Citation Nr: A21019246 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 210321-155972 DATE: December 2, 2021 REMANDED Entitlement to service connection for a heart disability, to include congestive heart failure (CHF), is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1995 to October 1998. Service in Southwest Asia is indicated by the record. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied the claim of entitlement to service connection for CHF. The Veteran filed a notice of disagreement (NOD) in October 2013 and a statement of the case (SOC) was issued in September 2014. He perfected a timely legacy appeal in September 2014. In an April 2018 decision, the Board remanded the appeal for further evidentiary development. A supplemental statement of the case (SSOC) was issued in February 2021. In a March 2021 Decision Review Request: Board Appeal (notice of disagreement) (VA Form 10182), the Veteran timely appealed that decision to the Board and selected the Hearing Lane Review option. In June 2021, the Veteran testified at a virtual hearing before the undersigned VLJ. A transcript is of record. As explained on the VA Form 10182, the Board Hearing option entails review of the evidence of record of the time of the decision on appeal, in this case the February 2021 Supplemental Statement of the Case, as well as evidence submitted at the hearing and within 90 days after the Board hearing. 1. Entitlement to service connection for a heart disability, to include CHF, is remanded. The Veteran asserts entitlement to service connection for a heart disability, which he contends was incurred during his active duty service to include as a result of documented in-service treatment with iron supplements. See the Board hearing transcript dated June 2021. He has additionally claimed that his heart disability was incurred as a result of service in Southwest Asia. See, e.g., the Veteran's statement dated December 2012. He has alternatively contended that his heart disability is secondary to iron supplements prescribed to treat his service-connected anemia. See the Veteran's statement dated February 2021. This matter was remanded by the Board in April 2018 to obtain a VA medical opinion addressing the etiology of the claimed heart disability, to include questions concerning both direct and secondary service connection. Pursuant to the Board remand, VA medical opinions were obtained in April 2019, in which the examiner concluded that the Veteran's heart condition is less likely than not proximately due to or the result of an incident in service to include his service-connected anemia. The examiner provided the following rationale: "[r]eview of records is negative for any heart condition in service. Records [do] not reveal evidence that his current heart condition has been attributed to his anemia." The Veteran was afforded a VA examination in August 2020 at which time the examiner confirmed diagnoses of CHF, valvular heart disease, implanted cardiac pacemaker, and atrial fibrillation. In an August 2020 VA opinion, the examiner determined that the Veteran's claimed heart disability "is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition." The examiner explained, "upon review, the Veteran was found with beta thalassemia on the lab on [April 1998] during service. A hematology report on [May 2018] mentions 'it appears his hyperferritinemia is likely reactive and not reflecting of true iron overload state given sat <40% and negative cardiac/liver biopsy.'" The examiner continued, "[a] cardiology report in January 2019 states 'Chronic systolic heart failure secondary to nonischemic etiology with hypertensive heart disease leading to dyspnea.' Thus, the Veteran's diagnosed heart conditions, CHF (2012), mitral and tricuspid regurgitation (2020), implanted cardiac pacemaker (2012, 2018), atrial fibrillation (2018), valvular heart disease(2021), and hypertensive heart disease (2018) are less likely than not proximately due to or the result of the Veteran's service-connected anemia condition." The August 2020 VA examiner further indicated that the Veteran's heart disability is not aggravated by his service-connected anemia. The examiner stated, "[a]s a cardiology patient on January 2019, the Veteran's CHF is more likely due to hypertensive heart disease than iron-overload etiology related to his claimed mistreatment with iron for his anemia." As to the question of direct service connection, the examiner stated that the Veteran's heart disability did not have its onset in service; "[t]he medical records during service are silent for any cardiac abnormalities." The Veteran asserts that the April 2019 and August 2020 VA medical opinions are inadequate and the Board agrees. Neither the April 2019 nor August 2020 VA examiners addressed the Veteran's contentions that his heart disability is related to environmental exposures during his service in Southwest Asia. In addition, the August 2020 VA examiner's negative opinions as to secondary service connection and aggravation do not fully address the medical evidence of record and rely upon a January 2019 VA cardiology note, which documented "[c]hronic systolic heart failure secondary to nonischemic etiology with hypertensive heart disease leading to dyspnea." The August 2020 examiner's reliance on this single notation ignores other medical evidence of record, which repeatedly documents VA treatment providers questioning the etiology of the Veteran's elevated ferritin and radiologic iron deposits in the heart. See, e.g., the VA treatment records dated December 2011, August 2012, and November 2017. In fact, there is no explanation provided in the Veteran's VA treatment records to support the January 2019 notation concerning causation of the diagnosed CHF. The Board further recognizes the Veteran's assertion that his hypertensive heart disease was diagnosed years after his CHF; this contention appears to be consistent with the record (including the examiner's own findings of a CHF diagnosis in 2012 and a hypertensive heart disease diagnosis in 2018). See the Veteran's statement dated February 2021; see also the November 2012 e-consultation from Dr. J.D., the Lake City VAMC chief of hematology and oncology. Therefore, the August 2020 VA examiner's conclusions concerning the causal relationship between the Veteran's hypertensive heart disease and CHF seem unsupported by the evidence of record. Thus, the failure to obtain an adequate VA medical opinion as to the questions of nexus to include direct and secondary service connection is a pre-decisional duty to assist error requiring remand. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4). The claim on appeal must therefore be remanded in order to obtain a new VA medical opinion concerning outstanding questions of nexus and aggravation. The Board additionally observes that, following the June 2021 hearing, the Veteran timely submitted medical evidence in support of his claim including a Mayo Clinic information sheet on thalassemia, which includes an advisement that people with thalassemia should be advised to avoid iron supplements because they are at risk of iron overload. The information sheet further indicates that "[c]ongestive heart failure and abnormal heart rhythms can be associated with severe thalassemia." The Veteran also submitted an article entitled, 'Iron Overload Cardiomyopathy, Better Understanding an Increasing Disorder.' The matters are REMANDED for the following action: The AOJ shall refer the VA claims file to a physician with appropriate expertise to provide an opinion as to the claimed heart disability to include CHF. If the examiner determines that an examination is necessary, one should be scheduled. After reviewing the record, and examining the Veteran if deemed necessary, the examiner should then respond to the following: (a). Whether it is at least as likely as not that a diagnosed heart disability to include CHF began during active service or is related to an in-service injury, event, or disease, to include as a result of the in-service prescription of an iron supplement and/or as due to environmental exposures during the Veteran's service in Southwest Asia? (b). If not, is it at least as likely as not that a diagnosed heart disability to include CHF was caused by a service-connected anemia to include iron supplements prescribed to treat it? (c) If not, is it at least as likely as not that the Veteran's diagnosed heart disability to include CHF is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by anemia to include iron supplements prescribed to treat it? If the Veteran's claimed heart disability to include CHF is aggravated by anemia to include prescribed iron supplements, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In providing the requested opinion and rationale, the examiner MUST ADDRESS the relevant evidence of record, to include: (a) the Veteran's service treatment records, to include the April 1998, June 1998, and July 1998 records documenting treatment for shortness of breath, malaise, and other symptoms; (b) the Veteran's in-service prescription for an iron supplement; and (c) the Veteran's lay statements concerning continuing cardiac symptoms dating from his military service. In addressing the above, the examiner must consider the Veteran's description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disabilities, this should be noted. Stated another way, do the Veteran's reports about his symptoms such as malaise and shortness of breath align with how a heart disability to include CHF is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? In this regard, the examiner should note that the absence of evidence of treatment for claimed disability in the Veteran's service treatment records should not serve as the sole basis for a negative opinion. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.