Citation Nr: 1302034 Decision Date: 01/18/13 Archive Date: 01/23/13 DOCKET NO. 08-30 009 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities. REPRESENTATION Veteran represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD C. Fields, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to August 1971, including in the Republic of Vietnam. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. No hearing was requested. The Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The paperless file includes VA treatment records dated through August 2012 (after the last adjudication) that are not in the paper claims file. As the Board's decision herein to grant service connection constitutes a full grant of the benefit sought on appeal, there is no need to refer these records for review by the agency of original jurisdiction. See 38 C.F.R. §§ 20.800, 20.1304(c) (2012). FINDING OF FACT The Veteran's current hypertension was proximately caused by his service-connected diabetes. CONCLUSION OF LAW The criteria for service connection for hypertension, as secondary to service-connected disability, have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board's decision herein to grant service connection for hypertension, as secondary to service-connected disability, constitutes a full grant of the benefit sought on appeal. Therefore, no further action is necessary to comply with the Veterans Claims Assistance Act of 2000 and implementing regulations. The Veteran contends that his currently diagnosed hypertension was either caused or aggravated by his service-connected disabilities, to include diabetes mellitus Type II (diabetes), coronary artery disease, and posttraumatic stress disorder (PTSD). As such, he seeks service connection on a secondary basis. There is no argument or indication that the Veteran's hypertension is directly related to his military service, to include on a presumptive basis as a chronic condition. Rather, the Veteran's hypertension was first diagnosed and treated many years after his separation from service in August 1971. See 38 C.F.R. § 3.303 (allowing for direct service connection for disease or injury that was incurred or aggravated by service); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (providing for presumptive service connection for chronic disability where hypertension manifests to a compensable degree within one year after active duty service). The Board notes that the Veteran has submitted an internet article referring to hypertension as related to Agent Orange exposure during service in Vietnam; however, this is not a condition that has been found to be presumptively related to such exposure. See 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (providing for presumptive service connection for certain listed conditions for Vietnam veterans). Further, there is no competent medical evidence linking the Veteran's hypertension to Agent Orange exposure. As such, service connection is not warranted on this basis. Service connection may be granted on a secondary basis for disability that is proximately due to or the result of a service-connected disease or injury. The evidence must show: (1) that a current disability exists, and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (worsened in severity beyond its natural progress) by a service-connected disability. Secondary service connection based on aggravation of a nonservice-connected condition is warranted for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). The Veteran's claim was received on October 27, 2006. For claims filed after October 10, 2006, service connection may not be awarded based on aggravation of a nonservice-connected disability unless a pre-aggravation baseline level of disability has been established to allow a comparison to the current level of disability. 38 C.F.R. § 3.310(b) (2012). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). The Veteran is currently service-connected for diabetes and associated complications of peripheral neuropathy of the upper and lower extremities, erectile dysfunction, urinary stress incontinence, and bilateral cataracts. He is also service-connected for coronary artery disease status post quintuple bypass surgery with scars, as well as for PTSD with anxiety disorder and depression disorder. The Veteran has been afforded several VA examinations concerning diabetes, coronary artery disease, and mental health disability, as well as the etiology of his hypertension. The examiners have consistently diagnosed essential hypertension. There is no medical opinion of record specifically addressing any relationship between the Veteran's coronary artery disease and hypertension, with consideration of all available evidence. A December 2011 records review and opinion report indicates that there was no causal link between his PTSD and hypertension, although there may have been an "aggravation link." The examiner explained that patients with PTSD appeared to have a higher incident of hypertension, but there was no evidence that hypertension was actually caused by PTSD. The examiner also noted that the Veteran's blood pressure readings submitted for review were within normal limits with treatment with atenolol. This examiner further stated that, if blood pressure readings over time showed episodic elevations during periods of stress, depression, or anxiety, then these could be aggravation of hypertension attributed to PTSD. This would be based on a physiologic relationship with increased catecholamine release leading to episodic vasoconstriction. The December 2011 examiner emphasized that there was a gap in the records between 2001 and 2008; however, such records were in the claims file (including blood pressure readings). Therefore, this examiner did not have all pertinent, available records, and this evidence is insufficient to adjudicate the Veteran's claim. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (an adequate opinion must be based on consideration of an appellant's prior medical history and examinations). As summarized below, there are several medical opinions of record concerning whether the Veteran's hypertension was proximately caused or aggravated by diabetes. A February 2007 VA examiner opined that the Veteran's hypertension was less than likely caused by diabetes because the hypertension diagnosis preceded the diagnosis of diabetes mellitus and there was no clinical evidence of renal complication. Similarly, a March 2008 VA examiner stated that there was no renal involvement with the Veteran's diabetes mellitus, and that he had been treated for high blood pressure for six years, which was prior to the onset of diabetes. In a November 2011 VA examination report concerning coronary artery disease, the examiner noted an established diagnosis of coronary artery disease status post bypass surgery, and presenting conditions of "hypertension, secondary to diabetes mellitus" and PTSD. The examiner then noted that hypertension was diagnosed in 2001 and was being treated at the time of the examination with hydrochlorothiazide and atenolol, and that the Veteran denied a history of renal failure. The final diagnoses were coronary artery disease status post bypass surgery, essential hypertension, and chronic congestive heart failure. No opinion was provided. In a December 2011 records review and opinion report that primarily concerned PTSD, the examiner noted that the Veteran's underlying renal function was normal, so an underlying renal vascular cause of hypertension appeared less likely. Although the examiner stated that he was not provided with records dated from 2001 through 2008, and such records were associated with the claims file, those records also contain no reports of abnormal renal function. The March 2008 examiner opined that diabetes "may" aggravate high blood pressure over time because hyperglycemia over time causes microvascular injury that elevates blood pressure. Similarly, in a July 2008 report, another VA examiner first opined that the Veteran's essential hypertension "is aggravated" by his diabetes. This examiner reasoned that diabetes, coronary artery disease, and hypertension had been existing together over time, and the Veteran's blood sugar was suboptimal but was not treated until 2007. She stated that this may have aggravated the Veteran's vascular condition because of metabolic syndrome. Nevertheless, the July 2008 VA examiner went on to say that the Veteran's hypertension developed due to compromised vascular system. The examiner stated that the Veteran's diabetes "took place" in 1999 and was discovered via elevated blood glucose levels. The Veteran was then diagnosed with coronary artery disease in 2001, at which point he had a five-vessel bypass graft and was started on atenolol. His diabetes was diet controlled at that time. The Veteran was later noted to have been diagnosed with hypertension in 2001. The examiner stated that the Veteran's hypertension may be due to suboptimal care for his diabetes, in that his blood sugars were in the 120s and he was not started on treatment for diabetes until 2007, which may have caused vascular compromise due to metabolic syndrome. The July 2008 VA examiner further stated, in other words, that the Veteran's diabetes had been longstanding for at least six years prior to receiving proper treatment. The examiner noted that the Veteran believed that he may have started to have glucose intolerance in 1999, although medical records did not support this timeframe. The examiner explained that, although the Veteran's diabetes was monitored, his blood sugars averaged in the 120s and no glucose tolerance test was ever performed, so it cannot be determined if the diabetes was truly diet controlled. The examiner again stated that there is concern for vascular compromise with longstanding diabetes because of metabolic syndrome. She opined that this is "quite obvious" in the Veteran's case, given that he was diagnosed with coronary artery disease that required a five-vessel bypass graft in 2001. She reasoned that this showed that the Veteran's vascular system had been compromised and that he had developed hypertension that was being controlled by atenolol. Similarly, when questioned as to whether the Veteran's hypertension was aggravated beyond its normal progression by his diabetes, the examiner responded that the hypertension may have been normal sequelae to the existence of diabetes because the diabetes was not treated with medication for several years. The Veteran has also submitted a July 2007 internet article from the Harvard Medical School stating that people with diabetes are more likely than other people to develop high blood pressure. A medical article or treatise "can provide important support when combined with an opinion of a medical professional" if it discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts. Mattern v. West, 12 Vet. App. 222, 228 (1999). This article is consistent with other evidence of record, and particularly the September 2008 examiner's opinion and explanation concerning the Veteran's development of hypertension due to diabetes. There is conflicting evidence as to when the Veteran's hypertension and diabetes were first documented or diagnosed. As summarized above, the negative causation opinions were based, in part, on a finding that the Veteran's hypertension existed prior to his diabetes. In contrast, the September 2008 VA examiner indicated that the Veteran's diabetes existed prior to the hypertension. This opinion was based on reports of elevated blood sugar levels as early as 1999 with no definitive evidence as to whether the condition was diet controlled, as well as evidence of vascular compromise based on the diagnosis of coronary artery disease and the need for bypass surgery in 2001. This opinion reflects consideration of the Veteran's reports of running periodic blood sugar tests on himself and noticing elevated blood sugars in 1999, although he did not keep records, and that he adjusted his diet to maintain the blood sugar levels for years. The Veteran has medical expertise, as he was a surgeon in the military and has reported practicing as a family physician. See, e.g., September 2009 VA Form 646 from representative; DD Form 214. Considering all evidence of record, the Board finds that the evidence is in relative equipoise as to whether the Veteran's hypertension was caused by his service-connected diabetes. Therefore, the benefit of the doubt doctrine applies, and all reasonable doubt in this regard will be resolved in his favor. As a result, the evidence establishes that hypertension was caused by diabetes, and service connection is warranted on a secondary basis. 38 C.F.R. §§ 3.102, 3.303(a). ORDER Service connection for hypertension is granted. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs