Citation Nr: 1326947 Decision Date: 08/22/13 Archive Date: 08/29/13 DOCKET NO. 07-04 752 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to a service-connected right shoulder disability. 2. Entitlement to service connection for coronary artery disease (CAD), to include as secondary to a service-connected right shoulder disability and/or claimed hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael J. Skaltsounis, Senior Counsel INTRODUCTION The Veteran had active service from February 1970 to October 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In December 2009 and October 2012, the Board remanded these matters to the RO via the Appeals Management Center (AMC), in Washington, DC, for additional development and readjudication. The requested action has now been completed to the extent possible, and these matters are now ready for further appellate review. The following determination is based on review of the Veteran's claims file in addition to his Virtual VA "eFolder." FINDINGS OF FACT 1. Hypertension was not present in service or within one year of service discharge; and, the competent and credible evidence fails to establish that the Veteran's diagnosed hypertension is related to his active service or his service-connected right shoulder disability, including medication for such disability. 2. CAD was not present in service or within one year of service discharge; and, the competent and credible evidence fails to establish that the Veteran's CAD is related to his active service or his service-connected right shoulder disability, including medication for such disability. CONCLUSIONS OF LAW 1. The Veteran's hypertension was not incurred in or aggravated by active service, may not be presumed to have been incurred therein, and is not proximately due to or aggravated by a service-connected right shoulder disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The Veteran's CAD was not incurred in or aggravated by active service, may not be presumed to have been incurred therein, and is not proximately due to or aggravated by a service-connected right shoulder disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In a letter dated in September 2005, prior to the initial adjudication of the claims, the RO notified the Veteran of the information necessary to substantiate the service connection claims on appeal, and of his and VA's respective obligations for obtaining specified different types of evidence. In a letter dated in December 2009, he was provided with more details regarding the evidence necessary to substantiate his service connection claims on appeal, and of his and VA's respective obligations for obtaining specified different types of evidence. He was told that the evidence must show a relationship between his current disabilities and an injury, disease or event in military service. He was advised of various types of lay, medical, and employment evidence that could substantiate his service connection claims. He was also provided with information regarding substantiating his secondary service connection claims, including a request that he submit information showing a relationship between medications the Veteran was taking for his right shoulder disorder and his hypertension/CAD. This and an earlier March 2006 letter also provided information regarding ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Although the March 2006 and December 2009 letters were not sent until after the initial adjudication of the claims, they were followed by readjudication and the issuance of supplemental statements of the case in June 2011 and May 2013. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). As to the duty to assist, the Veteran's VA and service treatment records have been obtained. Private medical records have been obtained, and the Veteran has not authorized the release of any other private records. Neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. VA examinations were obtained concerning the issues on appeal in February 2006, March 2011, and January 2013. All of the examinations and opinions were based upon consideration of the Veteran's prior medical history, including medical records and examinations, and also address the claimed disabilities and the contentions in support of a relationship between those disabilities and active service and/or service-connected disability with sufficient explanation and detail to permit the Board to make an informed decision. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board is also now satisfied there was substantial compliance with its earlier Remands. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Records from the Poplar Bluff VA Medical Center (VAMC) since 1975 have been obtained and included with claims file. Records from the Memphis VAMC are also of record. Further, taken together, the medical opinions obtained now address all the pertinent medical questions and are deemed adequate. Specifically, according to the 2009 Remand instructions, a VA cardiovascular opinion was procured in January 2013. Thus, there has been substantial compliance with these instructions; and, there is thus no Stegall violation in this case. Thus, the Board finds that all necessary notification and development has been accomplished, and that appellate review may therefore proceed. No further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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). Direct service connection may not be granted without evidence of a current disability; evidence of in-service incurrence or aggravation of a disease or injury; and evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. In addition, hypertension and cardiovascular disease may be presumed to have been incurred during service if they first became manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.307, 3.309(a). Hypertension means diastolic blood pressure predominantly 90mm or greater, and isolated systolic hypertension means systolic blood pressure that is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Note (1). Further, as hypertension and cardiovascular disease are recognized as chronic under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) is for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. The Board must assess the credibility and weight of all the 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 claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Service treatment records contain no findings of complaints, treatment, or diagnosis of hypertension or CAD. Pre-induction examination in January 1970 revealed blood pressure of 132/78. At the time of separation, it was 140/86. In addition, examination of the heart revealed negative findings and chest X-rays were normal. At the time of the Veteran's original VA compensation claim in November 1971, the Veteran requested service connection for injuries to the right wrist and shoulder. Nothing was mentioned about hypertension or a heart problem. At the Veteran's VA examination in November 1972, examination of the cardiovascular system revealed no murmurs and the heart sounds appeared strong and regular. The peripheral vessels also appeared normal. His blood pressure was 118/70. The Veteran was service connected for a right shoulder sprain and assigned a noncompensable rating for this disorder effective from October 1971. The rating for this disability was increased to 10 percent in November 1996, effective from September 1996. There was no mention of hypertension or CAD contemporaneous with his 1996 claim for an increased rating. The Veteran filed the subject claims for service connection for hypertension and CAD in July 2005. The Veteran stated that he was placed on high blood pressure medication while on active duty at Fort Hood, Texas. He further stated that over the course of the year prior to the filing of his claim, he had had one or two heart attacks and had double bypass surgery. VA treatment records for the period of May 2004 to November 2005 reflect that in May 2004, the Veteran's blood pressure was 157/86. It was noted that the Veteran had a recent history of chest pain and that a stress test had revealed hypokinesia with a left ventricle ejection fraction of 38 percent. The impression was probable CAD. A discharge summary from July 2004 reflects that the Veteran had experienced angina the previous six months. He subsequently was found to have CAD and underwent coronary artery bypass grafting times two on July 16, 2004. In September 2004, it was noted that the Veteran had undergone a recent bypass graft at Memphis VA Medical Center. It was also noted that he had a history of degenerative joint disease (DJD). In March 2005, there was a diagnosis of CAD status post bypass and history of DJD of the right shoulder. The plan was for the Veteran to discontinue naproxen (a pain medication that is also found in the prescription drug Naprosyn) and use Tylenol with Codeine. When he underwent a VA examination in February 2006, the Veteran reported starting on hypertension medication during active duty. He stated that because he worked in the hospital, a lot of the medications that were given to him were not really recorded in his record. He added that his medication during service was terminated at the time of his discharge and he did not continue the medication. The Veteran reported that he did not resume the medication until June 2004. He also claimed that his CAD was secondary to his hypertension. He also reported a history of CAD with the development of a coronary artery bypass graft (CABG) in two vessels in July 2004, which was performed at the Memphis VAMC. On review of the Veteran's claims folder, the examiner noted the only two blood pressure readings in service, a pre-induction reading of 132/78 in January 1970, and 140/86 at separation in August 1971. He also made reference to post-service readings from the VA located in Poplar Bluff, Missouri, which revealed the following: 11/9/93 124/80 1/4/94 136/78 3/16/94 144/90 3/17/94 130/78 10/5/94 140/94 12/19/94 139/68 12/28/94 124/96 3/20/95 133/78 6/5/95 140/73 10/12/95 142/80 2/15/96 134/84 3/29/96 136/90 8/29/96 160/88 12/2/96 170/90 2/17/99 133/99 6/17/99 122/86 8/6/99 122/64 8/23/99 142/72 11/9/99 139/68 1/31/00 153/88 5/23/00 129/77 5/25/00 121/75 8/14/00 112/69 The Veteran reportedly was not "started" on blood pressure medication until June 2004. Physical examination revealed blood pressure on the right arm of 118/74, left arm, 116/74, and prone position, right arm, 120/76. Heart sounds were noted at the left mid clavicular line, S1 S2, without rubs or murmurs. The diagnoses were hypertension, essential, which was adequately controlled with medication, and CAD with history of CABG, with future stress test scheduled for February 2006. The examiner noted that it was the Veteran's contention that his hypertension started during active duty, he was treated at that time, and that his treatment was restarted in 2004. However, the examiner observed that the available objective evidence revealed only two blood pressure readings during service, and there were no additional notations. Recognition was given to the Veteran's contention that he worked in a hospital and received most of his medications without record documentation. However, with the lack of additional readings from discharge until 22 years later in 1993, the examiner did not observe any consistency for a diagnosis of hypertension until the late 1990s. Therefore, the examiner could find no chronic development of hypertension that continued from active duty to the present. Thus, the examiner concluded that it was not likely with the evidence available for review that the Veteran's hypertension and CAD were secondary to active duty. A March 2006 rating decision increased the rating for the Veteran's DJD of the right shoulder to 30 percent, effective from August 23, 2005. In December 2006, the Veteran provided an article that addressed the effects of naproxen, a drug that was used for the treatment of mild to moderate pain, inflammation, and fever. It was noted that naproxen may reduce the blood pressure lowering effects of blood pressure medications, and that this may occur because prostaglandins play a role in the regulation of blood pressure. In December 2009, additional VA treatment records were received from the Poplar Bluff VA Medical Center for the period of October 1995 to September 2007. These records indicate that in August 2000, the Veteran was instructed to continue to take current naproxen for his right shoulder pain "as needed." In September 2001 and January 2002, it was noted that the Veteran was to continue to use naproxen for his shoulder pain. In October 2003, the Veteran was to discontinue naproxen. As of May 2004, the Veteran's medications again included naproxen and in a progress note from September 2004, it was noted that the Veteran was to continue to use this medication. In March 2005, the Veteran was once again discontinued on naproxen and prescribed Tylenol with Codeine. These records also reflect additional blood pressure readings on 1/2/01 of 121/77, on 9/17/01 of 136/75, on 1/11/02 of 133/76, on 3/11/02 of 131/84, on 3/19/02 of 129/81, on 5/29/02 of 129/59, on 5/14/03 of 129/70, on 6/24/03 of 129/70, on 10/14/03 of 133/83, on 5/24/04 of 145/79, on 5/26/04 of 157/86, on 6/10/04 of 145/79, on 9/14/04 of 121/77, on 3/22/05 of 153/81, on 6/30/06 of 110/69, on 7/1/06 of 118/76, and on 9/3/06 of 153/78. Also received VA treatment records from the Memphis VAMC for the period of July 2004 to December 2009. In July 2004, the Veteran had blood pressure readings of 131/77, 121/74, 109/65, 119/73, and 138/77. He reported that he had taken blood pressure medications for a short time in the military. Subsequent readings include 111/64 in August 2004, 119/72 in November 2004, 119/72 in January 2005, and 105/65 and 107/69 in March 2005. In September and December 2005, the Veteran's medication list again included naproxen. Between 2/21/06 and 2/22/06, the Veteran had blood pressure readings of 110/62, 112/72, 118/71, 122/82, and 110/73. In March 2006, it was noted that the Veteran's blood pressure would sometimes drop down to 44 and his systolic pressure below 100, and that the plan was to decrease the Veteran's metoprolol. At the end of the month, a VA psychiatric progress note reflects that the Veteran reported that he had taken naproxen long term and feared this medication may have caused some of his health issues. In May 2006, the Veteran underwent a cardiac catheterization. On June 9, 2006, the Veteran's blood pressure was 116/62. On August 6, 2006, the diagnoses included bradycardia likely due to metoprolol and codeine, and hypotension likely due to metoprolol and nitrates, consider decreasing metoprolol. Blood pressure readings at this time were 146/90 and 129/70. On August 19, 2006, the Veteran's blood pressure was 120/80. Between 9/7/06 and 9/8/06, the Veteran had blood pressure readings of 104/71, 92/44, 142/82, and 110/67. Numerous readings for the remainder of the month were not elevated and, if anything, revealed additional hypotensive results on 9/10/06 (97/69), 9/13/06 (94/62), and 9/14/06 (96/54). In December 2006, the Veteran's metoprolol was temporarily discontinued and he was started on Cardizem. The possible use of a pacemaker was discussed. In February 2007, a dual pacemaker was implanted for tachy-brady syndrome. Blood pressure readings on September 10 and 11, 2007 were 121/70 and 119/75, respectively. Blood pressure readings between 10/13/07 and 10/14/07 were 135/76, 130/75, and 108/67, respectively. Blood pressure on 11/22/08 was 136/85. At the end of November 2008, there was a reading of 133/88 and a change in the dose of metoprolol was again considered. In February and August 2009, there were several blood pressures taken with diastolic readings in the 90s. VA heart examination in March 2011 revealed problems of CAD and sick sinus syndrome. It was also noted that the Veteran required continuous medication for control of his hypertension and heart disease. It was the opinion of this examiner that it was unlikely that the Veteran's CAD was caused or aggravated by his non-service-connected hypertension or his service-connected right shoulder disability or the medication prescribed for right shoulder pain. In terms of her rationale, the examiner noted that in March 1995, the Veteran was prescribed ibuprofen as needed for pain. Over the next six months, he used 180 tablets or, on average, about one tablet a day. Although the examiner noted that ibuprofen is one of the non-steroidal anti-inflammatory drugs (NSAIDs) that can be associated with higher rates of cardiac disease, she believed that the very small dose taken by the Veteran over 6 months time was less likely than not to have any effect on the Veteran's coronary arteries nine years after he took the medication. The examiner further noted that no NSAID or pain medication was documented again until 2000, when the Veteran started on Naprosyn, 500mg BID (twice daily) (30 days worth in 1/2000, fairly consistently in 2001, approximately 6 month's worth in 2002-2005, and a 90-day supply in 2006). She pointed out that Naprosyn was the only NSAID that was associated with cardioprotective affect-showing a decreased number of adverse cardiac events with naprosyn use. It was thought to be because Naprosyn had not only anti-inflammatory properties, but also stronger anti-platelet function properties than the other non-selective NSAIDs. The examiner also noted that the Veteran started taking Tylenol #3 (acetaminophen and codeine) on a fairly consistent basis in March 2001 and had been taking it ever since. Opiates are the pain medications of choice in patients who are showing elevations in blood pressure as these are not associated with either elevations in blood pressure or CAD. The examiner further noted that in general, "opioids administered in patients who are not hypovolemic maintain cardiac stability fairly well and depress myocardial contractility only very slightly. (That includes ever the stronger hyrocodone.)" The examiner also opined that it was less likely than not that the Veteran's CAD was aggravated by his nonservice-connected hypertension. The examiner explained that on May 25, 2004, the Veteran first told his VA principal care provider that he had symptoms of chest pressure and neck pain, and had been given a stress test at San Francisco Medical Center. In California, they had found "global hypokinesis and an ejection fraction of 38 percent. In June 2004, he was put on an aspirin and a miniscule amount of metoprolol as preventive measures until a stress test could be done. At that time (May 24, 2004), in all the records that the examiner reviewed, the Veteran had never met the criteria for the diagnosis of hypertension. (Three readings of greater than 140/90 on 3 different days.) While on active duty, he had one blood pressure reading of 140/86, which was the highest reading the examiner could find. The examiner could not find any instances where he was treated for hypertension while on active duty. Reference was also made to the Veteran's July 2004 coronary catheterization and subsequent CABG. The examiner observed that the Veteran was started on medications for his CAD before he was diagnosed with hypertension (metoprolol which was changed to diltiazem and lisinopril which was changed to losartan). These medications lowered blood pressure in addition to their beneficial cardiac affects. After the Veteran was diagnosed with CAD, in 2006, the examiner indicated that hypertension medications were tried - Felodipine was tried for one month, Verapamil was the tried for 2 months, and Isosorbide dinitrate was then tried, which gave the Veteran headaches. This was changed to isosorbide mononitrate, which the Veteran tolerated. Hypertension was not added to his problem list until the end of 2007, when his metoprolol was increased. (His metoprolol was increased again in 2010 to its present dose.) The examiner further concluded that no other medication prescribed by VA aggravated or contributed to his CAD and/or hypertension. VA hypertension examination in March 2011 referenced the Veteran's contention that he was diagnosed as having hypertension in service. He said that he was gaining weight and experiencing dyspnea which caused him to get and evaluation at Fort Hood. He told the examiner that he was treated for hypertension in service. The Veteran reported taking the medication for a few months and then becoming irritable when he went off the medication. Current blood pressure readings (taken in March 2011) were 114/80, 112/74, and 108/74, and it was noted that the Veteran had an ejection fraction of 56 percent. The examiner concluded that it was less likely than not that the Veteran's hypertension was worsened or permanently aggravated by his right shoulder pain or the medication to treat the shoulder. The examiner explained that any pain could temporarily elevate blood pressure, but this didn't cause permanent elevations in blood pressure. Additional VA treatment records from Poplar Bluff VA Medical Center were received in December 2012 and cover the period of December 1975 to August 2006. Most importantly, they note additional blood pressure readings between December 1975 and February 1980 (12/8/75-120/72, 9/2/76-126/76, 9/25/76-120/80, 11/25/76-122/80, 11/26/76-118/76, 12/3/76-110/60, and 2/2/80-120/88), and an additional blood pressure reading from October 1993 (10/5/93-142/92). VA records for the period of December 2009 to January 2013 reflect frequent treatment for heart-related problems. The pain medication regularly prescribed for pain during this period was codeine/acetaminophen. In January 2013, another VA examiner reviewed the entire record, including the March 2011 VA examination reports, and concluded that there was no evidence of hypertension or any other cardiac risk factor during the Veteran's short period of service from 1970 to 1971 that would be responsible for causing CAD in this Veteran. Hence, the examiner concluded that it was unlikely that the currently diagnosed CAD had its onset during the Veteran's active service or was otherwise etiologically related thereto. Initially, the Board notes that the Veteran claims that he was treated for hypertension at a hospital where he worked during service. He says the treatment was informal, which was the reason why there was no written record. There is not a scintilla of evidence to support this assertion. The contemporaneous treatment records do not document his contention. The service discharge examination makes no reference to hypertension, a history of hypertension, or treatment related thereto. It also seems highly unlikely that a physician or medic would break with protocol and prescribe and administer medications with making some type of record. Moreover, as highlighted above, the VA examination conducted in February 1972 was also absent any findings of complaints, treatment, or diagnosis of hypertension and treatment records from 1970s through the 1990s are also silent for any findings of hypertension. Such severely undermines the credibility of the Veteran's assertion. Specifically, had the Veteran experienced hypertension in service and received treatment for the same, one would think he would have reported that history to his care providers. Buczynski v. Shinseki, 24 Vet. App. 221 (2011) ( a lack of notation of symptoms where such notation would normally be expected may be considered as evidence that the symptoms did not exist); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). The Veteran has also provided no salient argument as to why he did not include a claim for service connection for hypertension or CAD with his earlier claims. He was clearly aware of the benefits system and the claims process. Notwithstanding the credibility question discussed above, the Board also notes Veteran has not been shown to have any background or special training that would permit him to diagnose hypertension or CAD, and so while he may be able to describe symptoms such as dizziness, dyspnea, or fatigue, he is not able to diagnose those symptoms as hypertension, CAD, or the early onset of these disabilities. Similarly, although the Veteran is capable of saying that he suffered from a symptom like dyspnea since service, the Board finds that hypertension and CAD are not the type of disabilities that a lay person is capable of linking to service either by way of continuity of symptomatology or nexus to service. Consequently, with respect to a claim that the Veteran's hypertension and/or CAD had its onset during service or to a period of one year following service, there must be competent medical evidence linking such disorders to service, and the record does not contain any such evidence. In fact, the only opinions in the record that address this aspect of the claims are against such a relationship. More specifically, as was noted previously, the February 2006 VA examiner reviewed the record and the Veteran's statements about in-service treatment, and concluded that it was not likely that the Veteran's hypertension and CAD were secondary to active duty, and while the examiner's opinion was largely based on the lack of readings consistent with hypertension until the late 90s, given the fact that additional readings from 1975 to 1980 are also not reflective of hypertension, there is even greater support for this examiner's opinion. The examiner's opinion is also not contradicted by any other opinion of record. Similarly, the most recent VA examiner concluded that there was no evidence of hypertension or any other cardiac risk factor during the Veteran's short period of service from 1970 to 1971 that would be responsible for causing CAD in this Veteran, and that hence, it was unlikely that the currently diagnosed CAD had its onset during the Veteran's active service or was otherwise etiologically related thereto. Although the rationale is not extensive, it is based on an accurate assessment of the record and is also not contradicted by any other medical opinion of record. Consequently, for all of the foregoing reasons, the Board must conclude that a preponderance of the evidence is against the claims on a direct basis or on the basis that these disabilities had their onset within one year of the Veteran's discharge from service. As noted above, the record now contains early post-service treatment records from shortly after the Veteran's discharge from service that do not include elevated blood pressure readings and are devoid of any continuing care or evaluation for hypertension or CAD. The Veteran also maintains that his claimed disorders were caused or aggravated by his service-connected right shoulder disability, including the medications that he has used to treat his service-connected right shoulder disorder. In this regard, the medical opinions of record are all against the claims. Like the case with the Veteran's direct service connection claims, lay witness evidence is also insufficient, on its own, to link the Veteran's hypertension and CAD to the medication used to treat the Veteran's service-connected right shoulder disorder. As for the opinions of record, the Board notes that the March 2011 VA examiner clearly provided an extremely thorough review of the record prior to reaching her opinions in this matter. First, with respect to the question of whether the Veteran's CAD was caused or aggravated by his nonservice-connected right shoulder disability or the medication prescribed therefor, turning first to the Veteran's use of ibuprofen for a six month period beginning in March 1995, the examiner concluded that based on the very small dose taken by the Veteran over that time span, it was unlikely that the Veteran's CAD was caused or aggravated by this medication. The examiner further noted that no non-steroidal anti-inflammatory drug (NSAID) or pain medication was documented again until January 2000, at which time the Veteran started on Naprosyn at 500mg BID, fairly consistently during 2001, approximately 6 month's worth over the time frame of 2002-2005, and a 90-day supply in 2006. However, she pointed out that Naprosyn was the only NSAID that was associated with cardioprotective affect-showing a decreased number of adverse cardiac events with Naprosyn use. It was thought to be because Naprosyn had not only anti-inflammatory properties, but also stronger anti-platelet function properties than the other non-selective NSAIDs. The examiner further pointed out that the Veteran also started taking Tylenol #3 (acetaminophen and codeine) on a fairly consistent basis in March 2001 and had been taking it ever since. She pointed out that opiates are the pain medications of choice in patients who are showing elevations in blood pressure as these are not associated with either elevations in blood pressure or CAD. She further noted that in general, "opioids administered in patients who are not hypovolemic maintain cardiac stability fairly well and depress myocardial contractility only very slightly. (That includes ever the stronger hyrocodone.)" In summary, the examiner concluded that the medication for the Veteran's right shoulder disorder had not been shown to have caused or aggravated his CAD and hypertension because of the small daily dose of ibubrofen in 1995 and because both the Naprosyn (naproxen) and Tylenol with Codeine prescribed in January 2000 and beyond either had a cardioprotective affect (Naprosyn) or had not been shown to have a relationship to elevations in blood pressure or CAD. In addition, following the March 2011 hypertension examination, the same examiner concluded that it was less likely than not that the Veteran's hypertension was worsened or permanently aggravated by his right shoulder pain or the medication to treat the shoulder, noting that any pain could temporarily elevate blood pressure, but this did not cause permanent elevations in blood pressure. Since the record now contains numerous blood pressure readings over the course of many years, the Board has also examined those readings to determine whether there may have been any increase in elevated blood pressure during periods when the Veteran has used pain medication for his right shoulder disability, and this evidence does not support such a relationship. More specifically, after the Veteran began using ibuprofen in March 1995, the record does not reflect an appreciable difference in his readings for the next six months. Similarly, following the Veteran's initial prescription for Naprosyn in January 2000 and continuing thereafter until 2006, there is no indication that the Veteran experienced higher blood pressure readings during his use of this drug. In fact, following an initial diastolic reading of 88 in January 2000, the Veteran never experienced a diastolic reading equal or greater than 88 during the entire time frame between 2000 and 2006. Moreover, in terms of the internet article that has been offered by the Veteran to support his claims, as was noted by the RO, this evidence, which has not been related to the Veteran's case by any physician specifically, only proposes that naproxen may reduce the blood pressure lowering effects of blood pressure medications. It does not maintain that the use of this drug would cause or aggravate hypertension or CAD. In fact, as was noted above, the use of the drug did not result in any greater elevation in blood pressure readings during any of the relevant time periods. In fact, in early 2006, during the period when the Veteran had been taking naproxen, the Veteran's treating physician actually decreased the Veteran's blood pressure medication (metoprolol) because the Veteran was becoming hypotensive, a result which is clearly contrary to any notion that naproxen was aggravating his hypertension. If anything, at that time, his blood pressure medication had been too effective. In addition, to the extent the Veteran's secondary service connection claims also sought service connection for CAD as secondary to hypertension and the Board has determined that service connection is not warranted for hypertension, service connection may not be granted for CAD as secondary to hypertension. See 38 C.F.R. § 3.310(a). In summary, based on all of the foregoing, the Board finds that a preponderance of the evidence is against the claims for service connection for hypertension and CAD, either directly, presumptively, or as proximately due to or aggravated by a service-connected right shoulder disability. (CONTINUED NEXT PAGE) ORDER Entitlement to service connection for hypertension, to include as secondary to a service-connected right shoulder disability, is denied. Entitlement to service connection for coronary artery disease (CAD), to include as secondary to a service-connected right shoulder disability and/or claimed hypertension, is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs