Citation Nr: 1541030 Decision Date: 09/24/15 Archive Date: 10/02/15 DOCKET NO. 13-05 305 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for peripheral vascular disease of the bilateral lower extremities, to include as secondary to service-connected PTSD. 3. Entitlement to service connection for bilateral carotid artery disease, to include as secondary to service-connected PTSD. REPRESENTATION Appellant represented by: James Thompson, Attorney WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran had active service from April 1969 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from two rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In July 2010, the RO denied service connection for peripheral vascular disease of the bilateral lower extremities and hypertension. In November 2010, the RO denied service connection for bilateral carotid artery disease. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing in July 2015. A copy of the hearing transcript is of record. During the aforementioned hearing, the Veteran submitted additional evidence in support of his claim, along with an appropriate waiver of RO consideration. Therefore, the appeal may proceed. See 38 C.F.R. § 20.1304(c) (2015) (any pertinent evidence accepted directly at the Board must be referred to the agency of original jurisdiction (AOJ) for initial review unless this procedural right is waived by the appellant). FINDINGS OF FACT 1. Hypertension is etiologically related to service-connected PTSD. 2. Peripheral vascular disease of the bilateral lower extremities is etiologically related to service-connected PTSD. 3. Bilateral carotid artery disease is etiologically related to service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). 2. The criteria for service connection for peripheral vascular disease of the bilateral lower extremities have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). 3. The criteria for service connection for bilateral carotid artery disease have been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) outlines procedural assistance VA must provide claimants in certain cases. If the VCAA is applicable, the Board must ensure that the required notice and assistance provisions of the law have been properly applied. In this case, however, the Board is granting in full the benefit sought on appeal. Therefore, the Board need not discuss whether there has been compliance with the VCAA because any noncompliance ultimately amounted to no more than harmless error. 38 C.F.R. § 20.1102 (2015). See also Shinseki v. Sanders, 129 S. Ct. 1696 (2009). II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a) (2015). Service connection is also warranted for a disability which is proximately due to, aggravated by, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2015). A finding of secondary service connection requires competent medical evidence to connect the asserted secondary disability to the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 10 Vet. App. 432 (1997). Here, VA treatment records dated October 2010 reflect diagnoses of hypertension, peripheral vascular disease of the bilateral lower extremities, and bilateral carotid artery disease, and therefore a current disability has been established for each of the claimed conditions. The Veteran is also presently service-connected for PTSD, rated as 50 percent disabling. With respect to the issue of secondary service connection, the pertinent issue is whether there is competent medical evidence that the claimed disabilities are caused or aggravated by PTSD. In support of his claims, the Veteran submitted a private medical opinion from Dr. K.C.S., dated September 2010. She stated that she obtained a history from the Veteran, and reviewed his service treatment records, VA treatment records and previous VA examinations, and his private treatment records. She related all three of his claimed conditions (hypertension, peripheral vascular disease, and carotid artery disease) to his PTSD through two mechanisms. First, she noted that the July 2010 rating decision, citing the Veteran's private treatment records, attributed his hypertension and peripheral vascular disease to his unhealthy lifestyle, which included a history of abusing tobacco, alcohol, and other drugs. Citing to medical literature, she noted that persons with PTSD had higher incidence of smoking, alcohol use, and drug abuse, based on the hypothesis that they are self-medicating to reduce their PTSD symptoms. Second, she cited to additional medical literature which supported the conclusion that the development of hypertension and vascular disease was correlated to PTSD independent of other variables such as drug use and depression. This effect was due to the increased level of sympathetic discharge of the nervous system, which leads to recurrent episodes of hypertension and damages the endothelium of the arteries. Over time, this process leads to the development of atherosclerosis, which leads to hypertension and peripheral vascular disease. In a March 2012 opinion, a VA examiner, Dr. G.A.S., stated that peripheral vascular disease and hypertension were diagnosed many years after service and before the diagnosis of PTSD. He also stated that PTSD was not listed as a risk factor for cardiovascular disease in the medical literature. He echoed this statement in a June 2012 opinion. A separate opinion from Dr. K.D. also noted that he could not find any medical basis for Dr. K.C.S.'s contentions in the medical literature. While he acknowledged that her statements were logical, he stated that there was no medical support for them. In a July 2015 opinion, Dr. K.C.S. reiterated her previous conclusions, including that hyperarousal symptoms can result in activation of the sympathetic nervous system, triggering the release of norepinephrine in the brain and peripherally. The person can experience ongoing stress, which can result in hypertension, heart attacks, peripheral vascular disease, and other illness. This correlation between these conditions and PTSD is present even after the effects of smoking have been controlled. She again cited to specific medical treatises to support her statements. According to the U.S. Court of Appeals for Veterans Claims (Court), "the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches." Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The credibility and weight to be attached to these opinions is within the province of the Board. Id. In this case, the private opinions of Dr. K.C.S. are generally consistent with the evidence, and she accurately cited to medical literature to support her conclusions. In contrast, the VA opinions stated that there is no medical literature to support Dr. K.C.S.'s statements or the overall link between PTSD and cardiovascular disease. It is clear from a review of the record that such literature exists. Based on the statements of the VA examiners, it appears they reviewed the September 2010 private opinion but not the accompanying medical treatises cited in that opinion. For this reason, the Board finds these VA opinions to be less probative than the September 2010 and July 2015 private opinions in assessing the etiology of the Veteran's claimed disabilities. As a result, an etiological link between these disabilities and PTSD has been established, and service connection is warranted. The Board notes that Dr. K.C.S. indicated two mechanisms by which PTSD caused the Veteran's hypertension, peripheral vascular disease, and carotid artery disease. She stated that the increased level of sympathetic discharge of the nervous system associated with PTSD leads to recurrent episodes of hypertension and damages the endothelium of the arteries. She also stated that persons with PTSD had higher incidence of smoking, alcohol use, and drug abuse, which in turn can cause the claimed disabilities. Notably, service connection is generally not permitted when it is based on the effects of tobacco, alcohol, or drug abuse. See 38 C.F.R. §§ 3.300, 3.301. However, VA's General Counsel has held that such regulations do not bar a finding of secondary service connection for a disability related to a veteran's use of such products after service, where that disability is proximately due to a service-connected disability that is not service-connected on the basis of being attributable to the use of such products. See generally VAOPGCPREC 6-2003 (October 28, 2003). In this case, while the Board accepts both of the theories proffered by the private opinion, it also notes that the September 2010 opinion establishes that the Veteran's tobacco, alcohol, and drug use were the result of his service-connected PTSD, and therefore the effects of such use are not barred from service connection. ORDER Service connection for hypertension is granted. Service connection for peripheral vascular disease of the bilateral lower extremities is granted. Service connection for bilateral carotid artery disease is granted. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs