Citation Nr: 0922768 Decision Date: 06/17/09 Archive Date: 06/23/09 DOCKET NO. 06-10 888A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities of the knees. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Maureen A. Young, Counsel INTRODUCTION The Veteran had active military duty from August 1979 to April 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran originally sought service connection for hypertension. Subsequent to the denial of that claim and in his April 2006 substantive appeal he raised a claim for service connection for hypertension as secondary to his service-connected bilateral knees disabilities. In October 2006, the Veteran testified before a Decision Review Officer at the RO and in July 2008 a video conference hearing was held before the undersigned Veterans Law Judge. Copies of the hearing transcripts are associated with the claims folder and have been reviewed. This appeal is remanded to the RO via the Appeals Management Center in Washington, DC. VA will notify you if further action is required on your part. REMAND The Veteran claims that his hypertension is related to service or medication taken for his service-connected bilateral knee disability. The Veteran's service treatment records for his periods of active duty service are negative with respect to a diagnosis of hypertension. Most of his blood pressure readings were within normal limits, though he had blood pressure readings of 128/92 in May 1985 and 130/90 in March 1990. At his retirement examination in November 1999 no vascular disorder was shown; his blood pressure reading was 120/71 and he noted on his report of medical history at that time that he had not had high or low blood pressure. The first documented clinical diagnosis of hypertension appears in a May 2004 VA clinical follow-up appointment for degenerative joint disease, gastroesophageal reflux disease and allergic rhinitis. The Veteran testified at his personal hearing in October 2006 that while on active duty he was first put on a regimen of Motrin, 800 milligrams three times a day and he did that for several years. He stated that in 1998 he was prescribed Celebrex. He stated that he was on Celebrex until 2000. Service treatment records show that the Veteran was prescribed Motrin various times for complaints of chest pain, knees and low back pain. In a medical report in August 1999 it was noted that he had been on Motrin for five years and it had started to aggravate his stomach. It was further noted that he was prescribed Zantac secondary to chronic NSAID. A September 1999 clinical report indicated that Celebrex was approved. An October 1999 outpatient report showed Celebrex 100 milligrams twice daily was prescribed. VA outpatient treatment reports dated intermittently from September 2000 to April 2005 show that the Veteran's active outpatient medications have included Celecoxib 100 milligrams, twice daily and Etodolac 400 milligrams twice daily. In an April 2002 outpatient treatment report it was noted that "[patient] will continue the Celebrex through outside pharmacy." In November 2006 the Veteran submitted two medical opinions, both dated in October 2006, in support of his contention that he has hypertension secondary to taking NSAID prescribed for his service-connected bilateral knees disability. The written opinion of a VA physician's assistant (this physician's assistant provided the Veteran's initial diagnosis of hypertension) was as follows: Evidence has suggested that there may be a connection between the COX 2 inhibitors and hypertension and coronary artery disease. It is possible that his [the Veteran] prolonged treatment with Celecoxib may have contributed to his existing hypertension. In the written opinion of the Veteran's private physician, JSM, M.D., he noted the Veteran's history of being prescribed and taking NSAIDs he stated that the Motrin, Celebrex and Etodolac used to treat the Veteran's bilateral knee condition are considered NSAIDs. He stated as follows: "I can't say with certainty these medications are the total cause of his current condition of High Blood Pressure; but it's more likely than not a reason for it." The Veteran submitted an Internet excerpt related to Etodolac to show that Etodolac is considered an NSAID. And, that the Food and Drug Administration announced that they had asked manufacturers of all prescription NSAIDs to revise the drug labeling to include a warning about the potential for increased risk of cardiovascular events associated with their use. Another Internet article submitted by the Veteran discussed NSAIDs, antihypertensive agents and loss of blood pressure control. The author pointed out that NSAIDs have been reported to diminish the blood pressure-lowering effects of many antihypertensive agents. In May 2007 a VA physician after examining the Veteran and reviewing the claims folder indicated that in his medical opinion the Veteran's mild hypertension is less likely as not caused by medication prescribed for orthopedic complaints. The rationale was that the Veteran needs to be old and have compromised kidney function such as interstitial nephritis from medication to be effected. There was no indication whether hypertension had its onset in service or whether medication prescribed for service-connected disability aggravated the hypertension. Accordingly, the case is REMANDED for the following action: 1. The claims folder should be returned to the May 2007 VA examiner to ascertain the etiology of the Veteran's hypertension. The examiner is requested to provide an opinion as to whether there is a 50 percent probability or greater that hypertension had its clinical onset in service or is otherwise related to active duty. Any opinion should be reconciled with service treatment records, including the blood pressure readings of 128/92 in May 1985, 130/90 in March 1990, and 120/71 on the retirement examination in November 1999. If not, the examiner should comment as to whether medication taken for service- connected bilateral knee disability, including NSAIDs, resulted in a permanent increase in hypertension pathology, and if so, what measurable degree of hypertension pathology is due to the service-connected disability. The opinion should be reconciled with the October 2006 opinions and medical treatise cited herein. The examiner should provide a comprehensive report, and provide a complete rationale for any conclusions reached. 2. Upon completion of the above- requested development, the RO/AMC should readjudicate the Veteran's claim of service connection for hypertension. All applicable laws and regulations should be considered. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2008). ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2008).