Citation Nr: 21006994
Decision Date: 02/08/21	Archive Date: 02/08/21

DOCKET NO. 16-44 012
DATE: February 8, 2021

REMANDED

Entitlement to service connection for a cardiac disability is remanded.

REASONS FOR REMAND

The Veteran had active duty service from August 1976 to August 1996, including in Southwest Asia. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).

In November 2018, the Board of Veterans’ Appeals (Board) denied the service connection claim for a heart disability. In May 2020, the Court issued memorandum decision that vacated the Board denial and remanded the claim. 

Entitlement to service connection for a cardiac disability is remanded.

In the Court’s decision, the Board was found to have erred by relying on inadequate VA examination and opinion to deny the claims for service connection for a heart disability. Specifically, the Court noted a March 2015 VA opinion was inadequate based on the examiner’s reliance on a lack of documented evidence of cardiac disability to determine there was no cardiac disability, but without performing diagnostic testing. See May 2020 Decision. The March 2015 VA examiner did not complete the section for diagnostic testing for cardiac disability. See March 2015 Examination. 

The Court further found that it was unclear whether diagnostic testing had been completed at any time since 2009, and the Veteran had previously manifested an atrial flutter that was treated with ablation therapy. In light of the Court’s May 2020 decision, a new examination with diagnostic testing is warranted to determine the presence of cardiac disability and whether such disability is due to his service. 

The Veteran’s September 2019 brief to the Court raises the possibility that, if it exists, the Veteran’s cardiac disability is the result of his service-connected hypertension. As the Board must remand regardless, the Board directs the examiner to opine as to whether, assuming a cardiac disability is found, it is caused or aggravated by the Veteran’s service-connected hypertension. 38 C.F.R. § 3.310.

The matters are REMANDED for the following action:

1. Obtain outstanding VA medical records.

2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s claimed cardiac disability. Diagnostic testing should be conducted to determine the presence of cardiac disability. 

If a cardiac disability is found, the examiner must opine whether it at least as likely as not: 

(1) began during active service, 

(2) manifested after discharge from service, 

(3) was noted during service with continuity of the same symptomatology since service, 

(4) was caused by the Veteran’s service-connected hypertension, or

(5) was aggravated by the Veteran’s service-connected hypertension. 

The Board emphasizes that separate rationales are necessary for the causation and aggravation components of this question. A rationale for all opinions must be provided.

 

 

J. B. FREEMAN

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	J. Trickey

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.