Citation Nr: 21010374 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 16-24 932A DATE: February 24, 2021 ORDER Entitlement to service connection for a heart disability is denied. REMANDED Entitlement to service connection for cause of the Veteran’s death is remanded. FINDING OF FACT The Veteran did not have a heart disability that had its onset during his active service, or was otherwise etiologically related to such service; a heart disability was not present to a compensable degree within one year of his separation from active service; and the Veteran did not have ischemic heart disease. CONCLUSION OF LAW The criteria for service connection for a heart disability are not met. 38 U.S.C. §§ 1110, 1112, 1116, 5107 (2018); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from August 1967 to May 1971. The Veteran died in January 2010. The appellant is his surviving spouse, who has been properly substituted in the appeal. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The appellant testified at a hearing before the undersigned Veterans Law Judge in May 2019. A transcript of that hearing has been added to the record. This case was previously before the Board in June 2020, at which time the issues on appeal were remanded for additional development. The case has now been returned to the Board for further appellate action. Service Connection – Heart Disability Prior to his death, the Veteran asserted that he had a heart disability that was related to his active service, to specifically include as due to exposure to herbicides. The Veteran served in Vietnam and therefore his exposure to herbicides is presumed. Service treatment records (STRs) are silent for complaints of, treatment for, or a diagnosis of a heart disability while the Veteran was in active service. in The Board acknowledges that in November 1970, the Veteran was seen in medical for complaints of chest pain for the prior four months. Physical examination noted tenderness at costal cartilage and an impression of Tietze’s syndrome was noted. There was no indication from the treatment note that the Veteran’s chest pain was determined to be cardiac in nature at that time. In April 1971, the Veteran was afforded a separation examination. At that time, the Veteran specifically denied experienced pain or pressure in his chest, or any other cardiac symptoms on his Report of Medical History. The Veteran’s heart was clinically normal upon examination, and there is no indication from the examination report that the Veteran was found to have a heart disability at the time of his separation from active service. Post-service evidence of record shows that the Veteran filed a claim of entitlement to service connection for a heart disability in February 1984. The Veteran was afforded a VA examination in April 1984. At that time, the Veteran reported that he experienced racing heart rate, for which he had been seen at the hospital for observation. Chest X-ray taken at that time was essentially normal, and the cardiovascular silhouette was unremarkable. Electrocardiogram (EKG) at that time revealed an interventricular conduction defect; however, echocardiogram conducted at that time was normal. The examiner diagnosed paroxysmal tachycardia by history. An August 1997 myocardial perfusion imaging report revealed a small inferoapical defect consistent with attenuation artifact, but no ischemic changes were seen. In March 1998, a VA Medical Center mental health treatment note by a psychology student listed coronary arteriosclerosis in diagnoses. However, a review of the record shows that diagnosis to be in error. In this regard, there was no objective basis for that diagnosis, and the above described stress test referred to as supporting that diagnosis was negative for ischemia. Further, it also appears to have been noted that the Veteran’s reported chest pain at that time, after ruling out all medical possibilities, appeared to by psychogenic in origin. A February 1999 echocardiogram revealed normal left ventricular systolic function and normal atrial size. In June 2000, another echocardiogram was performed in an effort to determine the cause of recurrent cerebrovascular accidents (CVAs) while on cocaine, and paroxysmal atrial fibrillation. Echocardiogram results at that time were normal. A repeat echocardiogram performed in February 2002 was also normal. A December 2002 myocardial perfusion study with wall motion was normal, and was negative for ischemia or infarction, and revealed a normal left ventricular ejection fraction. A December 2009 echocardiogram revealed a normal left ventricular wall and ejection fraction. In October 2020, a VA medical opinion was obtained. Following a complete review of the record and citation to relevant records, the examiner opined that it was less likely as not that the Veteran’s heart disability of atrial fibrillation was related to his active service, to include exposure to herbicides. In so finding, the examiner noted that the record showed that the Veteran’s atrial fibrillation was noted to be caused by cocaine abuse multiple times in the record. Further, the examiner noted that the STRs were silent for evidence of a heart condition, either acute or chronic in nature. The examiner noted that the multiple available cardiac tests of record revealed no evidence of ischemia. The examiner noted that the 1998 mental health note showing a diagnosis of coronary arteriosclerosis was drafted by a psychology student who appeared to misinterpret the Veteran’s medical chart information and test results. The examiner acknowledged the 1984 EKG showing an interventricular conduction defect, but noted that the finding was of little clinical significance, and all subsequent cardiac diagnostic imaging showed no evidence of ischemia. The Board finds that the October 2020 medical opinion is adequate. In this regard, the examiner thoroughly reviewed and discussed the relevant evidence, considered the contentions of the appellant, and provided a supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As there is no medical opinion of record to the contrary, the October 2020 VA medical opinion is the most probative evidence of record. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for a heart disability is not warranted. 38 U.S.C. § 5107 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Service Connection – Cause of Death In the June 2020 remand, the Board directed that a medical opinion be obtained to determine the nature and etiology of the cause of the Veteran’s death. A review of the record shows that the directed medical opinion was obtained in October 2020. However, a review of the medical opinion shows that it is inadequate for adjudication purposes. In this regard, the examiner failed to adequately consider all the pertinent evidence of record, and failed to provide a sufficient rationale for the conclusions reached. Therefore, the Board finds that the development conducted does not adequately comply with the June 2020 Board remand directives. Compliance with a remand is not discretionary, and failure to comply with the terms of a remand necessitates remand for corrective action. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, an addendum opinion should be obtained to determine the nature and etiology of the Veteran’s cause of death. The matter is REMANDED for the following action: 1. Forward the Veteran’s claims file to a psychiatrist or psychologist with appropriate expertise to determine the nature and etiology of any psychiatric disability present at the time of the Veteran’s death, to specifically include whether the Veteran’s substance abuse was related to a psychiatric disability that should have been service-connected at the time of the Veteran’s death. The examiner must review the claims file, and note such review in the report. Based on a complete review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran had a psychiatric disability at the time of his death that had its onset during the Veteran’s active service, or was otherwise etiologically related to such service. In forming the opinion, the examiner must comment on the documented symptoms of anxiety the Veteran experienced while in active service. If the Veteran had a psychiatric disability that was related to his active service, the examiner must also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran’s documented polysubstance abuse and/or alcohol abuse were caused or aggravated by such psychiatric disability. A complete and detailed rationale for all opinions expressed must be provided. 2. If determined that the Veteran’s polysubstance abuse and/or alcohol abuse was caused or aggravated by a psychiatric disability that was related to his active service, the claims file should be forwarded to an examiner with appropriate expertise to provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any such related polysubstance abuse and/or alcohol abuse contributed substantially or materially to the Veteran’s listed causes of death, to specifically include liver failure and liver cirrhosis. A complete and detailed rationale for all opinions expressed must be provided. 3. Confirm that the VA medical opinions provided comport with this remand, and undertake any other development determined to be warranted. (Continued on the next page)   4. Then, readjudicate the remaining issue on appeal. If the decision is adverse to the appellant, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Andrew Ledman II 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.