally accepted medical definition of ischemic heart disease (IHD). In an undated DBQ, that was submitted in September 2016, the private examiner indicated that the Veteran had a diagnosis of acute, subacute, or old myocardial infarction; ventricular arrhythmia; heart block; cardiomyopathy; hypertensive heart disease; and implanted automatic implantable cardioverter defibrillator (AICD). The examiner indicated that the diagnosis of acute, subacute, or old myocardial infarction qualifies as IHD. The examiner stated that continuous medication was required to treat the Veteran's heart disabilities. The Veteran's diagnosis of acute, subacute, or old myocardial infarction was confirmed by a November 2008 stress test. In March 2017, a VA examiner reviewed the Veteran's medical records. The examiner indicated that the Veteran had a diagnosis of acute, subacute, or old myocardial infarction; coronary artery disease; heart block; cardiomyopathy; and implanted automatic implantable cardioverter defibrillator (AICD). The examiner indicated that the Veteran's occlusive cardiovascular disease with DBQ documented myocardial infarct in 2008 qualifies as an accepted definition of ischemic heart disease (IHD). In the July 2018 DBQ examination, the examiner noted that the Veteran had a diagnosis of congestive heart failure, cardiomyopathy, implanted automatic implantable cardioverter defibrillator, and "left bundle branch block." The examiner indicated that none of the Veteran's heart conditions qualify within the generally accepted medical definition of IHD. In August 2021, the Veteran submitted a correspondence prior to the Board hearing, most of which is included within the Veteran's Board hearing testimony. However, the Veteran explained that he was in really good shape prior to entering the military. He indicated that his doctors have speculated with him that many of his cardiovascular issues may have been at least in part a result of herbicide exposure. The Veteran indicated that he was never examined by VA for cardiac issues, but VA tried to reconcile the different diagnosis. In August 2021 the Veteran testified at a Board hearing. The Veteran testified that early on he had some issues. Through the 70's and 80's he had more issues and ended up on blood pressure medicine and took Lipitor. In the 1990's and 2000's he had lots of heart tests. Due to his symptoms, he was sent for cardiac catheterization, treadmills, and chemical stress testing. The Veteran testified that he had an implantable cardioverter defibrillator and had three wires going to his heart. The Veteran explained it was a pacemaker but also a defibrillator. The Veteran testified that he served in Vietnam, always in the field, way up north, just south of the DMZ "out in the mountains west of Hu." He testified that he was a combat engineer, and all of the water he drank came out of one water point or another along the Perfume River or one of its tributaries out in the mountains. A lot of defoliated area. The Veteran testified that he thinks all of his heart issues are due to his exposure to herbicides while in Vietnam. The Board finds that the Veteran has a diagnosis of acute, subacute, or old myocardial infarction which is included in the definition of ischemic heart disease. See 38 C.F.R. § 3.309(e). The Board acknowledges that while some of the reviews of the evidence did not mention this diagnosis, the undated DBQ examiner indicated that the diagnosis was confirmed by the November 2008 stress test Therefore, the Board concludes that service connection for acute, subacute, or old myocardial infarction is warranted on a presumptive basis. See 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS FOR REMAND 1. Entitlement to service connection for cardiomyopathy, to include as secondary to myocardial infarction and herbicide exposure is remanded. 2. Entitlement to service connection for ventricular arrhythmia, to include as secondary to myocardial infarction and herbicide exposure is remanded. 3. Entitlement to service connection for heart block, to include as secondary to myocardial infarction and herbicide exposure is remanded. The Veteran contends that his cardiomyopathy, ventricular arrhythmia, and heart block disabilities are due to his active service. Specifically, the Veteran testified that he thinks all of his heart issues are due to his exposure to herbicides while in Vietnam. See August 2021 Board Hearing Transcript. The Board cannot make a fully informed decision on the issues of entitlement to service connection for cardiomyopathy, ventricular arrhythmia, or heart block disabilities without first securing an addendum opinion determining whether the Veteran's heart disabilities are secondary to his service-connected acute, subacute, or old myocardial infarction. Thus, a remand is required to secure an addendum opinion. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's cardiomyopathy, ventricular arrhythmia, or heart block disabilities are at least as likely as not (1) proximately due to his service-connected acute, subacute, or old myocardial infarction disability (2) aggravated beyond its natural progression by the service-connected acute, subacute, or old myocardial infarction disability. (Does not have to permanently worsen). 2. After completing the above, and conducting any further development deemed necessary, readjudicate the claim for service connection. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Quist 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.