Citation Nr: 1331511 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 05-24 934 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUE Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION The Veteran served on active duty from June 1970 to January 1972. He is shown to have served in the Republic of Vietnam from January 1971 to January 1972. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the RO. The Veteran requested a hearing with the Board, but later withdrew his request in February 2007. The Board remanded this matter in September 2010, April 2012 and in September 2012 for additional development. The Board denied service connection for peripheral neuropathy in September 2010 and for visual problems in April 2012. In a January 2012 rating decision, service connection was granted for posttraumatic stress disorder (PTSD). An initial rating of 30 percent was assigned, effective on July 6, 2004. An increased rating of 50 percent was assigned, effective on August 19, 2008, and a 70 percent rating was assigned, effective on October 22. 2010. The issue of entitlement to a total disability rating based on individual unemployability by reason of service-connected disability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction and refers the matter to the AOJ for appropriate action. The records in the Virtual VA paperless claims processing system and the Veterans Benefits Management System have been reviewed and considered. FINDING OF FACT The currently demonstrated hypertension is not shown to be caused or aggravated by the service-connected PTSD and/or diabetes mellitus. CONCLUSION OF LAW The Veteran's disability manifested by hypertension is not proximately due to or the result of the service-connected PTSD and/or diabetes mellitus. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012); 3.310 (prior to October 2006). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. The January 2005 and March 2006 letters provide the Veteran with notice of VA's duties to notify and assist him in the development of his claim consistent with the law and regulations outlined hereinabove. In this regard, these letters informed him of the evidence and information necessary to the substantiate his claim, the information required of her to enable VA to obtain evidence in support of his claim, and the assistance that VA would provide to obtain information and evidence in support of his claim. The Board also finds that VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. The Veteran's service treatment records are associated with his claims file, and VA has obtained all pertinent/identified records that could be obtained and development requested in the September 2010 and April 2012 remands were completed. The Veteran was also afforded VA examinations that were adequate for adjudication purposes. Finally, the Board requested and opined a VHA medical opinion in June 2013. Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C.A. § 1110. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected condition. See 38 C.F.R. § 3.310. Service connection is possible when a service-connected condition has aggravated a claimed condition, but compensation is only payable for the degree of additional disability attributable to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In October 2006, VA amended 38 C.F.R. § 3.310 to incorporate the Court's decision in Allen except that VA will not concede aggravation unless there is medical evidence showing the baseline level of the disability before its aggravation by the service-connected disability. 38 C.F.R. § 3.310(b). In this case, the Veteran applied for service connection prior to the effective date of the amendment. As the Veteran's claim was pending prior to the effective date of the revised 38 C.F.R. § 3.310, the Board will consider the version in effect prior to October 2006, as it is more favorable to the claimant. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. Analysis In his claim of service connection for hypertension received in July 2004, the Veteran related the onset of his hypertension to exposure to Agent Orange in 1971 while serving in the Republic of Vietnam. The Veteran is service connected for both PTSD and diabetes mellitus based on his service in the Republic of Vietnam. In connection with VA outpatient treatment in June 2004, the assessment was that of hypertension improved control, diabetes mellitus improved control and anger management. In addition, according to a recently identified March 2012 article, studies had shown that people with PTSD had an increased risk in developing physical health problems, including heart-related disease and diabetes mellitus. A VHA medical reviewer in a June 2013 opinion noted that there was increasing evidence in the medical literature indicating that patients with PTSD had an increased incidence of cardiovascular disease and hypertension. The VHA medical reviewer identified a recent study that analyzed the relationship between PTSD, insulin resistance and a "metabolic syndrome" manifested by a cluster of conditions including elevated blood pressure, increased blood sugar levels, elevated cholesterol and excess body fat. The study was noted to conclude that patients with PTSD were "significantly more likely to develop insulin resistance and metabolic syndrome." The VHA medical reviewer added that the etiology "tended to be multifactorial usually involving a combination of a genetic predisposition and environmental factors as well as lifestyle" and that medical literature indicated a "strong correlation" between PTSD and hypertension, rather than a "causative relationship." Significantly, the VHA medical reviewer noted that "diabetes mellitus, on the other hand, [was] a well known independent risk factor for cardiovascular disease and hypertension tend[ed] to be about twice as frequent in patients with diabetes mellitus than without. In conclusion, the VHA examiner opined that, in the case of this Veteran who was diagnosed with both PTSD and diabetes mellitus, it was "reasonable to conclude that the combination of the service-connected PTSD and [d]iabetes [m]ellitus contributed to his [h]ypertension. The evidence against the claim consists of VA opinions dated in December 2004, October 2010 with an addendum in November 2011, June 2012 with an addendum in November 2012. In December 2004, the examiner concluded that there was no known cause for essential hypertension and that it was less likely as not caused by diabetes mellitus. In October 2010, a VA examiner concluded that "[i]t [was] 'less likely as not' that the [V]eteran [was] service connected for hypertension based on diabetes mellitus. The hypertension was noted to have been diagnosed at the time of diagnosis of diabetes mellitus. The [V]eteran [did] not have renal dysfunction." In an addendum in November 2011, the examiner concluded that "[i]t [was] less likely as not that diabetes mellitus ha[d] aggravated the [V]eteran's hypertension. His renal function [was] normal as discussed." In June 2012, a VA examiner concluded that it was less likely than not that hypertension was proximately due to or the result of the diabetes mellitus in that the hypertension preceded the diagnosis of diabetes mellitus, that the Veteran was taking a low dose of blood pressure medication and had mild elevation of blood pressure, and that diabetes mellitus had been well controlled with oral medication since 2009. In an addendum opinion in November 2012, the VA examiner explained that hypertension was not aggravated by the service-connected diabetes mellitus because the Veteran had hypertension before he was diagnosed with diabetes mellitus and had normal renal function. The VA examiner also concluded that hypertension was not caused or aggravated by the service-connected PTSD based on the rationale that risk factors for hypertension did not include emotional issues and the current literature did not show that a mental disorder could cause or aggravate hypertension. With regard to medical opinions, the credibility and weight to be attached to a medical opinion are within the Board's province as finder of fact. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Greater weight may be placed on one opinion over another depending on factors such as reasoning employed and whether the examiner was informed of the relevant facts. Nieves Rodriquez v. Peake, 22 Vet. App. 295 (2008). Among the factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The June 2013 VHA opinion and the November 2012 VA opinion addendum are the only two medical statements addressing the relationship between hypertension and the service-connected PTSD in this case. On close review of the record, the Board finds that the June 2013 VHA opinion was based on a careful review of the record and identified a recent medical studies to support its conclusion that there was "strong correlation" between PTSD and hypertension as well as the development of insulin resistance and what was characterized as "metabolic syndrome" that included increased blood pressure. However, the VHA medical opinion reviewer acknowledged that this did not serve to establish a "causative relationship." On the other hand, the VA examiner in the addendum opinion in November 2012 also concluded that hypertension was not aggravated by PTSD based on the rationale that the "current literature" did not show that a mental disorder could cause or aggravate hypertension. Significantly, the examiner added that the record did not show diabetic nephropathy. This, in the Board's opinion, clearly would indicate that the cause of the Veteran's hypertension was not related to pathology of the kidney that was commonly produced by diabetes mellitus and would suggest a more idiopathic etiology for the onset of his elevation of blood pressure. To the extent that these medical opinions are based on same conclusion regarding the current scientific research, the evidence does not serve to establish that the Veteran's hypertension in this case was caused or aggravated by the service-connected PTSD and/or diabetes mellitus for the purpose of granting service connection. ORDER Service connection for hypertension as secondary to the service-connected PTSD and diabetes mellitus is denied. ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs