Citation Nr: 21007640 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 13-18 791A DATE: February 10, 2021 REMANDED Entitlement to service connection for a cardiovascular disability is remanded. REASONS FOR REMAND The Veteran served honorably on active duty from January 1979 to January 1999. The Board thanks the Veteran for his service. This matter comes before the Board of Veterans’ Appeal (Board) from a June 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In his June 2012 notice of disagreement (NOD), the Veteran requested a local hearing with a decision review officer (DRO). In March 2013, the Veteran was scheduled to appear for a DRO hearing at the RO. However, he failed to appear at his hearing and has not since requested another hearing. Accordingly, the Board finds that there is no outstanding hearing request pending. In August 2017, the Board found the March 2013 VA examination inadequate and remanded this matter for additional development. Specifically, the Board noted that the March 2013 VA opinion did not consider the Veteran’s subjective complaints of gasping for air in-service nor his abnormal in-service ECG from November 1993. Moreover, the March 2013 VA medical opinion only provided an opinion for the Veteran’s hypertension and failed to discuss the Veteran’s other diagnoses of current cardiovascular disorders such as cardiomyopathy, congestive heart failure, and coronary artery disease. Following additional development, the Board again remanded the Veteran’s claim in October 2018 for an addendum opinion regarding the Veteran’s coronary artery disease. Specifically, the Board noted that medical records from the Medical University of South Carolina suggests a diagnosis for coronary artery disease from June 2014 through January 2015. However, the August 2017 VA examiner did not consider this evidence when concluding that the Veteran did not have coronary artery disease. Although the Board regrets the need for further delay, another remand is necessary to determine whether the Veteran’s claimed cardiovascular disability was incurred in or is related to service. Entitlement to service connection for a cardiovascular disability is remanded. The Veteran is seeking service connection for his cardiovascular disability, which he contends is related to his active duty service. He asserts that he began to experience heart problems around February 1988, when it was discovered that his chest was pressing on his heart. Further, he found himself gasping for air during physical training in service. He has also stated that at the time, he thought he just overworked himself or was having a reaction to something he ingested, so he “never went to medical for it.” See June 2013 VA Form 9; July 2017 Informal Hearing Presentation (IHP); June 2013 NOD. The Veteran’s service treatment records (STRs) show a self-report of high blood pressure relating to physical training in November 1986. Additionally, episodes of elevated blood pressure were noted in August 1997 and April 1998. An in-service x-ray dated January 1988 documents the lateral view of the chest showing straightening of the normal thoracic kyphosis with narrow AP diameter of the chest. Additionally, the x-ray noted that the AP diameter of the chest appears to cause the heart to be flattened between the sternum and the spine and produces the appearance of some prominence of the cardiac shadow on the PA view of the x-ray. A STR dated November 1993 shows an abnormal ECG. Specifically, the ECG reports, “sinus bradycardia rightward axis incomplete right bundle branch block T wave abnormality, consider lateral ischemia.” Post-service VA treatment records contains notes of elevated blood pressure. A record dated February 2004 documents the Veteran’s report of fainting spells over the past year. Additionally, a February 2004 ECG notes sinus bradycardia with 1st degree AV block, possible left atrial enlargement, incomplete right bundle branch block, and non-specific T-wave abnormality. An April 2004 record documents an ECG stating sinus bradycardia with occasional premature ventricular complexes, possible left atrial enlargement, and nonspecific T-wave abnormality. A May 2004 record documents a dimensional echo stating hypokinesis of distal inferior and lateral walls, aortic valve sclerosis, mild tricuspid regurgitation. Private treatment records from the Medical University of South Carolina (MUSC) show various diagnoses of current cardiovascular disorders, to include hypertension, congestive heart failure/cardiomyopathy, and coronary artery disease. In its October 2018 decision, the Board conceded that the Veteran has current diagnoses for hypertension, cardiomyopathy/congestive heart failure, and non-ischemic cardiomyopathy. Further, medical records from the MUSC suggest a diagnosis for coronary artery disease from June 2014 through January 2015. In the August 2018 IHP, the Veteran’s representative argued that this case should be referred to a cardiologist for an expert medical opinion. Specifically, it was argued that the medical examiner should be instructed to take into account all of the factors that may be related to in-service onset to include the 1988 x-ray, the in-service abnormal ECG, elevated in-service blood pressure, and the Veteran’s lay assertions of shortness of breath and chest pain in-service. The August 2017 Board remand directed an opinion “from an appropriate specialist physician” given the complex nature of the medical question involved. An addendum opinion was obtained in August 2017 from Dr. D. B., an attending physician in primary care. Following the Board’s October 2018 remand, an addendum opinion concerning the Veteran’s claimed coronary artery disease was obtained in November 2019 from Dr. K-S. The Court of Appeals for Veterans Claims has held that instances where a prior Board remand directs the agency of original jurisdiction (AOJ) to obtain a medical opinion from a particular specialist to discuss the facts of the case, and the AOJ obtains an opinion from a practitioner who lacks this specialty, the Board must address this discrepancy when the issue of the examiner’s competency is explicitly raised by the Veteran or is otherwise raised by the record. McCartney v. Wilkie, No. 18-6735, 2020 U.S. App. Vet. Claims LEXIS 1390 (Vet. App. July 21, 2020). In light of the August 2018 IHP, which argued that the matter should be evaluated by a cardiologist and explicitly raised the issue of the examiner’s competency, and the Board’s 2017 remand instructions for an opinion from an appropriate specialist physician, the Board finds that a remand is again warranted. The August 2017 addendum opinion was not obtained from the requested specialist. Moreover, it is unclear if the November 2019 opinion was rendered by an appropriate specialist physician as no specialty or additional information is noted with Dr. K-S’s signature. As such, remand is warranted so that a cardiologist may determine the nature and etiology of the Veteran’s cardiovascular disability. The matters are REMANDED for the following action: 1. Obtain updated VA and non-VA treatment records. 2. Obtain an addendum medical opinion from a cardiologist as to the nature and etiology of the Veteran’s current cardiovascular disorders. The examiner should review the Veteran’s claims file, including the entirety of this remand. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. The examiner is asked to answer the following: a. Clarify if the Veteran had a diagnosis of coronary artery disease at any point during the pendency of this claim. The examiner must address the private medical records from the Medical University of South Carolina (MUSC) which suggest a diagnosis for coronary artery disease from June 2014 through January 2015. b. The examiner is asked to opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s cardiovascular disorders had onset in service or are otherwise related to his military service. The examiner must provide an opinion for each of the cardiovascular disorders, to include hypertension, cardiomyopathy/congestive heart failure, non-ischemic cardiomyopathy, and coronary artery disease. In rendering a conclusion for each cardiovascular disorder, the examiner must complete the following: c. Consider the Veteran’s lay statements, such as his symptom of gasping for air and chest pain during physical training in-service. d. Discuss whether the elevated blood pressure in-service, is connected to each of the cardiovascular disorders, to include hypertension, cardiomyopathy/congestive heart failure, non-ischemic cardiomyopathy, and coronary artery disease. e. Discuss whether the November 1993 abnormal ECG is connected to each of the cardiovascular disorders, to include hypertension, cardiomyopathy/congestive heart failure, non-ischemic cardiomyopathy, and coronary artery disease. f. Discuss whether the January 1988 chest x-ray is connected to each of the cardiovascular disorder, to include hypertension, cardiomyopathy/congestive heart failure, non-ischemic cardiomyopathy, and coronary artery disease. The examiner is reminded that a detailed explanation is required to support the opinion. A complete and thorough rationale must be provided for any opinions expressed with consideration given to all evidence of record. If the examiner is unable to offer the opinion requested, he or she must explain in detail why that is the case. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Law Clerk for the Board N. Jamordee 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.