Citation Nr: 21030008 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 20-08 955 DATE: May 17, 2021 REMANDED Service connection for a cardiovascular condition is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1955 to March 1980. This matter originally came before the Board of Veterans' Appeals (Board) from a March 2018 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board for further development in October 2020. This matter is again before the Board and has been advanced on the docket pursuant to 38 C.F.R. § 20.902(c). During the pendency of the appeal, the RO granted service connection for the Veteran's back disability in a February 2021 rating decision. As such is a full grant of the benefit sought, the issue is no longer before the Board. Service connection for a cardiovascular condition is remanded. The Veteran believes that service connection for a cardiovascular condition is warranted. See February 2019 NOD. An October 2020 Board decision remanded the issue for a new VA examination because the March 2018 VA examination was found to be inadequate. Among other things, the new VA examination was to state whether the Veteran's heart conditions began during service, manifested within one year following separation from service, were noted during service with continuity of the same symptomatology since service, or were otherwise related to service. See October 2020 BVA Decision. The new VA examination took place in February 2021. The examination found that none of the Veteran's heart conditions, including hypertension, were related to service. See February 2021 C&P Exam. The Board finds the February 2021 examination inadequate, among other reasons, because it did not substantially comply with the Board's remand instructions. Specifically, the examination did not state whether any of the Veteran's heart conditions began during service, manifested within one year following separation from service, or were noted during service with continuity of the same symptomatology since service. See Stegall v. West, 11 Vet. App. 268 (1998). The examination is also inadequate because it did not consider all the relevant evidence of record, such as an apparent diagnosis of hypertension within one year following separation from service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); May 1980 VA Examination. Conclusory findings must be supported by explanatory discussions. For these reasons, among others, a remand is needed for a new VA examination. The matter is REMANDED for the following action: 1. Provide the Veteran with an opportunity to identify any relevant outstanding private and/or VA treatment records. After obtaining any necessary authorizations from the Veteran, make all reasonable attempts to obtain the outstanding records in accordance with 38 C.F.R. § 3.159. 2. Update VA and private treatment records. VA treatment records appear current up to February 2021. 3. Contact all appropriate sources to obtain the Veteran's Reserve/National Guard service treatment and personnel records. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran's claims file. The record suggests that the Veteran had Reserve service for approximately 16 years following separation from active service in 1980. 4. Make a formal finding for all periods of active service, ACDUTRA, and/or INACDUTRA in terms of specific dates. If this cannot be accomplished, provide an explanation. 5. Schedule one or more appropriate VA examinations for the Veteran's cardiovascular conditions. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) Identify all cardiovascular related disabilities existing at any point during the pendency of the appeal (i.e. since August 2017), even if they are currently asymptomatic or have resolved during the pendency of the appeal. In particular, determine whether the Veteran has ischemic heart disease. (B) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability had its onset in or is otherwise related to the Veteran's active service, active duty for training (ACDUTRA), and/or inactive duty for training (INACDUTRA), including but not limited to, herbicide agent exposure during service in Vietnam? If yes, which ones? (Whether a disability is a presumptive condition under 38 C.F.R § 3.309(e) is irrelevant for purposes of this question). (C) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is/was caused by any or all of the Veteran's service-connected disabilities (including any medications taken for the service-connected disabilities)? (D) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is/was aggravated beyond its natural progression by any or all of the Veteran's service-connected disabilities (including any medications taken for the service-connected disabilities)? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (E) Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran's service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran's obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (F) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated any or all of the Veteran's cardiovascular related disabilities including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. If yes, which ones? (G) Is it at least as likely as not (a 50 percent or greater probability) that any hypertension manifested to a compensable degree within one year from separation from active service? (H) Is it at least as likely as not (a 50 percent or greater probability) that any hypertension was noted during service/within one year following the Veteran's separation from active service, with continuity of symptomatology since? (I) Is it at least as likely as not (a 50 percent or greater probability) that at any time during the appeal period (i.e. since August 2017), the Veteran has had ischemic heart disease (which includes but is not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina)? In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: (1) A list of the Veteran's service-connected disabilities. See February 2021 Rating Decision Codesheet. (2) Medical records from 2021 showing a history of aortic stenosis, hypertension, hyperlipids, and TIAs. See February 2021 CAPRI. (3) A medical record from 2021 showing multiple diagnoses. The examination found that a 1979 in-service abnormal stress test may have been an indicator of ischemic heart disease. Further information is provided. See February 2021 C&P Exam. (4) Medical records from 2020 showing that omeprazole could increase the concentration of warfarin and that there may have been a potential problem with warfarin and the Veteran's atrial fibrillation. Further information is provided. See October 2020 CAPRI. (5) Medical records from 2002 showing hypertension and a history of hypertension. Medical records from 2003 showed possible transient ischemic attack symptoms. Medical records from 2013 showed mild atherosclerosis. Id. (6) Medical records from 2019 showing a history of a ST problem and an aortic valve disorder, the current need to decrease warfarin, and a current body mass index of 28. See January 2020 CAPRI. (7) Medical records from 2011 showing symptoms of vascular insufficiency. See October 2019 CAPRI. (8) Medical records from 2018 and 2019 showing an assessment of status post aortic valve replacement, chronic anticoagulation, atrial fibrillation, and varicose veins of the lower extremities. See July 2019 Medical Treatment Record. (9) Medical records from 2018 and 2019 showing a history of bilateral carotid bruits, a cardiac murmur, aortic sclerosis/stenosis, and a decrease in physical activity related to osteoarthritis. The Veteran had moderate aortic regurgitation, premature atrial contractions, a right bundle branch block, sinus bradycardia, an aortic valve disorder, and bilateral edema of the lower extremity. Further information is provided. See June 2019 Medical Treatment Record. (10) The Veteran's report of veins coming out of his leg below the knee to the ankle. It was red, itchy, and swollen. It seemed to start following the hip operation. See May 2019 C&P Exam. (11) Medical records from 2017 and 2018 showing that warfarin was affected by medications and changes in health, an impression of acute ischemic hemispheric infarcts, and an impression of ischemic stroke. See March 2019 CAPRI. (12) Medical records from 2018 showing right eye bleeding without an injury and that an endoscopy showed a bleeding vein which was cauterized. See March 2018 CAPRI. (13) Medical records from 2018 showing an assessment of bilateral swelling below the knees, which may have been related to aortic valve stenosis. See February 2018 CAPRI. (14) Medical records from 2017 showing a past problem of essential hypertension, a diagnosis of cerebral infarction due to thrombosis of an unspecified cerebellar artery, an assessment of permissive hypertension, and that the Veteran served in the military for 42 years. See December 2017 CAPRI. (15) Medical records from 2017 showing a diagnosis of an acute ischemic stroke, likely from clots from the heart. The Veteran was told to stop taking pradaxa, ranitidine, and hydrochlorothiazide. See November 2017 Medical Treatment Record. (16) Service records showing a problem with hemoglobin; an impression of sinus bradycardia; multiple records showing sinus bradycardia; weight problems; multiple high blood pressure readings, including readings of 162/82, 132/88, and 128/86; multiple abnormal heart tests; a screening for ischemic heart disease; and an adhesion at the apex of the heart. See August 2017 STR Medical. (17) A medical record from May 1980 showing that during service, the Veteran had an abnormal EKG and a slow pulse, and that EKG abnormalities were again noticed just before the Veteran's separation from active service. Further workup was supposed to be done around that time, but never was. The Veteran currently had a high blood pressure reading of 145/90, sinus bradycardia, a diagnosis of mild hypertension, and the Veteran was waiting for a further diagnosis. See May 1980 VA Examination. (18) The Veteran's report of being treated for sinus bradycardia from 1971 until at least April 1980. See VA 21-526. (19) All other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community's knowledge or due to the limits of the examiner's medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 6. Readjudicate the issue on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dougan, Associate 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.