Citation Nr: 21023703 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 17-55 592 DATE: April 21, 2021 REMANDED Entitlement to service connection for hypertension, to include secondary to herbicide exposure, is remanded. Entitlement to service connection for residuals of a stroke is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1986 to June 1971. This matter is before the Board of Veterans’ Appeals (the Board) on appeal from a September 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision, inter alia, denied service connection for residuals of stroke and confirmed the previous denial of service connection for hypertension. The Veteran’s Notice of Disagreement (NOD) was received in November 2015. The Statement of the Case was issued in October 2017, and the Veteran’s VA Form 9, substantive appeal to the Board was also received in October 2017. In February 2021, the Veteran, his representative, and his spouse appeared before the undersigned Veterans Law Judge (VLJ) for a Board virtual hearing. The transcript is of record. 1. Entitlement to service connection for hypertension, to include secondary to herbicide exposure. The Veteran seeks service connection for hypertension. He contends that his hypertension is related to his confirmed Agent Orange exposure. The Veteran has qualifying service in the Republic of Vietnam and is thus presumed to have been exposed to herbicides. 38 C.F.R. § 3.307 (a)(6)(iv). Alternatively, the Veteran contends that hypertension was an early symptom of his service-connected ischemic heart disease (IHD). Hypertension is not currently on the list of diseases under 38 C.F.R. §§ 3.309(e) that are presumed due to in-service herbicide exposure. However, in November 2018, the National Academy of Sciences (NAS) upgraded hypertension from the “limited or suggestive evidence” category to the “sufficient evidence” category, indicating that there was enough epidemiologic evidence to conclude that there is a positive association between hypertension and herbicide agent exposure in Vietnam. See Veterans and Agent Orange: Update 11 (2018), Table S-1 and footnote 1. As the evidence of record shows that the Veteran is diagnosed with hypertension, and is presumed to have been exposed to herbicides in the Republic of Vietnam, this matter must be remanded to obtain a VA medical opinion to address the nexus question in light of the most recent 2018 NAS update as it relates to the Veteran’s claim. The Veteran has not been afforded a VA examination since the 2018 NAS study findings were released. As such an addendum medical opinion is necessary to determine whether the Veteran’s hypertension was caused by or etiologically related to herbicide exposure during active military service. In September 2015, the Veteran underwent a VA examination for his claim. The VA examiner noted that the Veteran’s hypertension was diagnosed in the 2006 timeframe and that his stroke was in 2011. The VA examiner concluded that the Veteran’s hypertension was not due to or the result of IHD because hypertension was diagnosed before IHD. The September 2015 VA medical opinion is incomplete to the extent that it did not provide a definite timeline for the onset of the Veteran’s hypertension and IHD or address the Veteran’s contention that hypertension was an early symptom of his IHD. Specifically, a January 2002 VA treatment note indicates that the Veteran had borderline hypertension diagnosed in the 1970’s. The same note indicates that the Veteran had a cardiac catheter complete and was notified that he had a weak heart muscle at the tip, but that no surgery was recommended. However, the Veteran’s file does not contain the January 2002 cardiac catheter report. A July 2011 private treatment note indicates that the Veteran had paroxysmal supraventricular tachycardia. The September 2015 cardiac diseases VA examination report indicates that the Veteran was diagnosed with CAD in 2015. These records raise a possibility that the Veteran’s hypertension and IHD had their onset earlier than the September 2015 VA examination report suggests. As such, on remand, the RO should obtain any outstanding treatment records, and obtain an addendum medical opinion addressing a complete timeline of onset and etiology of the Veteran’s hypertension and IHD. Accordingly, the matter is remanded to obtain any outstanding private treatment records as well as an addendum medical opinion. 2. Entitlement to service connection for residuals of a stroke. The Veteran seeks service connection for residuals of a stroke. He contends that he first developed hypertension, which was an early symptom of IHD, and that his IHD and hypertension caused his stroke. In September 2015 the Veteran underwent a VA examination for his claim. The VA examiner concluded that the residuals of a stroke are less likely than not proximately due to, or a result of IHD. The VA examiner cited a January 2014 cardiology note indicating that the Veteran did not have a history of myocardial infraction (MI), coronary artery disease (CAD), or other cardiac diseases. The VA examiner also indicated that the Veteran’s stroke was not caused by IHD because it occurred prior and was embolic in nature. With respect to the history of these disabilities, the VA examiner noted that the Veteran had transient ischemic attacks (TIAs) in January 2002, August 2009, and September 2010. The Veteran’s stroke was noted to occur in 2011. The September 2015 VA medical opinion is incomplete to the extent that it did not provide a definite timeline for when the Veteran developed his cardiac disability. The September 2015 VA examiner cites a January 2014 VA treatment note indicating that the Veteran had no history of cardiac disability. However, the January 2002 VA treatment note indicates that the Veteran may have had a prior onset of his heart disability. As such, an addendum medical opinion is necessary to establish a detailed timeline of onset and etiology of the Veteran’s IHD. These matters are REMANDED for the following action: 1. To the extent possible, obtain any outstanding VA or other treatment records and associate them with the file, including, but not limited to, the Veteran’s January 2002 cardiac catheterization report. All attempts to obtain the requested documents should be documented. 2. Obtain an addendum medical opinion on the issue of service connection for hypertension. The claims file, including a copy of this remand, must be available to the examiner for review, and the examiner should indicate that the claims file was reviewed in connection with providing the opinion. The examiner is requested to offer an opinion as to the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension is related to disease or injury in service, to include exposure to herbicides during service, and to include secondary to the service-connected IHD. (b.) A complete, clearly-stated rationale for the conclusions reached-to include identification of evidence and medical authority relied upon-must be provided. The examiner should consider and discuss the National Academy of Sciences (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 2018 and all other medical literature and/or studies used in offering his or her opinion. (c.) In providing this opinion, the VA examiner is requested to obtain from the Veteran and the treatment records an accurate timeline of the onset and etiology of the Veteran’s hypertension and IHD. The VA examiner is requested to address the January 2002 VA treatment note indicating that the Veteran had a cardiac catheter showing a weak heart muscle and the July 2011 diagnosis of paroxysmal supraventricular tachycardia. (d.) The VA examiner is requested to address the Veteran’s contention that hypertension was an early symptom of his service-connected IHD. (e.) The VA examiner is requested to provide a full rationale for all conclusions reached. 3. Obtain an addendum opinion on the issue of service connection for residuals of a stroke. The claims file, including a copy of this remand, must be available to the examiner for review, and the examiner should indicate that the claims file was reviewed in connection with providing the opinion. The examiner is requested to offer an opinion as to the following: (a.) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s stroke residuals are etiologically related to active military service, to include secondary to his service-connected IHD. (b.) In providing this opinion, the VA examiner is requested to obtain from the Veteran and the treatment records an accurate timeline regarding onset of the Veteran’s IHD, and address the January 2002 VA treatment note indicating that the Veteran had a cardiac catheter showing a weak heart muscle and the July 2011 diagnosis of paroxysmal supraventricular tachycardia. (c.) The VA examiner is requested to provide a full rationale for all conclusions reached. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kuksova, Kseniya 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.