Citation Nr: 21028100 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 17-37 625 DATE: May 10, 2021 REMANDED Entitlement to a rating in excess of 60 percent for hypertension with atherosclerotic coronary artery disease, to include entitlement to separate compensable ratings, is remanded. REASONS FOR REMAND The Veteran had active service from May 1963 to October 1985. A February 2020 electrocardiographic study revealed findings consistent with "probable inferior infarct age undetermined." The report of a February 2020 heart examination conducted for the Department of Veterans Affairs (VA) concurrently states that a contemporaneous electrocardiographic study revealed "first degree AV block, Q wave in lead III can indicate old inferior infarct" and left the checkbox for "acute, subacute, or old myocardial infarction" blank. Given the apparently contradictory findings, the Board of Veterans' Appeals (Board) is unable to determine if the Veteran has suffered a myocardial infarction and has any recurrent myocardial infarction residuals. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Board finds that further VA cardiovascular evaluation is needed. Clinical documentation dated after July 2019 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). When readjudicating the Veteran's entitlement to an increased rating for the service connected cardiovascular disability, the Agency of Original Jurisdiction should consider whether separate ratings are warranted for the hypertension and the arteriosclerotic coronary artery disease. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for the service-connected cardiovascular disabilities. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's VA clinical documentation not already of record, including that pertaining to treatment after July 2019. 3. Schedule the Veteran for a VA cardiovascular examination to assist in determining the nature and severity of service-connected hypertension with arteriosclerotic coronary artery disease. The examiner must review the record and should note that review in the report. All indicated tests and studies, including echocardiographic and METs testing, should be accomplished and the findings then reported in detail. If METs testing is medically contraindicated, the examiner should so state and the examiner should provide a METs estimate. A rationale for all opinions should be provided. The examiner should: (a) Indicate whether the Veteran has experienced a myocardial infarction and/or had any myocardial infarction residuals. (b) Specifically note whether chronic congestive heart failure is present and the frequency of any episodes. (c) Provide an opinion as to the impact of the cardiovascular disability on the Veteran's vocational pursuits and whether it is at least as likely as not (50 percent or greater probability) that the Veteran is unable to secure or follow a substantially gainful occupation due to the effects of the cardiovascular disability and the other service connected disabilities. If the Veteran is felt capable of work despite the service connected disabilities, the examiner should describe what type of work and what accommodations would be necessary due to the service-connected disabilities. J. T. HUTCHESON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Cryan, 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.