Citation Nr: 21015035 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 16-05 664 DATE: March 16, 2021 REMANDED Entitlement to service connection for a heart disorder, diagnosed as non-ischemic cardiomyopathy, with chronic atrial fibrillation, and left ventricular dysfunction (claimed as ischemic heart disease), as a result of exposure to herbicides is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1965 to December 1968. The Veteran died in March 2012. The appellant is the Veteran’s surviving child and has been appropriately substituted. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a January 2011 rating decision of the Cleveland, Ohio Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously remanded by the Board in September 2018 for additional development to include a new VA opinion. Entitlement to service connection for a heart disorder, diagnosed as non-ischemic cardiomyopathy, with chronic atrial fibrillation, and left ventricular dysfunction (claimed as ischemic heart disease), as a result of exposure to herbicides is remanded. The Veteran asserted that he is entitled to service connection for a heart disability which was caused by exposure to herbicides during his service in Vietnam. The Veteran’s personnel records confirm that he served in the Republic of Vietnam from August 1966 to September 1967. Thus, the Veteran’s exposure to herbicides is conceded. The remaining questions for the Board are whether the Veteran had a diagnosis of IHD which is presumptively related to his conceded herbicide exposure or a diagnosis of any other heart condition that was related to active service. An October 2010 VA opinion and January 2011 addendum indicate the Veteran’s mildly dilated left ventricular chamber and diastolic dysfunction are not evidence of ischemic heart disease. The examiner found there was no objective evidence that supports a diagnosis of ischemic heart disease. The echocardiogram results of March 2009 confirm the diagnosis of mild cardiomyopathy. The examiner noted that since many causes exist for cardiomyopathy, LVH, and atrial fibrillation (such as hypertension), and since when cathetered, the Veteran had no evidence of CAD, IHD cannot be assumed. A March 2012 autopsy report showed myocardial hypertrophy due to hypertension with subsequent ischemic changes causing fibrosis. The report states that the underlying cause of death was most likely hypertension, being the most common cause of left ventricular hypertrophy leading to dilatation and failure. Pursuant to the Board’s September 2018 remand directives, a supplemental medical opinion was obtained in January 2020. The reviewing physician concluded that the Veteran’s diagnosed cardiac conditions were more likely related to underlying risk factors such as long-standing hypertension, and obesity, rather than exposure to herbicides during service. The Board notes that the National Academy of Sciences (NAS) Institute of Medicine's Veterans and Agent Orange: Update 2006 (2006 Update) elevated hypertension to the “limited or suggestive evidence” category, explained in the NAS 2012 Update as meaning that the “evidence suggests and association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence. See Fed. Reg. 20, 309 (Apr. 11, 2014). Notably, this Update was not discussed in the January 2020 opinion, which concluded that the Veteran’s heart conditions were more likely related to underlying risk factors to include long-standing hypertension. Thus, on remand, a supplemental medical opinion should be provided addressing the etiology of the Veteran’s hypertension, and the likelihood that it is related to the Veteran’s exposure to herbicide agents in service. The matters are REMANDED for the following action: Arrange for a supplemental medical opinion by an appropriate medical professional (“clinician”) to address the nature and likely etiology of the Veteran’s hypertension and heart disorders. The clinician is asked to address the following: a. Is it at least as likely as not (50 percent or greater probability) that the Veteran’s heart disability (diagnosed as non-ischemic cardiomyopathy, with chronic atrial fibrillation, and left ventricular dysfunction) was caused or aggravated by his hypertension? b. Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is related to his active service, to include his presumed exposure to herbicide agents? In responding to the above, the clinician is advised that the fact that a VA presumption has not been established for a particular disorder is not dispositive of the question of etiology, and consideration must still be given to the herbicide exposure. In rendering an opinion, the clinician’s attention is directed to the NAS updates regarding hypertension and herbicide exposure. A clear rationale must be provided for any opinion and/or conclusion stated. Citation to specific medical literature and evidence supportive of the conclusion would be useful to the Board. A. SOLOMON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. M. Donahue Boushehri, 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.