Citation Nr: 21032540 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 14-24 735 DATE: May 27, 2021 REMANDED Entitlement to service connection for a cardiac disorder, to include uncontrolled angina, and to include as secondary to his service-connected post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1966 to November 1970. This appeal is before the Board of Veterans' Appeals (Board) from a September 2012 rating decision from a Department of Veterans Affairs (VA) Regional Office. The Board notes the Veteran's claim was previously remanded in June 2018 and March 2020. The Veteran claims that his cardiac disability is related to service or his service-connected PTSD. While the Board regrets further delay in adjudicating the Veteran's claim, the Board finds the VA opinions of record are inadequate and a remand is necessary to correct these errors. Treatment records since October 2001 document ongoing complaints of chest pain and tightness. An October 2001 treatment record noted a diagnosis of unstable angina. The Veteran underwent a left heart catheterization, selective coronary arteriography, and a left ventriculography. A February 2002 record noted an additional diagnosis of coronary artery disease. April 2004 treatment records note that the Veteran underwent a left heart catheterization which revealed 50% eccentric lesion of the mid right coronary artery and a 20% proximal LAD lesion with normal ejection fraction." In December 2004, the Veteran received treatment for chest pain and underwent a catheterization. An April 2006 record noted acute coronary syndrome with chest pain at rest. He underwent a cardiac catheterization and a selective coronary arteriography, and the post and preoperative diagnosis were angina pectoris. In September 2006, the Veteran received treatment for chest pain described as "sharp chest discomfort." A January 2008 EKG indicated "ischemia with stress." An August 2008 record noted an "auscult heart." A January 2010 record noted treatment for worsening chest pain in the substernal area and examination revealed a "II/IV systolic ejection murmur." A September 2010 record noted that the Veteran suffered from "episodes of sinus tachycardia" and an angiogram revealed angina pectoris. A September 2010 VA PTSD examination report noted the Veteran suffered from "uncontrolled angina" and that "doctors think it may be related to anxiety." In May 2013, private treatment records indicate he received treatment for coronary artery disease, and a "systolic ejection murmur" was noted and his CAD was determined to be stable. In this case, the record contains three etiological opinions. An August 2012 VA ischemic heart disease examination report indicated that the Veteran experienced dyspnea during activity. The Veteran reported he had not had an episode of chest pain since 2010. The examiner opined that the Veteran's uncontrolled angina was less likely than not the result of or proximately due to his PTSD. The examiner stated that other health factors such as obesity, sleep apnea, and a "long history of tobacco abuse, pose greater health risks for cardiac events caused by ischemia which can precipitate angina." A May 2019 VA ischemic heart conditions examination report noted a diagnosis of CAD in 2014 and "atypical chest pain" in 2012 and noted that the etiology of the Veteran's CAD was arteriosclerosis. The examiner opined that the Veteran's claimed angina was less likely than not aggravated by his PTSD. The examiner reasoned that the Veteran's chest pain is consistent with a diagnosis of atypical chest pain. Atypical chest pain is a term used to describe discomfort or pain centered in the chest that is not cardiac pain. A July 2020 VA medical opinion noted the Veteran was diagnosed with coronary artery disease in 2014 and that the Veteran did not have uncontrolled angina, but rather atypical chest pain. The examiner opined that the Veteran's cardiac disorder was not aggravated by PTSD. Here, the August 2012, May 2019 and July 2020 VA examiners state the Veteran was diagnosed with coronary artery disease in 2010 or 2014; however, the evidence of record indicates he was diagnosed in 2001. As such, it is unclear whether the examiners reviewed the complete medical record, to include the evidence detailed above. Further, no examiner opined whether the Veteran's atypical chest pain is caused or aggravated by PTSD. The Board notes that any functional impairment may constitute a current disability under Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Thus, the Board finds the Veteran's claim must be remanded for a new VA medical opinion to determine the nature and etiology of the Veteran's cardiac disorder. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Additionally, the Board notes that the Veteran's representative submitted medical literature indicating that patients with PTSD had double the risk of death from heart disease during a 15-year follow up period. See April 2021 Appellate Brief. Consequently, on remand, the examiner must address this submission. This matter is remanded for the following actions: 1. Acquire a VA addendum opinion from a qualified examiner to determine the nature and etiology of the Veteran's cardiac disorder to include uncontrolled angina. The examiner is ordered to review the above outlined evidence prior to answering the following questions: Is it at least as likely as not (at least a 50 percent probability or greater) that the Veteran's cardiac disorder, to include coronary artery disease, uncontrolled angina and chest pain, is related to service? If not, is it at least as likely as not that the Veteran's cardiac disorder is caused by or aggravated by his service-connected PTSD? The examiner must address the medical literature submitted by the Veteran's representative in April 2021. It is within the examiner's discretion to decide if a VA examination is warranted. Note 1: If functional impairment is found as a result of his cardiac disorder, to include uncontrolled angina and chest pain, this will constitute a current disability under Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Note 2: The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Note 3: A detailed rationale supporting the examiner's opinion should be provided. The rationale for any opinion expressed must be provided. If an opinion cannot be made without resort to speculation, the examiner should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. (Continued on the next page) 2. Conduct any other development deemed necessary and then readjudicate the Veteran's claim. Roya Bahrami Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Law Clerk, Tyler R. Masters 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.