Citation Nr: 1319614 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 03-36 625 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a heart disability, to include coronary artery disease and severe systolic dysfunction with secondary cardiomyopathy, claimed as secondary to hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Patricia Veresink, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1950 to November 1954. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which found that new and material evidence had not been received to reopen claims for service connection for hypertension and a heart disability. The Board reopened the claim of service connection in a decision dated September 2004. At the same time, the Board remanded the issues for additional development of the record. In April 2006, the Board denied service connection for hypertension and heart disease. The Veteran filed an appeal with the United States Court of Appeals for Veterans Claims (Court), which, by Order dated August 2007, granted a Joint Motion for Remand (JMR). By decision dated January 2008, the Board again denied the claims. In January 2009, a Court Order granted another JMR. In May 2009 the Board remanded the claim for additional development. Upon completion of that development, the Board denied service connection for hypertension and a heart disorder in May 2010. The Veteran again appealed the decision to the Court, which remanded the issues for further development in a February 2012 memorandum decision. In August 2012, the Board requested a medical opinion from a specialist with the Veterans Health Administration (VHA). The medical opinion was received in October 2012 and an addendum to that opinion was received in April 2013. In light of the favorable decision below, the Veteran is not prejudiced by consideration of the VHA opinion and addendum in the first instance. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in May 2004. A copy of the transcript of that hearing has been associated with the record. 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). FINDINGS OF FACT 1. The record does not contain clear and unmistakable evidence that the Veteran's hypertension pre-existed service. 2. Probative medical evidence indicates that the Veteran's current hypertension is a maturation of the labile hypertension noted in service. 3. Probative medical evidence indicates that the Veteran's coronary artery disease and systolic dysfunction with secondary cardiomyopathy is related to the Veteran's hypertension. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for service connection for coronary artery disease and systolic dysfunction with secondary cardiomyopathy have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants service connection for hypertension and coronary artery disease and systolic dysfunction with secondary cardiomyopathy. As this represents a complete grant of the benefits sought on appeal, no discussion of VA's duty to notify and assist is necessary regarding this issue. Service Connection - Laws & Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular-renal disease, including hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Under the governing criteria, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by service. 38 U.S.C.A. § 1111. If a disorder was not noted on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness for wartime service under 38 U.S.C.A. § 1111. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the preexisting condition." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. If the government fails to rebut the section 1111 presumption, the claim is one for service connection, not aggravation. Id. The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection - Hypertension The Veteran contends that he has hypertension that is causally related to the high blood pressure findings during service. Service treatment records show that in December 1950, upon entry into service, the Veteran's physical examination revealed mild tachycardia due to tension. The Veteran's blood pressure was 140/98. In October 1954, a military examiner noted that the Veteran was found to have a diastolic pressure constantly over 90 mm Hg with systolic pressures up to 176 mm Hg. The examiner noted his service entrance blood pressure reading. Although the Veteran was asymptomatic, the examiner recommended that he be transferred to Corona Naval Hospital for investigation of hypertension. Attempts to obtain additional records from Corona Naval Hospital have been unsuccessful; however, a service treatment record from that facility notes the Veteran was admitted to the hospital on October 19, 1954 with the diagnosis of "DU (Hypertension)". Blood pressure on admission was 160/110. No other abnormalities were noted. An eye consultation revealed the eye grounds were described as showing Grade I or equivocal hypertensive changes. A genitourinary consultation disclosed chronic prostatitis, which was treated with medication and massage. The Veteran's blood pressure was recorded at approximately 150/85, soon returned to normal limits (130/85), and remained there throughout the hospitalization. The diagnosis on hospital discharge was chronic prostatitis, organism unknown. A November 10, 1954 note changed the Veteran's diagnosis to prostatitis, chronic, nongonoccocic, organism unknown. He was discharged to duty on November 10, 1954. In a November 1954 examination, the examiner again noted mild tachycardia due to tension. On a subsequent November 1954 discharge report of medical examination, the examiner noted the Veteran's heart and vascular system as clinically normal. His blood pressure was 128/86. Following service, a letter from the Veteran's private physician, Dr. Haupt, dated in February 1961 noted that his blood pressure was 170/90 in November 1955. The doctor noted that he has seen the Veteran over the past six years and his diastolic pressure has always been elevated. The doctor again noted two high readings of 170/70 in September 1960 and 170/100 in February 1961. The Veteran was afforded a VA examination in April 1961. At that time, the Veteran's blood pressure readings were 130/100 sitting, 145/100 recumbent, 140/100 standing, 160/90 sitting after exercise, and 140/90 two minutes after exercise. The examiner diagnosed essential hypertension. During the hearing before the Board, the Veteran testified that he was first placed on high blood pressure medication in 1968. The Veteran was afforded a VA examination in September 2005. The examiner commented that, with a blood pressure reading of 140/98, the Veteran manifested moderate hypertension at his induction physical examination in December 1950. He further stated that the blood pressure at that time clearly reflected that hypertension unmistakably pre-existed service. The examiner stated that the Veteran's hypertension was not caused or worsened as a result of his military service. He indicated the record clearly reflected that the Veteran's hypertension was not worsened beyond natural progress, and that his condition actually improved by the time of his hospital discharge. He also noted the Veteran's problem with hypertension worsened following discharge when he was not under treatment for hypertension. However, the Court has found the September 2005 VA examination insufficient regarding the issue of service connection for hypertension. Following the Court's remand in 2012, the Board requested a medical opinion from a specialist with the Veterans Health Administration (VHA). In October 2012 the VHA internist provided a medical opinion concluding that the Veteran's essential hypertension did not preexist service. He noted that only one blood pressure reading was shown and no pre-induction medical information was provided. He specifically noted that a series of blood pressures taken on several different occasions is the absolute requirement for documenting hypertension. He opined that the Veteran suffered from labile hypertension during service and shortly following service, due to the fluctuating nature of the elevated blood pressure readings. In the April 2013 addendum, the internist opined that it was at least as likely as not that the Veteran's labile hypertension existed prior to service, specifically noting the odds are evenly split. However, in order to rebut the presumption of soundness, the evidence must clearly and unmistakably show that the disability existed prior to service. A 50 percent chance that it pre-existed service is not clear and unmistakable proof of pre-existence. As there is not clear and unmistakable evidence that the Veteran's hypertension (whether labile or essential) pre-existed service, the presumption of soundness has not been rebutted, and the claim is one for service connection. See Wagner, 370 F.3d 1089. In the April 2013 addendum, the VHA internist opined that the Veteran's currently diagnosed essential hypertension is at least as likely as not related to or a maturation of the labile hypertension during service. He noted that the Veteran's blood pressures were high during and immediately after service. He also noted that the Veteran's labile state of hypertension, present during active duty, persisted for many years following active duty discharge in 1954 and continued until treatment began in 1968. This opinion was provided following claims file review and included a detailed rationale for the opinion. Accordingly, it is afforded great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). As noted above, the Court has found the opinion from the September 2005 VA examiner concerning hypertension is insufficient. In light of the probative and persuasive opinion by the VHA internist, the Board finds that service connection is warranted for the Veteran's hypertension. Service Connection - Heart Disability The Veteran contends that he has a heart disability secondary to his hypertension. As noted above, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Veteran has current diagnoses of coronary artery disease and systolic dysfunction with secondary cardiomyopathy. In a statement dated November 2002, P.D.T, M.D, noted the Veteran apparently developed hypertension in service, and had since developed cardiomyopathy and coronary artery disease. The physician stated hypertension was a risk factor for the development of these conditions. The Veteran was afforded a VA examination in September 2005. The examiner reviewed the Veteran's records and provided a physical examination. The examiner opined that the Veteran's coronary artery disease and systolic dysfunction with secondary cardiomyopathy were caused by or a result of his hypertension. The examiner noted the Veteran's lack of treatment for his hypertension for an extended period of time post-service as the cause of his worsening hypertension and his heart disease. Specifically, he noted that hypertension is one of the primary risk factors in the development of coronary artery disease. Left ventricular hypertrophy and scarring develops with longstanding hypertension if it is not well controlled. The Board notes no conflicting medical opinion of record with respect to the relationship between hypertension and his heart disability. Therefore, based on the evidence of record, the Board finds that service connection for coronary artery disease and systolic dysfunction with secondary cardiomyopathy is granted. ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for coronary artery disease and systolic dysfunction with secondary cardiomyopathy is granted. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs