Citation Nr: 22016557 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 07-34 383 DATE: March 22, 2022 ORDER Entitlement to service connection for old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder is granted. REMANDED Entitlement to a rating in excess of 10 percent for premature ventricular contractions (PVCs), old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran's diagnosed heart conditions of old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder are causally related to his active service. CONCLUSION OF LAW The criteria for service connection for old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty with the United States Air Force from December 1970 to December 1992. This matter is before the Board of Veterans' Appeals (Board) on appeal of June 2007 and July 2009 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified about these claims at hearings held in March 2010 and in December 2020. As explained in the Board's July 2021 decision, these claims are addressed by a panel composed of three Veterans Law Judges (VLJs) in accordance with Arneson v. Shinseki, 24 Vet. App. 379 (2011). The claims were previously remanded for additional development as directed in Board decisions of August 2010, April 2016, June 2018, and July 2021. As detailed below, service connection is now established for additional cardiac disabilities. Accordingly, the claim for a rating in excess of 10 percent for PVCs is now listed as a claim for an increased rating for all service-connected heart disabilities. In October 2021, a VA examiner noted the Veteran's heart condition impacted his ability to work. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is raised by the record as an element of the claim seeking an increased rating for PVCs. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue is listed above and addressed below. Entitlement to service connection for old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The evidence must show (1) the existence of a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005). "[I]f the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise), the claimant receives the benefit of the doubt." Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). A March 1994 rating decision established service connection for premature ventricular contractions (PVCs). Here, the Veteran seeks service connection for additional cardiac conditions. An August 2021 VA heart conditions examination confirmed current additional diagnoses of old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder. The Veteran's service treatment records document in-service heart rhythm irregularities and a diagnosis of PVCs. These records also show additional cardiac symptoms were present during the Veteran's active service. The treatment records include August 1972 reports of chest pain with nausea and dizziness, March 1983 reports of left chest pain, lightheadedness, and nausea, October 1991 reports of radiating chest pain with deep breaths and coughing, an October 1991 chest x-ray documenting cardiac transverse diameter at upper limit of normal and small soft tissue density possibly indicating scar tissue, an April 1992 comparison chest x ray documenting the previously seen density "is more retracted and smaller. (Scarred)," and a June 1992 chest x ray (provided to rule out pneumonia) confirming heart within normal limits. In September 1992, the Veteran completed a medical history associated with his separation examination and reported pain and pressure in chest and his diagnosis with PVCs. A September 1992 chest x-ray report showed Veteran's heart was within normal limits at retirement. The separation examiner noted normal heart function, but he also observed EKG (electrocardiogram) testing was not completed prior to the Veteran's retirement. In August 2016, a VA examiner addressed the issue of direct service connection and opined the Veteran's current heart condition was not causally related to his active service because evidence did not indicate the presence of CAD (coronary artery disease) during or in close proximity to active service and there was no evidence that a chronic cardiac condition was caused by in-service PVCs. This examiner did not discuss the in-service cardiac symptoms. In June 2018, the Board found the opinion was insufficient to evaluate the claim because it was not supported by a complete rationale. This opinion is entitled to little weight. See Washington, supra. In June 2019, an additional VA etiology opinion was obtained. The examiner provided a positive etiology opinion. In support, he observed the Veteran's diagnosed ischemic heart disease and myocardial infarction were presumptively linked to herbicide exposure in Vietnam. However, the Veteran did not serve in Vietnam or in any other location where exposure to herbicide agents is presumed by VA. In July 2021, the Board found this opinion was inadequate because it was not based on an accurate medical history. It is entitled to no weight. Id. Following the August 2021 examination, an VA etiology opinion evaluating direct service connection was obtained in October 2021. The examiner opined the current heart conditions (other than PVCs) were less likely than not caused by the Veteran's active service because his exposure to herbicide agents was not presumed. The examiner did not discuss the Veteran's in-service cardiac symptoms. The opinion did not fully address the issue of direct service connection and it is entitled to no weight. Id. Another VA examiner provided an October 2021 addendum opinion. He opined the August 2021 diagnosed cardiac conditions were at least as likely as not due to the Veteran's active service. Unfortunately, he supported his opinion by incorrectly stating the Veteran had been exposed to herbicide agents while serving in Vietnam. This opinion is based on a factual error and it is entitled to no weight. Id. Later in October 2021, the examiner provided another addendum opinion. He opined that the old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder were causally linked to the Veteran's active service. In support, he noted the Veteran's history of in-service recurrent chest pain, heart fluttering, and palpitations indicated a heart condition. He explained that the current cardiac diagnoses were likely a progression of a heart condition incurred during active service. This opinion is supported by a complete rationale and it is based on an accurate medical history as documented in the service treatment records. It is entitled to great weight. See Washington, supra. Here, the evidence supports a finding that the Veteran's heart disabilities, in addition to PVCs, are causally related to cardiac symptoms documented during his active service. Entitlement to service connection for old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder is warranted. See Shedden, supra. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for a heart disability, diagnosed as premature ventricular contractions (PVCs), old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder is remanded. In January 2007, the Veteran filed a claim seeking an increased rating for his service-connected heart disability (PVCs) and reported recent treatment for heart problems. As discussed above, service connection is now established for additional conditions of old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder. In August 2021, a VA heart conditions examination was provided to evaluate the severity of the Veteran's service-connected heart condition. At that time service connection was established for only one heart condition, PVCs. The examiner diagnosed additional conditions of old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder. In October 2021, she opined these additional heart conditions were less likely than not caused by the Veteran's active service or secondary to his PVC disability. It is not clear whether the examiner considered the additionally diagnosed (and now service connected) heart disabilities in evaluating the severity of the Veteran's heart conditions. Thus, the examination is inadequate to evaluate the claim. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded The issue of entitlement to TDIU is intertwined with the remanded claim for an increased rating for heart disabilities. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected heart disabilities (premature ventricular contractions (PVCs), old myocardial infarction, atherosclerotic cardiovascular disease, coronary artery disease, valvular heart disease, and implanted cardiac loop recorder). The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. The examiner should fully explain the level of impairment (including ejection fraction or metabolic equivalents) which are attributed to the service-connected heart disabilities rather than to any other non-service-connected disability. If the level of impairment due to the service-connected conditions cannot be distinguished from the impairment due to non-service-connected conditions, the examiner must so state. M. HYLAND Veterans Law Judge Board of Veterans' Appeals K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.