Citation Nr: 1309351	
Decision Date: 03/19/13    Archive Date: 04/01/13

DOCKET NO.  04-06 325	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Waco, Texas


THE ISSUE

Entitlement to service connection for hypertension to include as secondary to posttraumatic stress disorder (PTSD) or other service-connected disabilities.


REPRESENTATION

Appellant represented by:	Vietnam Veterans of America


ATTORNEY FOR THE BOARD

M. G. Mazzucchelli, Counsel








INTRODUCTION

The Veteran served on active duty from February 1966 to February 1970.

This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in September 2002 of a Department of Veterans Affairs (VA) Regional Office (RO). 

In a decision in April 2011, the Board denied service connection for hypertension.  On appeal to the United States Court of Appeals for Veterans Claims, in October 2011, the Court granted a Joint Motion for Remand of the parties (VA Secretary and the Veteran), and vacated the Board's decision and remanded the case pursuant to 38 U.S.C. §7252(a) for readjudication consistent with the Joint Motion.

In May 2012, the Board remanded the case for additional development.


FINDING OF FACT

Hypertension is related to service-connected PTSD. 


CONCLUSION OF LAW

The criteria for service connection for hypertension have been met.  38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.310 (2012). 








The Veterans Claims Assistance Act of 2000 (VCAA)

The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim.  

As the claim of service connection is granted, VCAA compliance need not be addressed further. 


REASONS AND BASES FOR FINDING AND CONCLUSION

Service connection may be granted for disability resulting from injury or disease incurred in or aggravated by active military service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303.

Service connection may also be warranted for disability proximately due to or the result of a service-connected disorder 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(a).  Secondary service connection requires (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.  Wallin v. West, 11 Vet. App. 509, 512 (1998). 

The service treatment records contain no complaint, finding, history, symptom, treatment, or diagnosis of high blood pressure or hypertension.

After service, VA records show that in May 1999 the Veteran's blood pressure readings were 150/102 and 150/110.  The assessment was hypertension.  In June 1999 the Veteran was prescribed Naprosyn for treatment of right neck and right hand pain and cramps. 


In October 2000, the Veteran's blood pressure was 151/91.  In March 2001, the Veteran's blood pressure was 150/90.  In March 2001, a VA physician noted that the Veteran had chronic pain and that multiple nonsteroidal anti-inflammatory drugs had failed to relieve the pain.  In October 2001, blood pressure was 142/87. 

In May 2002 and in August 2004, V.G., M.D., a private physician stated that the Veteran's elevated and difficult-to-control blood pressure had been aggravated by stress during military service and by PTSD.  The physician referred to several studies associating the severity of blood pressure elevation and stress-related disorders.

In June 2002, a VA physician stated that primary essential hypertension was of unknown etiology and unlikely to result from a single cause.  The VA physician stated that it would be impossible, on the basis of available information, to state that the Veteran's hypertension was the result of PTSD. 

On VA examination in August 2002, the VA physician stated that he knew of no evidence in the medical literature to support a causal relationship between sustained essential hypertension and PTSD. 

On VA examination in August 2006, a VA physician, who also reviewed the medical literature, found no relationship between PTSD as an aggravating factor for hypertension and hypertension was less likely than not aggravated beyond normal progression by PTSD. 

In December 2009, the Board obtained an independent medical opinion.  The physician stated that it was unlikely that hypertension was related to service.  In an addendum in January 2011, the physician stated that nonsteroidal anti-inflammatory agents can aggravate hypertension. 

On VA examination in June 2012, the VA examiner did not address the question of aggravation of hypertension by service connected PTSD or the use of NSAIDs.


The record contains a report submitted by the Veteran from the National Heart Foundation of Australia addressing the relationship between stress and cardiovascular disease.

In March 2013. the Board obtained an opinion from a VA internist who reviewed the record.  The VHA expert cited a medical journal article that noted that PTSD had been associated with increased risk of hypertension in the National Comorbidity Survey and in an epidemiologic study of Vietnam era veterans from Australia to the effect that individuals with PTSD were more likely to have hypertension due to autonomic arousal which includes an increase in plasma and urinary norepinephrine, epinephrine, and r metabolites.  The VHA expert also cited another report that suggested that male Veterans with combat-related PTSD have higher resting blood pressure as compared to Veterans without PTSD.  The VHA expert stated that as essential hypertension is frequently of a multifactorial etiology, it was not possible to state that PTSD caused or aggravated the Veteran's hypertension.

While there is conflicting medical evidence in the file that weighs both for and against the Veteran's claim for service connection for hypertension, the Board finds that there is competent evidence to support the claim that the current hypertension is medically related to the service-connected PTSD.  Resolving all reasonable doubt in favor of the Veteran, there is a basis of entitlement to service connection on a secondary basis under 38 C.F.R. § 3.310. 

ORDER

Service connection for hypertension is granted.


____________________________________________
George E. Guido, Jr.
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs