Citation Nr: 22013447 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 15-40 065 DATE: March 9, 2022 REMANDED Entitlement to service connection for a heart disability, to include coronary artery disease (CAD), including myocardial infarction, is remanded. Entitlement to individual unemployability prior to March 28, 2019, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from July 1980 to July 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The matter first appeared before the Board in September 2018 at which time the issues were remanded for further development, including to obtain an addendum opinion. After having reviewed the addendum opinion, the Board finds that the opinion is inadequate, and remand is warranted. 1. Entitlement to service connection for a heart disability, to include coronary artery disease including myocardial infarction is remanded. The Veteran underwent an additional heart conditions examination in January 2020. The examiner diagnosed the Veteran with CAD and as having had a myocardial infarction. The examiner opined that the condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. On review of the claims file, the examiner acknowledged that while in service, the Veteran reported chest pain and the cardiac workup was normal in July 1997, continued radiating pain to both shoulders in August 1997, a history of pleurisy as noted in April 1998. The examiner then noted that the Veteran's May 2000 separation examination noted elevated LDL cholesterol at 139 and next noted the Veteran's 2008 diagnosis of CAD via a percutaneous catheterization following a heart attack. The examiner explained that Veteran's chest wall pain in service was diagnosed as pleurisy, cited to medical reference of what pleurisy is and the causes of the condition, and specifically noted that pleurisy is not a cardiac condition which would cause the development of CAD or a myocardial infraction. The examiner next expounded on the reason why the Veteran's in service elevated LDL was not a cause of her CAD, specifically noting that the Veteran's calculated 10-year risk of heart disease based on her vital signs and lipid panel from May 2000 separation examination shows a 3.1 percent 10-year risk of heart disease and stroke, and that despite her elevated cholesterol, there was no indication for her cholesterol to be treated back in 2000 and she was considered a low risk for cardiac events. The examiner then found that the more likely cause for the Veteran's condition is a combination of family history/genetics, and social factors, especially tobacco use. The Veteran's attorney has advanced arguments including that elevated LDL cholesterol and elevated lipids during service is a well-documented risk factor for cardiovascular disease and that speculation that the Veteran's in-service chest pain was not a cardiac event is not enough to reject the contemporaneous record of chest pain with family history of heart attack for a determination that the actual condition must have been pleurisy in service. On this note, the attorney argued that the evidence reflects that the contemporaneous records address a cardiac event. Here, the Board notes that the medical literature citation that the examiner referenced for pleurisy notes the symptoms, causes, diagnosis and treatment, and the July 1997 service treatment record (STR) note reflects that after the Veteran reported chest pain, an EKG, urine, and other tests were ordered, and the diagnosis of July 1997 was chest wall pain, with an EKG within normal limits. The August 1997 follow-up STR notes an assessment of chest pain and family history of myocardial infarction, costochondritis, and smoker. Next, the April 1998 STR reflects that a diagnosis of pleurisy is written by an examiner who also made remarks regarding the Veteran's general medical history. Here, the Board notes that even arguendo, if the April 1998 diagnosis of pleurisy was a correct diagnosis, the January 2020 examiner only accounted for the pleurisy diagnosis and did not discuss the costochondritis or other assessments, as the record reflects that there may have been multiple conditions noted in service. Along these lines, although the examiner discussed the Veteran's elevated LDL and other risk factors such as family history, the examiner did not address the Veteran's other symptoms or complaints noted in service, such as congested feelings, low blood pressure, pneumonia, or obesity. Further, notably, when discussing the Veteran's in service elevated LDL, the examiner indicated that the claimed condition is generally attributed to an elevated LDL and did find that the Veteran had a 3.1 percent 10 year risk of heart disease, but only rationalized as to why the elevated LDL was not treated back then, as opposed to explaining why the 3.1 percent 10 year risk could not specifically be the cause of the Veteran's claimed condition outside of noting that the Veteran only had minimal elevations. Neither did the examiner comment on the Veteran's argument regarding the length of time necessary to develop CAD and the impact of hypercholesterolemia on CAD. In this regard, the examiner further indicated that the Veteran's family history risk factors are found to be equal to other standard risk factors including cholesterol level and cigarette smoking. From this, the Board is unable to determine whether adequate consideration was afforded to the complete evidence of record. Moreover, as previously noted in the September 2018 Board remand, such is further evidenced by the continued lack of discussion of 2001 records noting the Veteran's report of chest pain, including a December 2001 VA medical center (VAMC) treatment record that reflects that the Veteran was there to establish care for follow-up chest pain which started the day before. Furthermore, the examiner failed to address additional lay evidence of record submitted by the Veteran, including the article by Curtis M. Rimmerman with the Cleveland Clinic Center for Continuing Education regarding coronary artery disease, as also requested by the prior Board remand. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Hence, remand is warranted to obtain an adequate opinion. 2. Entitlement to individual unemployability prior to March 28, 2019, is remanded. Adjudication of the Veteran's claim of service connection for a heart disability will likely impact adjudication of her individual unemployability claim, these claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Forward the claims file to a cardiologist to determine the nature and etiology of the Veteran's heart disability. Based on an examination, review of the record, and any tests or studies deemed necessary, the examiner should provide opinions responding to the following: For each diagnosed disability, please opine as to whether it is at least as likely as not (a 50 percent probability or greater) that such disability is related to the Veteran's military service. In responding, consider and address as necessary the following: Service treatment records in September 1994 and July 1997 noting normal chest x-rays; A July 1997 emergency treatment record noting chest pain; August 1997 service treatment record follow-up; A December 2001 VAMC treatment record noting the Veteran was there to stablish care for follow-up chest pain, mostly on the left side, non-radiating which started the day before; A December 2001 private treatment record noting the Veteran's report of left sided chest pain and fluid in her heart three years prior. A diagnosis of possible musculoskeletal chest pain was given; A December 2008 private treatment record noting diagnoses of non-ST elevation myocardial infarction, atherosclerotic coronary artery disease, hyperlipidemia, and tobacco abuse; A May 2015 private treatment record noting diagnoses of old myocardial infarction, S/P PCS; tobacco abuse, hypercholesterolemia, and benign hypertension; and The article by Curtis M. Rimmerman with the Cleveland Clinic Center for Continuing Education regarding coronary artery disease. The examiner is also requested to comment on the Veteran's argument regarding the length of time necessary to develop CAD and the impact of hypercholesterolemia on coronary artery disease. If any current heart disability is deemed to be unrelated to service, the examiner should identify the cause considered more likely, and explain why that is so. (Continued on the next page) A detailed explanation (rationale) is requested for all opinions provided. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Alli, 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.