Citation Nr: 1306347	
Decision Date: 02/25/13    Archive Date: 03/01/13

DOCKET NO.  10-43 089	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUE

Entitlement to service connection for hypertension.


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the United States


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

K. K. Buckley, Counsel


INTRODUCTION

The Veteran served on active duty from August 1965 to August 1967.  Service in the Republic of Vietnam is indicated by the record.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida.

In January 2012, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge.  A transcript of the hearing has been associated with the Veteran's claims file.


FINDING OF FACT

Resolving reasonable doubt in favor of the Veteran, he has hypertension that is likely caused by his service-connected diabetes mellitus.


CONCLUSION OF LAW

The Veteran's hypertension is proximately due to his service-connected diabetes mellitus.  38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2012).


REASONS AND BASES FOR FINDING AND CONCLUSION

Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service.  38 U.S.C.A. § 1110.  That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease.  If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity.  38 C.F.R. § 3.303(b).  Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service.  38 C.F.R. § 3.303(d).

Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Certain chronic diseases (e.g., cardiovascular-renal disease, including hypertension) may be presumed to have been incurred in or aggravated by service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service.  38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012).

Additionally, service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability.  See 38 C.F.R. § 3.310(a) (2012); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993).  Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a).  Allen v. Brown, 7 Vet. App. 439, 448 (1995).

In order to establish service connection for a claimed disability on a secondary basis, there must be (1) competent and credible evidence of a current disability; (2) a service-connected disability; and (3) competent and credible evidence of a nexus between the service-connected disease or injury and the current disability.  See Wallin v. West, 1 Vet. App. 509, 512 (1998).

In arriving at a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant.  Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.  The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied.  Gilbert, 1 Vet. App. at 54.

In this case, the Veteran has asserted that he has hypertension that is due to his service-connected diabetes mellitus.  See the November 2008 claim.  It is undisputed that he is currently service-connected for diabetes mellitus, type II.  See the rating decision dated September 2001.

As will be detailed below, the Board concludes that the Veteran is entitled to service connection for hypertension as secondary to his service-connected diabetes.  The Veteran has not asserted entitlement to service connection for hypertension on a direct basis and, as the Board is granting the Veteran's claim on a secondary basis, the issue of direct service connection will not be discussed further.

The Board notes that the term hypertension refers to persistently high arterial blood pressure.  Medical authorities have suggested various thresholds ranging from 140 mm. Hg systolic and from 90 mm. Hg diastolic.  See Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007).  Similarly, for VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater.  The term isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm.  See 38 C.F.R. § 4.104, Code 7101, Note 1 (2012).

A review of the record demonstrates that the Veteran was diagnosed with diabetes mellitus, type II, in May 2000.  See the private treatment records dated May 2000.  VA treatment records documented a continuing diagnosis of "elevated blood pressure readings without a diagnosis of hypertension" as early as October 2005.  It was repeatedly noted that the Veteran's home blood pressure readings were normal; in fact, a March 2006 VA treatment record indicated that the Veteran's treatment provider suspected he had "white coat hypertension."  A continuing diagnosis of hypertension was documented beginning in August 2008.  See the VA treatment records dated August 2008.

The Veteran was afforded a VA examination in April 2009 as to the claimed hypertension.  The examiner confirmed a diagnosis of hypertension and, as to the question of medical nexus, concluded "it is less likely as not (less than 50/50 probability)" that the Veteran's hypertension is caused by or the result of his diabetes mellitus.  The examiner explained that "hypertension and type II diabetes mellitus frequently coexist probably due to underlying risk factors they have in common.  However, the fact that diabetes and hypertension commonly coexist does not establish a cause and effect relationship, because the vast majority of hypertension...is essential hypertension, meaning there is no specific underlying causal condition."  The examiner continued, "[t]he National Institute of Health (NIH) states that diabetic nephropathy, which usually occurs after 15 years of diabetes appears to be an important cause of hypertension.  There is no documented medical evidence to support that this Veteran has diabetic nephropathy."

Similarly, in a follow-up VA examination in March 2011, the examiner concluded that the Veteran's hypertension was less likely as not permanently aggravated by service-connected diabetes mellitus.  In particular, the examiner reiterated that the NIH states that diabetic nephropathy appears to be an important cause of hypertension.  The examiner further opined that the Veteran's renal function is normal and there is no evidence that he has diabetic nephropathy.

In contrast, the Veteran submitted a medical opinion from Dr. J.J. in support of his claim that his currently diagnosed hypertension was caused by his service-connected diabetes mellitus.  With respect to the question of medical nexus, Dr. J.J. stated "[i]t is my belief that diabetes can cause hypertension.  Diabetes affects the lining of the arteries.  It can destroy the architecture of the walls of the arteries.  Consequently, it can make the arteries stiffen which can increase blood pressure."

There is, therefore, conflicting evidence of record concerning the question of the etiology of the Veteran's currently diagnosed hypertension.  In this regard, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant.  Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.  Nevertheless, when, after considering all the evidence, a reasonable doubt arises regarding a determinative issue, the benefit of the doubt shall be given to the claimant.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.

The opinions of the VA examiners and Dr. J.J. are probative as to the issue of medical nexus.  The record reflects that these providers were familiar with the Veteran's medical history, to include the development of his hypertension.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  Curiously, the VA examiners do not address Dr. J.J.'s assessment regarding the effects of diabetes on the walls of arteries, and Dr. J.J. does not address the VA examiners' assessments regarding diabetic nephropathy.  A reasonable inference from reading these opinions is that Dr. J.J.'s analysis is entirely different from the VA examiners and has not been contradicted by the VA opinions.  Consequently, the Board does not find that one position outweighs the other.

Accordingly, it may be said that the evidence is at least in equipoise as to the matter of whether the Veteran's currently diagnosed hypertension was caused by his service-connected diabetes mellitus.  The benefit-of-the-doubt rule is thus for application.  38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012).  The Board will therefore resolve reasonable doubt in the Veteran's favor and grant service connection for hypertension.  38 U.S.C.A §5107 (West 2002 & Supp. 2012).


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ORDER

Entitlement to service connection for hypertension is granted.



_________________________________
MARK F. HALSEY
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs