Citation Nr: 1311349 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 10-37 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for essential hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD J. T. Sprague, Counsel INTRODUCTION The Veteran had active service in the United States Army from September 1968 to April 1970, to include combat duty in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The entire claims file, to include the portion contained in the electronic "Virtual VA" system, was reviewed in this case. In January 2013, the case was dispatched to the Veterans Health Administration (VHA) for an expert internal medicine opinion. An opinion was returned in March 2013 and it fully answered the questions posed by the Board. FINDING OF FACT The Veteran's service-connected PTSD produces elevations in systolic and diastolic pressures of a greater severity than what would occur without PTSD; there is a greater risk of vascular complications associated with the Veteran's hypertension as a result of his PTSD, and thus, there is aggravation of the hypertension beyond the natural course of the disease process. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). This law redefines the obligations of VA with respect to the duty to assist and includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. First, VA has a duty to notify the appellant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103 (West 2002); 38 C.F.R. § 3.159(b) (2012). Information means non-evidentiary facts, such as the claimant's address and Social Security number or the name and address of a medical care provider who may have evidence pertinent to the claim. See 66 Fed. Reg. 45620, 45,630 (August 29, 2001); 38 C.F.R. § 3.159(a)(5) (2012). Second, VA has a duty to assist the appellant in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). As discussed in more detail below, sufficient evidence is of record to grant the claim for service connection for hypertension. Therefore, no further development is needed with respect to this claim. Legal Criteria-Service Connection Applicable law provides that service connection will be granted if it is shown that the Veteran experiences a disability resulting from an injury or disease contracted in line of duty, or for aggravation of a preexisting injury or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury or disease occurred in service alone is not enough; there must be chronic disability resulting from that injury. 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 discharge, 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). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998) (citing Cuevas v. Principi, 3 Vet. App. 542, 548 (1992)). 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Analysis The Veteran in this case carries a diagnosis of essential hypertension. He developed this condition many years after service, and has not alleged that the disorder first manifest while on active duty. Instead, it is the Veteran's contention that his service-connected PTSD, which is resultant from exposure to the traumatic events of combat service in Vietnam, either caused or aggravated hypertension beyond the natural course of the disease process. Indeed, the Veteran notes that while he did not seek help for PTSD until many years after service (with a diagnosis being entered in 2007), that he has felt the symptoms of the condition since his active service, and that accordingly, the disorder pre-existed hypertension and played an etiological role in establishing essential hypertension. The Board, in January 2013, dispatched the claim to a VA expert in internal medicine. The reason for this was that several clinical records suggested a positive correlation between a worsening of hypertension and the anxiety levels associated with his service-connected mental illness. It was requested that an internist with the Veterans Health Administration (VHA) review the claim and opine as to if it was at least as likely as not that service-connected PTSD caused or aggravated essential hypertension. The returned opinion was based of a thorough review of the claims file, is very detailed in its rationale, and is fully supportive of the Veteran's contentions. Indeed, the VHA internist noted that there had been medical studies conducted on Veteran patients receiving psychiatric care. Of that tested group, the ratio of higher blood pressures in the Veteran population with PTSD over that without was 2.90. That is, there was a correlation between higher systolic and diastolic pressures to those Veterans who carried the PTSD diagnosis. The internist explained that there is "strong data" supportive of autonomic dysregulation in a patient with PTSD. A medical reference was cited for this proposition, and the VHA internist stated that based on this, "the appellant's PTSD certainly could aggravate his hypertension and increase the chance of vascular complications from hypertension, even while on antihypertensive treatment." While PTSD was not diagnosed until many years after service, the VHA internist noted that the nature of the disease is such that it would manifest after exposure to the causative traumatic event. In this case, such an event would be the Veteran's exposure to combat in Vietnam, and thus, the PTSD would be present since military service. Blood pressure variability has been documented in the Veteran's records, and the VHA internist noted that PTSD has been linked to heightened autonomic arousal, elevated blood pressure readings, and the development of hypertension. Because of this, the internist stated that it was his belief that it was at least as likely as not that PTSD aggravated hypertension beyond the natural course of the disease process. This opinion is well-rationalized and fully supported by medical literature. It is the only opinion of record that directly addresses a secondary relationship based on aggravation, and is thus uncontroverted. There is no reason to doubt the thoroughness of the opinion or any of the medical literature references cited therein. Essentially, the evidence establishes that the Veteran experiences essential hypertension and that he has had PTSD since his exposure to combat in Vietnam. The PTSD has caused fluctuations in systolic and diastolic pressures above and beyond the normal course of essential hypertension, and the existence of the co-morbid service-connected psychiatric disorder has put the Veteran at a higher risk for vascular complications associated with his hypertension. Thus, the preponderance of the evidence supports a finding that service-connected PTSD aggravates essential hypertension, and the claim will be granted. ORDER Entitlement to service connection for essential hypertension is granted. ____________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs