Citation Nr: 1306266 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 05-29 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to June 1969, with additional service in the Army National Guard from October 1973 to July 2002. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), in Columbia, South Carolina. The Board remanded the case for additional development in February 2008, March 2010, and September 2011. Unfortunately, in the course of the RO's processing of the remand request, the Veteran's claims file was lost. Returned to the Board is what is characterized as a "rebuilt" file, containing a copy of the February 2006 rating decision, copies of the Veteran's personnel and service treatment records, some VA treatment records from 2009 and 2012, the Board's September 2011 remand, and VA examination reports dated in 2009 and 2012. The "rebuilt" file also includes a copy of the June 2011 and December 2012 Supplemental Statements of the Case (SSOC), and the January 2012 Post-Remand Brief from Disabled American Veterans (DAV). This record is adequate to properly address the merits of the appeal. FINDINGS OF FACT Resolving all doubt in the Veteran's favor, hypertension is aggravated by his service-connected PTSD. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for establishing service connection for hypertension, as secondary to (aggravated by) service-connected PTSD have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Because the Veteran has been awarded a full and complete grant of the benefit sought on appeal, the Board finds that no further development is needed under the VCAA. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). Service Connection - Applicable Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (2012). Service connection may also be granted for a disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Further, effective October 10, 2006, 38 C.F.R. § 3.310 was amended to codify the Court's holding in Allen, which relates to secondary service connection on the basis of aggravation of a nonservice-connected disorder by a service-connected disability. See 38 C.F.R. § 3.310(b). The amendment essentially requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. Here, however, as the Veteran's claim was filed prior to October 2006, the amended regulation does not apply to this case. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such 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, 53-56 (1990). The Board notes that it is well-established that in cases such as this where records in the custody of VA have been lost, VA has a "heightened" duty to assist in the development of the claim. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005). Facts and Analysis The Veteran contends that his service-connected PTSD and related symptoms of anxiety and insomnia aggravate his non-service connected hypertension. Notably, the available evidence does not show, and the Veteran does not contend, that the hypertension originated in service or until many years thereafter. As such, the below analysis focuses solely on whether service connection for hypertension is warranted on a secondary/aggravation basis. As an initial matter, the medical evidence of record confirms a current hypertension diagnosis/disability. See, e.g., February 2012 DBQ Examination Report; see also December 2009 VA Treatment Record. As such, the current disability requirement has been met in this case. See Wallin, supra. With respect to evidence of a service-connected disability, the Veteran is currently service connected for PTSD (rated as 100 percent disabling), among other disabilities (e.g., venous insufficiency, left and right leg; headaches; scars; residuals of shell fragment wounds to the neck and left leg; and prostate carcinoma). Thus, Wallin element (2) is established here. The Board now turns to its final inquiry, namely, whether there is medical evidence of a nexus (or a showing of aggravation) between the Veteran's service-connected PTSD and his non-service connected hypertension. There are conflicting medical opinions of record on this point. As noted in the Board's prior remand, in September 2005 and April 2006 the Veteran's private treating physician stated that the Veteran suffered from hypertension, which was always exacerbated by the stress and anxieties in his life. See September 2011 BVA Remand, p. 6. The physician reported that the Veteran's PTSD was certainly exacerbating his bouts of stress and anxiety, and that this made his high blood pressure a more complex problem. The private physician opined that the Veteran's hypertension was exacerbated by his PTSD. Upon VA examination in January 2006, the examiner opined that the Veteran's essential hypertension was not likely secondary to his service-connected PTSD because of the pathophysiology behind essential hypertension. The examiner also found that exacerbations of PTSD could cause transient and short-lived lability in blood pressure, but did not contribute to any worsening of the overall hypertension. He also noted that there was no objective medical literature suggesting that PTSD could cause or permanently aggravate hypertension. See September 2011 BVA Remand, p. 6. Upon VA examination in July 2009, the examiner reported that there was no direct link between PTSD and hypertension in the medical literature. He also noted that there were no definite elevated blood pressure readings during the Veteran's period of active duty. Based on these findings, the examiner opined that that the Veteran's current hypertension was less likely than not related to his period of active duty or PTSD. Because the July 2009 VA examiner failed to reconcile the conflicting findings related to aggravation, and did not otherwise discuss aggravation, the Board remanded the claim for an additional medical opinion in September 2011. That medical opinion (along with a July 2012 addendum opinion) was obtained in February 2012. In that regard, the February 2012 VA/DBQ examiner opined the Veteran's hypertension was less likely than not incurred in, or caused by "the claimed in-service injury, event, or illness" (i.e., PTSD). The VA examiner's sole rationale was that there was "no direct relationship within the medical literature between PTSD and HTN [hypertension]." The RO requested an addendum opinion to address the issue of aggravation, and in July 2012, a different VA examiner opined that it was less likely than not that the hypertension was aggravated by the service-connected PTSD. The only rationale provided by the examiner was that the Veteran was noted to have "high-normal" blood pressure readings normally, and elevated readings prior to or after procedures. Thus, the examiner stated that he did not "feel that his hypertension is aggravated by his service-connected PTSD." In addition to the above private and VA medical opinions, the Veteran's representative has directed the Board to several journal articles which relate PTSD to increased stress hormone release and, in turn, to inflammation of the arteries and damage to the cardiovascular system. See PTSD causes Early Heart Disease Death, O & P Business News 17 (16), 48; Dr. Joseph Boscarino, PhD. The other cited medical journal article discusses a link between PTSD, chronic sleep impairment, and the development of hypertension. See Sleep Deprivation: Cognitive Function and Health Consequences, IDEA Fitness Journal, 9 (2), 18-21 (February 2012). In sum, the Board is left with the positive, private September 2005 and April 2006 opinions, finding that the Veteran's hypertension was exacerbated (or aggravated) by his PTSD; the negative January 2006 VA opinion, which found that there was no permanent aggravation of the hypertension due to PTSD; the July 2009 and February 2012 VA opinions, which failed to discuss aggravation entirely (and/or reconcile the private examiner's findings and the January 2006 opinion); and the July 2012 VA addendum opinion, which found that there was no aggravation of hypertension, but provided little, if any, rationale. On review and under the circumstances of this case, the Board finds that the factual evidence of record leaves in relative equipoise the question the response to the question of whether the Veteran's PTSD aggravated his hypertension. Indeed, as neither the July 2009 nor February 2012 VA opinions discussed aggravation, and as the February 2012 VA opinion was unsupported by rationale, the Board is left with the more probative private opinions supporting a theory of aggravation, and the also probative January 2006 VA opinion finding against a theory of aggravation. Resolving reasonable doubt in his favor, as is required (see 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102), the Board concludes that the evidence supports the Veteran's claim and that secondary service connection for hypertension (on the basis that it was aggravated by PTSD) is warranted. ORDER Service connection for hypertension is granted. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs