Citation Nr: 1324858 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 10-07 043 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea to include as secondary to service-connected disability. 2. Entitlement to service connection for hypertension to include as secondary to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active duty from September 1952 to October 1981. This appeal to the Board of Veterans' Appeals (Board) arose from a March 2008 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) in St. Petersburg, Florida. In pertinent part, the rating decision denied service connection for sleep apnea; reopened the claim of service connection for deviated nasal septum and denied it on the merits; and, declined to reopen the claim of service connection for hypertension. The Veteran perfected a timely appeal of those determinations. A Board hearing at the RO the Veteran requested was scheduled. In a January 2012 letter, however, he withdrew his request for a hearing. See 38 C.F.R. § 20.702 (2012). In an April 2012 decision, the Board reopened the claim for entitlement to service connection for hypertension and remanded this matter to the RO for further development. The Board also remanded the matters of entitlement to service connection for sleep apnea and for deviated nasal septum for further development. While the matter was on remand status, the RO in an April 2013 rating decision granted service connection for a deviated nasal septum, which constitutes a full award of the benefits sought on appeal with respect to this issue. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The record currently before the Board contains no indication that the appellant initiated an appeal with the initial ratings or effective date assigned. Thus, this matter is no longer in appellate status. Grantham, 114 F.3d at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). The matter was returned to the Board which in May 2013 remanded this matter for additional development. The Board notes that VA treatment records from CAPRI were obtained that were shown to belong to a different Veteran. However it does not appear that the RO relied on these records in its adjudication, thus there is no prejudice to the Veteran in this matter. This matter has been returned to the Board for further adjudication. 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. Obstructive sleep apnea did not have its clinical onset in service and is not otherwise related to active duty, and was not caused or aggravated by service-connected disability. 2. Hypertension did not have its clinical onset in service and is not otherwise related to active duty; it was not exhibited within the first post service year; and was not caused or aggravated by service-connected disability. CONCLUSIONS OF LAW 1. Obstructive sleep apnea was not incurred or aggravated in service and is not proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 1154, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Hypertension was not incurred in or aggravated by service, may not be presumed to have been incurred in service, and is not proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In this case, the VCAA duty to notify was satisfied by way of a letter dated in March 2007 for the sleep apnea issue and dated in April 2007 for the hypertension, prior to the March 2008 rating, that fully addressed all notice elements. The letters informed the Veteran of what evidence was required to substantiate his claims, and of the Veteran's and VA's respective duties for obtaining evidence. The Veteran was also advised as to how disability ratings and effective dates are assigned. See Dingess, supra. The Board concludes that the duty to notify has been met and will proceed with adjudication of his appeals. Mayfield v. Nicholson, 444 F.3d 1328 (2006). The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records and VA treatment records have been obtained. Private medical records were obtained. He was afforded an appropriate VA examination in May 2012, with addendum to further provide rationale in June 2013 and a relevant opinion has been obtained from the examiner. There is no indication that there is any relevant evidence outstanding in the claim in the claims folder or electronic record. The Board also finds that VA has complied with all assistance provisions of VCAA, to include substantial compliance with the instructions in the May 2013 Board Remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). An addendum opinion was obtained by the VA examiner in June 2013 to clarify the earlier VA examination opinion of May 2012. Issuance of a June 2013 supplemental statement of case reflects consideration of this VA examination addendum of May 2013. The Board is satisfied that there was substantial compliance with its remand orders. Id., See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issue on appeal. II. Analysis The Board has reviewed all the evidence in the claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Also, the Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b) (2012). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). 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). 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). If hypertension becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of these disabilities during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303 -04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Sleep Apnea The Veteran contends that service connection is warranted for obstructive sleep apnea. He alleges that this is the result of a deviated septum that he received due to trauma to his nose in service. The VA has conceded such nasal trauma took place in service and service connection is in effect for a deviated nasal septum. Service treatment records are silent for any symptoms or findings suggestive of sleep apnea. The September 1952 preinduction examination revealed normal pulmonary and nasal findings. The Veteran was treated for an acute upper respiratory infection (URI) deemed cured in December 1959. He was again treated for URI with hoarseness, sore throat and slight cough in March 1969. Another URI was treated in January 1976. None of the records treating URI's gave any indication of a sleep apnea problem. Multiple periodic examinations throughout service were negative for pulmonary and nasal findings suggestive of sleep apnea and he denied any ear, nose or throat trouble, pulmonary trouble or frequent trouble sleeping in the accompanying reports of medical history. He had a persistent URI that was treated in February 1981, said to have persisted for 12 months. However no sleep apnea was reported. On separation examination in July 1981 he again had normal pulmonary and nasal findings, and in the report of medical history he denied frequent trouble sleeping or any pulmonary trouble but he did report ENT trouble. Post service records are silent for sleep apnea symptoms prior to 2006. In September 2006, the Veteran was seen by Dr. F, a private Otolaryngologist for complaints of obstructed breathing patterns and nasal obstruction. His symptoms included loud snoring, with symptoms increased when lying on his back. His history included a history of nasal obstruction and 2 nasal fractures, one at age 8 and one in 1953. Following examination which noted an extreme septal deviation to the right, and a prominent uvula, he was diagnosed with nasal obstruction and sleep apnea. A few days later in September 2006, he was seen by a private pulmonologist, Dr. P, for evaluation of abnormal sleep with complaints such as loud snoring, stopping breathing at night and waking up in the night while snoring. He also had issues waking with a dry mouth and throat and morning headaches. He complained of mood changes and some difficulty learning and remembering things. He also reported being very tired during the day and falling asleep very easily during monotonous situations. Following examination he was assessed with obstructive sleep apnea (OSA) syndrome, with a significant clinical history for OSA. He was noted to snore loudly, had witnessed apneas and daytime tiredness and sleepiness. An overnight sleep study was deemed clinically necessary. CT scan done for sleep apnea confirmed the presence of a marked deviated nasal septum towards the right side, as well as mild chronic sinusitis and a small left maxillary sinus polyp. After undergoing such an overnight sleep study, the diagnosis of OSA was confirmed in October 2006. He was prescribed a CPAP machine. The diagnosis of sleep apnea was noted in records following treatment for a heart attack in November 2006, with sleep apnea diagnosed in December 2006. Elsewhere the records continued to note a diagnosis of sleep apnea including an October 2007 letter from his private cardiologist that addressed his cardiovascular problems. The Veteran continued to be treated for sleep apnea by Dr. P, in 2007, with notes of treatment for OSA requiring CPAP treatment in January 2007 and March 2007. He continued to be followed up for sleep apnea, with another sleep study done confirming this diagnosis in December 2008. A medical opinion of an unknown date and an unidentified author was associated with the claims folder. Although the author of this opinion is unidentified, the opinion described having seen the Veteran after treating his wife, when she complained about his snoring and stopping breathing. The Veteran was described as having a diagnosis of sleep apnea and a deviated septum, with the deviated septum described as a contributing factor for the sleep apnea. The Veteran submitted a number of articles from various medical publications dealing with sleep apnea discussing the etiology of sleep apnea. These articles generally suggest that deviated septum may be a factor in the cause or worsening of sleep apnea, including due to obstruction of airflow caused by the narrowed nasal passageways. However these articles also suggest other possible factors including obesity, alcohol, muscle relaxants and sleeping tablets. The Veteran's wife submitted a statement dated in April 2007 which confirmed that she married the Veteran in 1981 while he was still in the service and that she had noticed he snored loudly and stopped breathing for short periods of time if he slept on his back. She indicated that she put up with it but finally mentioned his symptoms to an ear, nose and throat (ENT) specialist she was seeing in 2006. She said that the ENT diagnosed the Veteran with a deviated septum and also referred him to a pulmonary specialist who diagnosed OSA. A May 2012 VA examination addressing sleep apnea included review of the claims file. The Veteran was noted to have been diagnosed with OSA in 2006, with sleep study done the same year. He claimed it was the result of a deviated septum he received in service. He required CPAP treatment. His current findings attributable to OSA included persistent daytime hypersomnolence. Another pertinent physical finding was that he exhibited a grade III Friedman tongue position. The examiner opined that sleep apnea was neither the result of nor caused by the URI's or hoarseness/sore throats documented in the service treatment records. It was caused by relaxation of the anterior throat muscles causing the airway to close. This was the result of morbid obesity in most people who have sleep apnea. However, congenital abnormalities may also be the cause. Additionally the aging process limits the brain's ability to maintain necessary tension in the throat muscles needed to ensure a patent airway. Thus aging sometimes worsened or initiated sleep apnea. In this Veteran's case, a Grade III Friedman tongue positioning on examination today indicated that the sleep apnea was congenital in nature, probably with ageing initiating or worsening symptoms of this condition. The report of a June 2013 VA medical opinion confirmed review of the records, and stated that the sleep apnea was a standalone entity neither caused nor aggravated by his service connected deviated septum with subsequent snoring. The rationale included the statement that snoring is not the same thing as sleep apnea. It was important to distinguish between snoring and OSA. Many people were noted to snore, estimated to be about 30 to 50 percent of the U.S. population snores at one time or another. Estimates of sleep apnea prevalence are in the 3-7 percent range. Certain subgroups were noted to be at higher risk-factors included obesity, gender, age, family history or craniofacial abnormalities. Additionally certain health behaviors like smoking and alcohol use were factors. Anatomical risk factors included obesity, facial mouth and jaw abnormalities, prominent tongue base and neck size. Postmenopausal status, and aging medical factors were also cited. Online medical sources were cited by the examiner in support of the opinion and discussion of the risk factors. The examiner stated that review of the current and recent medical literature was silent for any mechanism by which deviated septum, even traumatic, may cause or aggravate sleep apnea. Having reviewed the evidence, the Board lends the greatest weight to the findings and conclusions of the May 2012 VA examination, coupled with the June 2013 addendum, (which further clarified and explained the unfavorable opinion made by this examiner in the May 2012 examination). The opinions from this May 2012 examination and June 2013 addendum determined that the Veteran's OSA neither began in service nor was neither caused nor aggravated by his service connected deviated nasal septum. The examiner included a comprehensive review of the records and examination of the Veteran and provided solid rationale for the opinions rendered regarding causation. The examiner provided a detailed explanation as to why OSA is neither caused nor aggravated by the deviated septum. The examiner explained that there were numerous other potential factors for causing sleep apnea, and additionally noted findings in the May 2012 VA examination of a potential congenital cause for this condition, manifested by a Grade III Freidman tongue position. The June 2013 addendum provided further detailed rationale as to why the OSA was unrelated to the nasal septum deviation. The Board has reviewed the medical treatise evidence submitted by the Veteran pertaining to potential relationships between deviated nasal septums and OSA. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998) (medical treatise evidence discussed generic relationships with a degree of certainty to establish a plausible causality of nexus), and Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case, however, the Veteran has not submitted an opinion from a medical professional to accompany the treatise evidence. Thus, the article submitted is insufficient to establish the required medical nexus opinion for causation. Regarding the undated opinion submitted by an unidentified individual which appears to link the Veteran's deviated septum as a contributing factor for the sleep apnea, the lack of a clear identity of the author is problematic. Further the author provides no clear rationale explaining why these two diagnosed disorders should be linked. Thus the Board lends little probative value to it. The record does not show and the Veteran does not claim that obstructive sleep apnea is due to any other service-connected disability. Regarding the lay statement submitted by the Veteran's wife, while she is competent to describe observed symptoms such as snoring and troubled breathing, she is not shown to be competent to provide an opinion diagnosing such symptoms as an indicator of sleep apnea. As was noted in the June 2013 opinion, snoring is not necessarily symptomatic of obstructive sleep apnea. The rest of the medical evidence while documenting ongoing treatment for OSA does not reflect this condition to have begun in service. Nor does the rest of the medical evidence suggest any relationship between the OSA and his service connected deviated nasal septum. Thus it is of limited probative value. The Board has weighed the evidence and found that it is not in equipoise; the reasonable doubt rule is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Based on all of the evidence, the claim is denied. Hypertension The Veteran claims service connection is warranted for hypertension to include as secondary to his service connected PTSD. Alternately, the evidence submitted by the Veteran via articles also raise the question of hypertension being caused aggravated by his sleep apnea. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with a diastolic blood pressure of less than 90. 38 C.F.R. § 4.104 , Note (1) (2012). Service treatment records are silent for any symptoms or findings suggestive of hypertension. The September 1952 preinduction examination revealed normal cardiovascular findings, other than a systolic apical murmur, functional, but his blood pressure was 136/70. None of the records treating other medical problems gave any indication of a hypertension. Multiple periodic examinations (including electrocardiograms) throughout service were negative for blood pressure readings suggestive of hypertension and he denied any history of high blood pressure accompanying reports of medical history. On separation retirement examination in July 1981, the Veteran had normal cardiovascular findings with his blood pressure of 128/86, and in the report of medical history he denied having high blood pressure. The report of a February 1983 VA examination noted the Veteran's blood pressure readings as follows. Sitting was 160/100, recumbent was 150/90, standing was 150/110 and sitting after exercise was 170/90. The diagnoses included hypertension. Another February 1983 clinical record gave a diagnosis of hypertension with blood pressure 160/100. VA records from the late 1980's to 1995 persistently show blood pressure readings within the normal range. In December 1995 he was seen for results of lab work done to follow up on hyperlipidemia, with the Veteran denying having hypertension or a family history of hypertension. His blood pressure reading was 118/98. He was assessed with hyperlipidemia responding to treatment, rule out hypertension. He was ordered a 5 day blood pressure check, however he did not complete this. The readings taken for this incomplete work-up showed his blood pressure exceeded the parameters set, with 2 day readings shown to be 160/72 on the left and 158/78 on the right on Day 1, and shown to be 159/94 on the left and 154/91 on the right on Day 2. An April 1996 treatment note diagnosed mild systolic hypertension with a reading of 150/88. Thereafter private treatment records documenting treatment for prostate cancer in 1996 and 1997 showed no significant findings of hypertension and an August 1996 record specifically showed no findings of high blood pressure. VA records from 2000 and 2001 show elevated blood pressure with a reading of 186/90 shown in a December 2000 follow-up note for urinary symptoms. In June 2001 he was seen again for urinary complaints with a blood pressure reading of 167/96. He was described in September 2001 as having elevated blood pressure readings with home readings said to have been around 140/80 consistently after sitting quietly for several minutes. His clinical reading was 176/76 and he was assessed as normotensive. In November 2001, follow-up of blood diagnostic checks, he was described as having blood pressure consistently above 140 systolic the last 4 days, with the ranges from 155-180's systolic. He was assessed with systolic hypertension. Hypertension is noted in his review of systems in a February 2006 private medical record addressing residuals of prostate cancer. Private medical records from 2006 also document treatment following a myocardial infarction (MI) in November 1996, with hypertension noted in his past medical history. While these records noting the history of hypertension did not discuss the etiology of the hypertension, he was noted to have a family history of his father having had his first MI at age 48, and a history of hypertension and hyperlipidemia. His discharge summary from November 2006 diagnosed coronary artery disease (CAD) status post coronary angioplasty and stenting of the left anterior descending, hypertension and recent findings of elevated hemoglobin A1C with possibility of Type II diabetes mellitus. A December 2006 outpatient follow-up after his heart attack noted essential hypertension, benign in the problem list, and his blood pressure taken during this visit was 132/61. Essential hypertension, benign and well controlled on medication (now Diovan) was diagnosed. A January 2007 follow-up for sleep apnea noted a history of CAD with a statement that it was very important for the Veteran to use the CPAP sleep apnea treatment due to his coronary condition. An October 2007 VA examination for arteries and veins addressing questions regarding the etiology of a deep vein thrombosis, noted a history of hypertension but did not address this further. The evidence reveals the Veteran is service connected for PTSD, with treatment for this disorder in 2000 and in September 2007 and VA examination in January 2008. None of these records provided any evidence as to the possible relationship between the PTSD and hypertension, although his cardiovascular disorders were noted in discussions of his medical history. An October 2007 letter from Dr P. the Veteran's Cardiologist, described treating for the Veteran for his MI and CAD stated that the Veteran's past medical history was a contributing factor to his heart disease. His past medical history was noted to include multiple medical disorders including pulmonary hypertension and sleep apnea. Another October 2007 letter from W. C., PA at Patrick Air Force Base described the Veteran as having established care there since 1983 with diagnose that include hypertension, elevated cholesterol and sleep apnea. He was noted to have had a MI in November 2006 which could be the result of his hypertension and elevated lipids. The stress of his PTSD was also said to potentially aggravate these conditions, to include hypertension. The Veteran submitted a number of articles from various medical publications dealing with sleep apnea, primarily discussing the etiology of sleep apnea, but also indicating that severe obstructive sleep apnea is associated with a higher risk for high blood pressure and other cardiovascular complications. A May 2012 VA examination addressing hypertension confirmed the diagnosis of hypertension for VA purposes. Review of the Veteran's medical records were noted to detail elevated blood pressure in February 1983, but he did not meet the criteria for VA definition of hypertension, as he only had 2 elevated resting blood pressures taken the same day. Therefore he would have been diagnosed with hypertension at some time subsequent to February 1983. Current blood pressure readings were taken, of 144/80, 148/86 and 148/89. The examiner opined that essential hypertension is not caused by or the result of a condition, illness or event shown in the service treatment records. These were noted to be silent for evaluation or treatment of the claimed condition and his separation examination was negative for a diagnosis of hypertension. Multiple blood pressure readings documented during active service were within normal range. The first mention of elevated blood pressure in the claims file was shown in February 1983. Although hypertension was listed as a diagnosis he did not meet the criteria for hypertension nor was he prescribed antihypertensive medications at that time. This examiner concluded that the actual diagnosis of hypertension came after February 1983. This effectively put the diagnosis outside the presumed post separation period. The report of a June 2013 VA addendum medical opinion, provided by the same physician who examined the Veteran in May 2012, confirmed review of the records, and stated that the Veteran's essential hypertension is neither due to nor aggravated by the Veteran's PTSD. The rationale was that while it may be true that PTSD may be responsible for increased vasomotor response secondary to epiniepherine-norepherine release resulting in increased peripheral vascular resistance, and it is also true that increased vascular resistance is responsible for a short term rise in blood pressure, this mechanism has no effect on long term blood pressure. The examiner cited medical literature online to support this opinion. The examiner noted that review of the medical literature is silent for any mechanism by which PTSD may cause or aggravate essential hypertension. The Veteran's hypertension was deemed to be a standalone process, neither due to nor aggravated by PTSD. Additionally as his OSA was neither due to nor aggravated by his service connected deviated septum with subsequent snoring thus no additional medical opinion was indicated. Having reviewed the evidence, the Board lends the greatest weight to the findings and conclusions of the May 2012 VA examination, coupled with the June 2013 addendum, (which further clarified and explained the unfavorable opinion made by this examiner in the May 2012 examination). The opinions from this May 2012 examination and June 2013 addendum determined that the Veteran's hypertension did not begin in service or manifest to a compensable degree within the initial post service year. The opinion additionally determined that the hypertension was neither caused nor aggravated by his service connected PTSD. The examiner included a comprehensive review of the records and examination of the Veteran and provided solid rationale for the opinions rendered regarding causation. The examiner provided a detailed explanation as to why essential hypertension is not aggravated by PTSD. While an opinion regarding possible causation or aggravation of hypertension from OSA was not obtained, the need for such is mooted by the fact that OSA is found by the Board not to be service connected. For the same reason, medical evidence including from his treating medical providers and articles and treatises that suggest a possible link between OSA and hypertension are of no probative value in this matter. The record does not show and the Veteran does not claim that hypertension is due to any other service-connected disability. Regarding the conflicting evidence from W.C. PA in October 2007, this evidence suggested that PTSD may be a factor in his hypertension, but fails to provide any rationale for this opinion. Thus the Board lends little weight to this evidence. The rest of the medical evidence while documenting ongoing treatment for hypertension, including some evidence of elevated blood pressure readings dating back to 1983, (but not to a compensable degree and not found by the May 2012 VA examiner to meet the VA criteria for hypertension) does not reflect this hypertension to have begun in service or within a year of discharge in 1981. Nor does the rest of the medical evidence suggest any relationship between the hypertension and his service connected PTSD. Thus it is of limited probative value. The Board has weighed the evidence and found that it is not in equipoise; the reasonable doubt rule is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Based on all of the evidence, the claim is denied. ORDER Entitlement to service connection for obstructive sleep apnea is denied. Entitlement to service connection for hypertension is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs