Citation Nr: 1237862 Decision Date: 11/05/12 Archive Date: 11/09/12 DOCKET NO. 04-34 411 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Peter J. Meadows, Attorney WITNESSES AT HEARING ON APPEAL Appellant and Witnesses ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran had active service from April 1969 to April 1971, with service in the Republic of Vietnam from October 1969 to October 1970. He also served in the Louisiana Army National Guard (LARNG) from November 1981 to November 1996. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in January 2009. A transcript is of record. This claim was remanded by the Board for additional development in August 2008, April 2009 and April 2011. FINDING OF FACT Resolving doubt in the Veteran's favor, hypertension is causally related to the service-connected diabetes mellitus and PTSD. CONCLUSION OF LAW Hypertension is proximately due to or the result of the service-connected diabetes mellitus and PTSD. 38 U.S.C.A. §§ 1110, 1154(a), 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2006, 2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS The grant of service connection for hypertension constitutes a full grant of the benefit sought. As such, no discussion of VA's duty to notify or assist is necessary. The Veteran seeks service connection for hypertension, to include as secondary to his service-connected diabetes mellitus and/or his service-connected PTSD. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The second and third elements may be established by showing continuity of symptomalogy. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In addition, a disability that is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310. Furthermore, the Court has held that the term "disability" as used in 38 U.S.C.A. §§ 1110, 1131 should refer to "any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended in order to implement the holding in Allen regarding secondary service connection on the basis of the aggravation of a nonservice-connected disorder by a service-connected disability. See 71 Fed. Reg. 52744 (2006). However, as this change is not liberalizing the Board will consider this appeal under the former criteria because the Veteran filed this claim in February 2004. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the Veteran served, the Veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303. Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The minimum compensable disability rating (of 10 percent) for hypertension requires diastolic pressure of predominantly 100 or more or systolic pressure of predominantly 160 or more; or if a claimant has a history of diastolic pressure of predominantly 100 or more and requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101 (2012). Hypertension is defined as diastolic blood pressure that is predominantly 90 millimeters (mm.) or greater, and isolated systolic hypertension is defined as systolic blood pressure that is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. To support a diagnosis of hypertension, the blood pressure readings must be taken two or more times on at least three different days. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); 38 C.F.R. § 4.104, DC 7101(Note 1) (2012). Service treatment records are negative for diagnosis or treatment of hypertension during active duty service. There also is no evidence of hypertension, manifested to a compensable degree, within one year of active duty service. A diagnosis and treatment of hypertension is not shown until 1995 during National Guard service. In March 2004, a VA nurse practitioner submitted a medical opinion on behalf of the Veteran. The nurse practitioner noted that the Veteran had been diagnosed with hypertension around 1992 and was subsequently diagnosed with diabetes mellitus. She opined that since the onset of diabetes often begins 10-15 years before it actually becomes apparent, she believed the diabetes likely influenced and worsened his hypertension. The Veteran was afforded a VA examination in September 2010 to determine the onset and etiology of his hypertension. After providing a diagnosis of hypertension, the examiner opined that it was at least as likely as not that the Veteran's hypertension was related to service. The rationale was that per the Veteran's statements, he was exposed to extremely stressful situations during Vietnam combat. Further, even though he did not yet have a formal diagnosis of PTSD, his service did and continues, to affect him emotionally. The examiner noted that those types of stressors have been medically shown to lead to hypertension. The examiner further opined that hypertension was neither caused nor aggravated by his service-connected diabetes mellitus. A well-explained clinical rationale was provided for the latter opinion as well. The Veteran was also afforded a VA examination in May 2011. The examiner diagnosed the Veteran with hypertension, but did not provide a nexus opinion. In a May 2012 addendum report, the examiner noted that the claims file was reviewed. She opined that it was less likely as not that the Veteran's hypertension had onset during active service and it was not likely that it was caused or aggravated by his service-connected diabetes mellitus. The examiner provided adequate clinical rationales for the opinion. In May 2012, the Veteran submitted an opinion from a private physician who had reviewed his medical records. This physician opined that, based on his review of the Veteran's records and his clinical interview, it is at least as likely as not that his currently diagnosed hypertension is related to his service-connected diabetes mellitus. His clinical rationale was that it is well known that having diabetes increases one's risk of developing hypertension because diabetes adversely affects the arteries, predisposing one to atherosclerosis. Based upon review of the evidence of record, and resolving all doubt in the Veteran's favor, the Board finds that service connection for hypertension is warranted. A current diagnosis of hypertension has been made by VA examiners and a similar diagnosis is noted in the VA treatment records. Thus, the only element of service connection that needs to be established is a nexus between the hypertension and service, or a service-connected disability. VA and private physicians have reached different conclusions regarding whether the current hypertension is related to the service-connected diabetes mellitus and/or the PTSD. However, each of these opinions is considered competent and probative as the physicians reviewed the evidence in the claims file, interviewed the Veteran, performed clinical examinations, and supported their opinions with adequate clinical rationales. A medical opinion that is a factually accurate, fully articulated, and based on sound reasoning carries significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board finds therefore that there is sufficient evidence to place the question of causal nexus at least in equipoise. The Board also notes that VA has recently recognized that PTSD may promote poor health through a complex interaction between biological and psychological mechanisms, and that the experience of trauma brings about neurochemical changes in the brain that may create a vulnerability to hypertension and atherosclerotic heart disease. On the basis of these findings and following a full review of the record, reasonable doubt is resolved in the Veteran's favor. Service connection for hypertension is granted. ORDER Service connection for hypertension is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs