Citation Nr: 1320800 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 10-18 397 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for heart disease, to include as secondary to hypertension. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran had active duty service from July 1951 to June 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Hartford, Connecticut, that denied the benefits sought on appeal. The Veteran testified at a hearing in November 2009 before a Decision Review Officer. He subsequently testified at a June 2010 videoconference hearing before a Veterans Law Judge, who is no longer employed by the Board. A transcript of the hearing is of record. The Veteran was notified that the Veterans Law Judge who heard his testimony in June 2010 was no longer employed at the Board. The Veteran requested another videoconference hearing and was afforded a second videoconference hearing in December 2012 before the undersigned Acting Veterans Law Judge. The hearing transcripts are associated with the record. In July 2010, the Board remanded the Veteran's claims for service connection for hypertension and for heart disease, including as secondary to hypertension. The case was again remanded by the Board in June 2012 for additional development. Please note that this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a) (2) (West 2002). FINDINGS OF FACT 1. The Veteran has hypertension that was incurred during active military service. 2. The Veteran has coronary artery disease that developed secondary to his service-connected hypertension. CONCLUSIONS OF LAW 1. Resolving doubt in the Veteran's favor, his hypertension was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Resolving doubt in the Veteran's favor, his coronary artery disease is caused by his service-connected hypertension. 38 U.S.C.A. §§ 1110, 1131, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes at the outset that on November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq; 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2012). This law eliminated the concept of a well-grounded claim, redefined the obligations of VA with respect to the duty to assist, and imposed on VA certain notification requirements. Without deciding whether the notice and development requirements of the VCAA have been satisfied with respect to the Veteran's claim for service connection for hypertension and heart disease, it is the Board's conclusion that the VCAA does not preclude the Board from adjudicating the claim. This is so because the Board is taking action favorable to the Veteran by granting service connection for hypertension and for coronary artery disease, which represents a full grant of the issues on appeal. A decision therefore poses no risk of prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92 (July 24, 1992), 57 Fed. Reg. 49,747 (1992). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131. 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 diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown , 7 Vet. App. 439, 448 (1995) (en banc). The Veteran contends that service connection is warranted for hypertension and for heart disease, including as secondary to hypertension. Although service treatment records do not reference hypertension, the Veteran asserts that he had high blood pressure in service that has continued to the present. The Veteran's entrance examination report, dated in July 1951, reflects a blood pressure reading of 120/78. At separation, the Veteran reported taking medicine to lower his blood pressure upon the advice of a physician. He noted that a satisfactory blood pressure reading was necessary to pass his separation examination. At his June 1955 separation examination, the examiner measured the Veteran's blood pressure as 136/94. Following separation, the Veteran reportedly sought medical treatment for hypertension, but those records are not available. Current VA and private treatment records confirm that the Veteran is receiving treatment for both hypertension and coronary artery disease. At a VA examination in April 2011, the Veteran reported a history of elevated blood pressure and a heart condition. He reported being on hypertension medication since September 2000 and stated that he had first been diagnosed with hypertension in service. He contended that, while in service, he regularly worked with dynamite, which exposed him to nitroglycerine and caused severe headaches. He stated that he believed the exposure to nitroglycerine over a period of time caused an increase in his blood pressure. A VA intake report noted a heavy usage of alcohol following separation. The VA examiner diagnosed the Veteran with hypertension, not well controlled. In so finding, the examiner found there to be no current evidence to support chronic hypertension stemming from service. The examiner concluded that the Veteran had a past history of smoking and alcohol use to excess and was overweight, which as likely as not were the causes of his hypertension. The examiner further found that the Veteran carried a diagnosis of coronary artery disease linked to, among other risk factors, hypertension. In a February 2011 letter, the Veteran's private physician opined that the Veteran's coronary artery disease was due primarily to his hypertension and secondarily to his hyperlipidemia. The physician noted that "it is well known that stress exposure ... can aggravate hypertension, which in return may increase the risk of cardiovascular disease. It is my understanding that [the Veteran] had had stress exposure in the past during his military service." The physician further found that "it is certainly possible that high stress exposure may aggravate hypertension and attribute to later development of coronary artery disease." To address these contrasting findings, in March 2013, the Board requested an opinion from a VHA medical specialist as to whether it at least as likely as not that the Veteran's currently diagnosed hypertension is related to service, including as a result of his presumed in-service exposure to nitroglycerin; had its onset during service; or was manifested within one year of service discharge; or is either caused by or aggravated by his service-connected PTSD. The medical specialist was further asked to opine as to whether the Veteran's heart disease had been caused or made by worse by his hypertension. In providing his report, the specialist reviewed the entire claims file. He also reviewed medical literature as well as the relationship between PTSD and cardiovascular disease. He noted that the Veteran's blood pressure was within normal limits at the time of service entrance in 1951. However, at separation in 1955, his blood pressure was measured as 136/94. As his systolic pressure was over 90, the specialist found that the Veteran had displayed stage I hypertension at his separation from service. He specifically found that the Veteran's hypertension was "likely incurred in service." The specialist also noted that hypertension is a major risk factor for coronary artery disease. The specialist thus concluded that the Veteran's "blood pressure was stage I hypertension at the time of service separation in 1955." The examiner further found that the Veteran's hypertension contributed to his later development of coronary artery disease. The positive VHA opinion serves to place the matter of causal nexus in relative equipoise. The Board further notes that all of the medical opinions were based on a review of the medical evidence, the clinicians' medical expertise, and review of relevant scientific literature. In this case, the Veteran's service treatment records reflect that he displayed diastolic blood pressure of 94 at his separation from service-a finding that the VHA medical specialist determined represented stage I hypertension. Since that time, he has been diagnosed with hypertension and with coronary artery disease, which both the VA examiner and the VHA specialist linked to his hypertension. Importantly, the VHA specialist, in his June 2013 report, specifically found that the Veteran's hypertension was incurred in service and that his coronary artery disease is etiologically linked to that hypertension. The Board acknowledges that the April 2011 VA examiner found the Veteran's hypertension not to be related to service. However, the Board finds that the negative opinion is outweighed by the well-reasoned opinion of the VHA specialist, who took the Veteran's in-service and post-service medical history into account in rendering those findings. Here, the competent medical evidence has established that the Veteran's hypertension was incurred while he was in service and that his coronary artery disease is etiologically linked to that hypertension. The Board thus concludes that the Veteran suffers from hypertension that began during active duty and from coronary artery disease that has been caused or worsened by hypertension. Service connection for hypertension and for coronary artery disease is thus granted. ORDER Entitlement to service connection for hypertension is granted. Entitlement to service connection for coronary artery disease is granted. ____________________________________________ CAROLINE B. FLEMING Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs