Citation Nr: 1331103 Decision Date: 09/26/13 Archive Date: 09/30/13 DOCKET NO. 07-17 879 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office in Los Angeles, California (RO). In his May 2007 substantive appeal, the Veteran indicated that he wished to have a hearing before the Board with respect to his claim. However, in a March 2012 statement, the Veteran withdrew his request for such hearing and requested that the Board proceed with adjudication of his appeal. The Veteran's appeal was remanded by the Board in May 2013 for an additional VA opinion addressing whether the Veteran's hypertension was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). A VA opinion discussing this issue was obtained in May 2013. Accordingly, the Board finds that there has been substantial compliance with the directives of the May 2013 remand in this case, such that an additional remand to comply with such directives is not required. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran has a current diagnosis of hypertension. 2. The evidence of record does not establish that the Veteran experienced symptoms of chronic hypertension during service or continuous symptoms of hypertension since separation from service. 3. The Veteran's hypertension did not manifest within one year of separation from service. 4. The Veteran's hypertension is not causally or etiologically related to service. 5. The Veteran's hypertension is not causally or etiologically related to his service-connected PTSD; nor was it aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C.A. §§ 1110, 1112, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Letters dated in July 2005 and July 2008 satisfied the duty to notify provisions and notified the Veteran of the regulations pertinent to the establishment of an effective date and of a disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's service treatment records, VA treatment records, and identified private treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that the Veteran is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1320-21 (Fed. Cir. 2010). The Veteran was provided with a VA examination to determine the etiology of his June 2012, and in May 2013, a supplemental VA opinion discussing whether the Veteran's hypertension was aggravated by his service-connected PTSD was obtained. Review of the opinions reflects that they are adequate upon which to base an appellate decision, as the opinions provided are based upon a complete review of the evidence in the claims file as well as the Veteran's contentions, and are supported by explanation and rationale. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Review of the record does not indicate that additional evidence pertinent to the issue adjudicated in this decision is available, but not associated with the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that VA did not provide sufficient notice or assistance, such that it reasonably affects the outcome of the case, the Board finds that any such lack of sufficient notice is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Veteran contends that service connection for hypertension is warranted, and that his hypertension is either directly related to his active duty service or was caused or aggravated by his service-connected PTSD. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). 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) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2012). 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 if the disability is one that is listed in 38 C.F.R. § 3.309(a). The Federal Circuit recently held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under the pertinent regulations, hypertension means that the diastolic blood pressure is predominantly 90 millimeters (mm.) or greater, and isolated systolic hypertension means that the systolic blood is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The Veteran's service treatment records are silent as to any complaints of or treatment for hypertension or elevated blood pressure. A May 1965 pre-induction examination shows that the Veteran's heart was normal. Blood pressure at that time was reported to be 120/80. In a report of medical history, completed at that time, the Veteran denied a history of high or low blood pressure. A May 1967 separation examination also reveals that the Veteran's heart was normal. Blood pressure was reported as 118/82. In a report of medical history, completed at that time, the Veteran denied a history of high or low blood pressure. Private medical treatment records from 1990 to 2004 reveal findings of elevated blood pressure. In July 1991, blood pressure was 120/90. In February 1997, blood pressure was 138/93. In October 1997, blood pressure was 169/99, and hypertension was diagnosed. A November 1997 treatment record reflects that blood pressure was 140/90, and hypertension was diagnosed. Private treatment records from 1999 through 2004 reflect continued elevated blood pressure readings, as well as diagnoses of and treatment for hypertension. A May 2004 treatment record notes that the Veteran was sedentary and obese with a stressful lifestyle. Low sodium diet was discussed along with weight management as a way to manage his high blood pressure. VA treatment records from September 2006 through May 2007 reflect elevated blood pressure readings and diagnoses of essential hypertension. A September 2006 record notes that the Veteran used to take hypertension medication in 2003, but that he stopped the medication because it made him depressed. He noted that he started eating better, and that his blood pressure was okay. He denied exercising lately, and indicated that this caused his blood pressure to go up. He stated that he last saw a physician one year before. In June 2012, the Veteran underwent a VA hypertension examination. The Veteran reported that he saw a private physician and that he had hypertension medication prescribed by his private physician. Blood pressure at that time was 138/93. The examiner reported that the Veteran had other pertinent physical findings, including obese body habitus at a body mass index of 37. The diagnosis was hypertension. After reviewing the Veteran's claims file, the examiner opined that the Veteran's hypertension was less likely than not proximately due to or a result of his service-connected PTSD. The examiner explained that the Veteran's service treatment records were silent for any elevated blood pressure readings and his post-service medical records showed elevated blood pressure readings in 1991, a diagnosis of hypertension in 1997, and a diagnosis of PTSD in 1996. The examiner stated that obesity, high sodium intake, and a sedentary lifestyle were well-recognized major risk factors for hypertension, and noted that the Veteran's hypertension was consistent with this etiology, as his body mass index was 37, prior medical records revealed that his blood pressure increased with reduced exercise, and he was advised to reduce sodium intake and increase cardiovascular activity. Accordingly, the examiner concluded that, as is the case for most people who have hypertension, the Veteran's hypertension was caused by his lifestyle choices, and that his obese body habitus, high sodium intake, and sedentary lifestyle were not related to his active duty service. In a May 2013 supplemental opinion, the examiner who provided the June 2012 opinion stated that the Veteran's hypertension was not aggravated by his service-connected PTSD. The examiner explained that the Veteran's hypertension was aggravated by lifestyle and nutritional choices and that there was no evidence to support a relationship between the Veteran's hypertension and his active duty service or service-connected PTSD. The examiner again stated that the Veteran's hypertension was due to his well-documented obesity, high sodium intake, and sedentary lifestyle. After a thorough review of the evidence of record, the Board concludes that service connection for hypertension, to include as secondary to service-connected PTSD, is not warranted. There is a current diagnosis of hypertension. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Hypertension was not diagnosed within one year after service discharge, as the first medical evidence of a diagnosis of hypertension was in 1997. Accordingly, service connection is not warranted on a presumptive basis. See 38 U.S.C.A. § 1101, 1112, 1113, 1137; see also 38 C.F.R. § 3.307, 3.309. Additionally, there is no evidence of hypertension or elevated blood pressure readings during service, and the Veteran does not contend that he had hypertension during service. Therefore, there is no evidence of in-service incurrence of hypertension. Moreover, the competent and credible evidence of record does not relate the Veteran's hypertension to his active duty service or to a service-connected disability. In that regard, the only medical evidence of record addressing the etiology of the Veteran's hypertension are the June 2012 and May 2013 VA opinions, which found that the Veteran's hypertension was not directly related to service and that his hypertension was not caused or aggravated by his service-connected PTSD. The June 2012 and May 2013 VA opinions are supported by supporting explanation and rationale, and are based upon a review of the Veteran's claims file. Accordingly, the Board finds them to be probative. Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that factors for assessing the probative value of a medical opinion include access to the claims file and the thoroughness and detail of the opinion). Accordingly, the only probative medical evidence of record does not relate the Veteran's hypertension to his active duty service or to his service-connected PTSD. Although hypertension is a chronic disease and may be found to be service-connected when there is evidence of continuity of symptomatology since the condition was noted during service, there is no evidence of hypertension during service. Moreover, the Veteran has not alleged that he has had hypertension consistently since active duty service. 38 C.F.R. §§ 3.303(b), 3.309(a); see also Walker, 708 F.3d 1331. In that regard, the first medical evidence of elevated blood pressure readings was in 1991, and the first evidence of a diagnosis of hypertension was in 1997, nearly 30 years after the Veteran's discharge from service. The Veteran has not stated that he had symptoms of hypertension during service and continuously since that time, and the evidence does not show continuity of symptomatology. For the foregoing reasons, the criteria for entitlement to service connection for hypertension are not met, as the preponderance of the evidence is against the claim. There is no doubt to be resolved, and service connection is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hypertension is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs