Citation Nr: 1340641	
Decision Date: 12/09/13    Archive Date: 12/20/13

DOCKET NO.  08-01 676	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Providence, Rhode Island


THE ISSUE

Entitlement to service connection for hypertension as secondary to service-connected posttraumatic stress disorder (PTSD).


REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

A. Fagan, Associate Counsel


INTRODUCTION

The Veteran served on active duty from January 1968 to October 1969. 

The appeal comes before the Board of Veterans' Appeals (Board) from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to service connection for hypertension.

This matter was remanded by the Board in October 2011 for additional development.  In March 2013, the Board obtained a medical opinion from the Veterans Health Administration (VHA) in accordance with 38 C.F.R. § 20.901(a) (2013).  An addendum opinion was obtained in August 2013.  In a September 2013 letter, the Veteran was afforded an opportunity to respond to the VHA opinion.  In November 2013, the Veteran's service representative submitted additional evidence accompanied by a waiver of RO consideration.  38 C.F.R. § 20.1304 (2013).

The Board notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim.  A review of the documents in such file reveals that they are either duplicative of the evidence 
in the paper claims file or are irrelevant to the issue on appeal.


FINDING OF FACT

The most probative evidence of record does not link the Veteran's hypertension to his service-connected PTSD. 


CONCLUSION OF LAW

The criteria for establishing service connection for hypertension secondary to PTSD have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013).



REASONS AND BASES FOR FINDING AND CONCLUSION

I.  Duties to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim.  VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013).

The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain.  38 C.F.R. § 3.159(b) (2013).  Compliant VCAA notice was provided in a January 2007 letter.  Neither the Veteran nor his representative has alleged or demonstrated any prejudice with regard to the content or timing of the notice.  See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination).  See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). 

The record also reflects that VA has made reasonable efforts to obtain relevant records.  In this regard, the RO obtained service treatment and personnel records, relevant post service treatment records, and VA examination and opinion reports.  Additionally, the Board obtained a supplemental VHA opinion and addendum.  Also of record and considered in connection with the claim are various lay statements and medical articles.  The Veteran has not identified any other evidence relevant to this claim. 

The Board notes that it previously remanded the matter on appeal in October 2011 for development, to include a VA examination and to obtain ongoing VA treatment records.  The requested VA examination and opinion were obtained in November 2011, and the Board supplemented the opinion with a VHA opinion and 
addendum.  Ongoing VA treatment records were also associated with the claims file.  Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary.  See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). 

As discussed above, the VCAA provisions have been considered and complied with.  The appellant was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the appellant and VA in obtaining such evidence.  Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so.  Thus, consideration of this matter on the merits at this time is appropriate.

II.  Service Connection

The Board has reviewed all the evidence in the record.  Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail.  Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim herein decided and what the evidence in the claims file shows, or fails to show, with respect to that claim.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).

The Veteran contends that he has hypertension secondary to service-connected PTSD and that his blood pressure has remained elevated even while on medication due to increasing symptoms of PTSD.  As the Veteran alleges entitlement to service connection on a secondary basis only, and the record does not otherwise raise a theory of entitlement to service connection for hypertension on a direct or presumptive basis, the Board will not address those theories of service connection.  

Service connection may be established for disability which is proximately due to or the result of a service-connected disability.  38 C.F.R. § 3.310(a) (2013).  Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown.  38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995).  Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened.  See Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002). 

By way of history, the record shows that the Veteran was diagnosed with hypertension in August 2000.  In an October 2006 VA treatment note, a PTSD screen was positive, and he was diagnosed with PTSD based on military combat experiences on VA examination in December 2006.  A January 2007 RO decision awarded service connection for PTSD and assigned an initial 30 percent rating; and a June 2010 RO decision increased the assigned rating for PTSD to 50 percent, effective May 6, 2009. 

The record contains various positive and negative opinions pertaining to a possible nexus between the Veteran's PTSD and hypertension.  For reasons explained below, the Board finds that the most probative and persuasive opinion evidence of record is against the Veteran's claim, and thus, service connection for hypertension is denied.

Initially, the Board finds the most probative and persuasive evidence of record to 
be a March 2013 opinion and August 2013 clarifying addendum from a VHA examiner, indicating that it is less likely as not that the Veteran's hypertension is caused by his PTSD.  In support of the opinion, the VHA examiner noted that the record shows that the Veteran was diagnosed with hypertension in 2000, prior to 
his reported exacerbation of PTSD symptoms in 2001 and prior to significant worsening in 2006.  The examiner acknowledged the Veteran's statement that his PTSD symptoms were present for decades prior to the hypertension diagnosis, 
and that there is medical literature that has found an association between PTSD 
and hypertension.  However, he noted with reference to medical literature accompanying the March 2013 opinion, that vulnerability factors that predispose trauma-exposed populations to mental health conditions are most likely shared with vulnerability factors for the development of hypertension and other general medical conditions.  It was also noted that most persons with hypertension do not have PTSD, and not all persons with PTSD have hypertension.  He also determined that to conclude that a specific individual's hypertension is related to his/her PTSD would be speculative.  Regarding whether the Veteran's hypertension is permanently worsened by hypertension, the examiner opined that the answer is "currently not knowable."  He stated that although it is known in a very few 
cases the physiologic mechanism(s) that contribute to hypertension (such as pheochomocytoma and renal artery stenosis), there are currently no available objective measures that can directly measure the presence of a mechanism for PTSD symptoms.  Therefore, to answer the question or to attempt to quantify a degree of aggravation would be "entirely speculative."

The March 2013 opinion and August 2013 addendum were based on a review of 
the Veteran's claims file, addressed positive evidence of an association between hypertension and mental health, cited to pertinent clinical findings of record, and included a rationale accompanied by an abstract of findings from a relevant medical study.  Therefore, they are accorded significant probative value.  Moreover, while the examiner indicated that an opinion regarding aggravation would be speculative, he supported that conclusion with adequate rationale.  See Jones v. Shinseki, 23 Vet. App. 382 (2010).  

The Board also finds the 2013 VHA opinions to probative as they are consistent with the medical evidence of record, which shows that hypertension was diagnosed prior to PTSD and that the Veteran's hypertension remained generally stable through the period on appeal.  For example, VA treatment notes show in June 2007 and December 2007, the Veteran's blood pressure readings were 140/82 and 130/84 respectively.  During February 2009 VA treatment, blood pressure was 112/66 and noted to be under good control.  A June 2009 private treatment similarly notes blood pressure under control.  During VA treatment in October 2009, readings were 134/70 and 122/66 in the right arm, and 136/72 and 124/68 in the left arm.  In April 2010, blood pressure was as low as 106/66 and again noted to be under good control.  The 2013 VHA opinions are also consistent with a November 2011 VA examination opinion that the Veteran's hypertension was neither caused by nor aggravated by his PTSD.  The examiner reasoned that hypertension was diagnosed prior to PTSD and had "remained fairly stable over the last couple of years."  Given that the November 2011 opinion was based on a review of the claims file, physical examination of the Veteran, and was supported by rationale, the Board also accords it significant probative value.

While the Veteran, his friend, and service representative have challenged the expertise of the nurse practitioner who performed the November 2011 examination, they have not provided any specific reasons as to why the nurse practitioner is not qualified to give such an opinion.  Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed. Cir. 2010).   Therefore, absent persuasive argument or evidence that the November 2011 opinion was flawed or inaccurate, or that the nurse practitioner was otherwise not qualified to render an opinion, the Board finds the November 2011 opinion to be competent.  See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (physician's assistant was competent to perform examination); Goss v. Brown, 9 Vet. App. 109 (1996) (recognizing that nurses' statements regarding nexus were sufficient to make a claim well grounded); Williams v. Brown, 4 Vet. App. 270, 273 (1993) (finding opinions of a VA registered nurse therapist competent medical testimony and requiring the Board to provide reasons or bases for finding those opinions unpersuasive).

For the foregoing reasons, the Board accords the March 2013 opinion and August 2013 addendum great probative weight, and finds the opinions to be generally supported by medical evidence of record, including a November 2011 VA opinion.

In contrast, the Board finds the evidence in support of the Veteran's claim to be neither probative nor persuasive.

Specifically, an April 2009 VA examiner opined that the Veteran's hypertension is "at least as likely as not 50/50 probability caused by or a result of PTSD." However, he failed to reconcile that conclusion with evidence of record - notably, evidence acknowledged by the VA examiner in the report - showing that the Veteran was diagnosed with hypertension several years prior to being diagnosed with PTSD.  Absent supporting rationale, it is unclear how the examiner concluded that PTSD could have caused preexisting hypertension.  Nor did the examiner address other risk factors of record, including the Veteran's high body mass index.  Thus, that opinion is afforded little probative value, as it is contrary to the evidence of record and unsupported by adequate rationale.  See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship 
to other items of evidence).

Parenthetically, the Board points out that an addendum opinion was provided by the VA examiner in May 2009 regarding the possibility of permanent aggravation of the Veteran's hypertension by his PTSD.  However, the examiner indicated that he could not come to a conclusion without resorting to mere speculation, and provided no rationale for that statement.  While that conclusion is consistent with the VHA examiner's opinion regarding aggravation, it was unaccompanied by rationale.  The Court has held that an examiner's report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement.  See Jones v. Shinseki, 23 Vet. App. 382 (2010).  Thus, as no rationale was provided, that opinion is afforded no probative value.  

In a May 2009 treatment note, a VA physician noted that the Veteran had PTSD and indicated that it "could push his BP up a little."  However, the physician provided no explanation for the statement, and such statement is speculative at best.  As such, it is afforded little, if any, probative weight.  See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009) (holding that a doctor's statement that a veteran's brain tumor "may well be" connected to Agent Orange exposure was speculative); Bloom v. West, 12 Vet. App. 185, 187 (1999) (noting that the use of the term "could," without other rationale or supporting data, is speculative); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). 

Also in support of the Veteran's claim is a June 2009 consultation report from private cardiologist, S. F., M.D., which shows an assessment of well-controlled hypertension with PTSD and depression.  The report shows that prior to performing a physical examination, Dr. S. F. obtained a subjective history from the Veteran that included his present complaints, medications, family and social history, and review of symptoms.  The physician explained that, at present, the Veteran did not appear to have any ongoing symptoms to suggest a change in his cardiovascular status.  
He also noted that PTSD has an unpredictable impact on the development of cardiovascular disease.  Nevertheless, he indicated that certainly studies have shown a link and, while the Veteran's blood pressure appeared to be well controlled at present, it seemed from his history that it is likely that his PTSD and depression were likely having a significant contribution to his blood pressure elevation.  In a January 2012 treatment note, Dr. S. F. found that the Veteran's blood pressure was inadequately controlled and had remained elevated since June 2009, when it was last noted to be well-controlled.  He then stated that it "is evident that [the Veteran's] concerns about the impact of post traumatic stress syndrome on his health is likely amplifying his BP."  Dr. S. F. found that the Veteran may benefit from an increase in medication.

As with the April 2009 VA opinion, the private June 2009 opinion is accorded little probative value.  Without a more detailed rationale, the physician's June 2009 opinion that PTSD was significantly contributing to blood pressure elevation appears to be contradicted by his conclusions that the Veteran's hypertension is well controlled and that there did not appear to be a change in cardiovascular status.   Moreover, Dr. S. F. did not describe how the Veteran's hypertension disability had permanently worsened beyond the normal progression.  In this regard, it does not appear that Dr. S. F. had the opportunity to review the Veteran's recent VA treatment records to accurately determine whether hypertension permanently worsened in severity beyond normal progression due to PTSD.  The Board also points out that, while the Veteran indicated that he provided his records to Dr. S. F. for review, the June 2009 report indicates the report is "a review of [the Veteran's] clinical findings and an assessment;" it does not reference a review of the Veteran's medical records.  For these reasons, the Board finds the June 2009 opinion neither particularly probative nor persuasive.

Regarding the January 2012 treatment note authored by Dr. S. F., the Board points out that the statement suggests a link between the Veteran's blood pressure and his concern over the affect PTSD has on his blood pressure; it does not provide a nexus between PTSD symptoms and blood pressure.  The Board also notes that, while Dr. S. F. stated that the Veteran's blood pressure had remained elevated (and was thus, presumably uncontrolled) since June 2009, the same treatment note indicates that the Veteran observed that his "BP has remained elevated, which was noted in August for the first time" (emphasis added).  Again, the physician appears to contradict himself as with the earlier June 2009 opinion.  

Moreover, relevant VA treatment notes contradict the January 2012 notations that Veteran's blood pressure had been elevated since June 2009, or even since August 2011.  For example, as stated, blood pressure readings in October 2009 were 134/70 and 122/66 for the right arm, and 136/72 and 124/68 for the left arm.  In April 2010, blood pressure was 106/66 and hypertension was noted to be in good control.  More recently, a September 2011 VA treatment was 130/88, and hypertension was assessed as fair.  The Board also points out that VA mental health treatment notes during the period on appeal also frequently indicate the Veteran to be stable or "basically appear stable," and that in March 2012, the Veteran reported that he ended his therapy because he "thinks he has had enough therapy at this time."  This evidence tends to contradict the Veteran's assertion of worsening PTSD symptoms, which in turn, he alleges are worsening his hypertension.  

Given the inherently contradictory nature of the June 2009 private opinion and January 2012 treatment note, as well as the inaccurate factual predicate on which the latter opinion was based, the Board finds the opinions to lack probative value and to be outweighed by the VHA opinion and addendum.

The Board recognizes that the Veteran subsequently submitted a February 2012 statement from his primary care physician, Dr. R. L., recounting various prior blood pressure readings and medication changes since diagnosis of hypertension 2000.  However, that physician offered no opinion regarding any nexus between PTSD and hypertension.  Thus, that statement is not probative of an etiological link between the Veteran's PTSD and hypertension.  Nor does that statement otherwise support aggravation of the Veteran's hypertension by PTSD.  Indeed, while the Veteran has reported significant worsening of his PTSD symptoms in 2006 and thereafter, and relates a worsening of hypertension to those symptoms, the February 2012 statement shows that elevated blood pressure readings and increases in medication for hypertension occurred multiple times prior to 2006 when the Veteran was diagnosed with PTSD.

To the extent that the Veteran, and his friend in a statement dated in February 2012, have alleged that the Veteran suffered from PTSD symptoms prior to 2006 and since service, the Board finds those reports to lack credibility due to inconsistent statements.  For example, upon presenting for initial VA treatment in October 2006, the Veteran stated that when he came back from Vietnam he was depressed but did nothing about it.  He then reported that his symptoms became worse about three years prior (around 2003).  Then, during December 2006 treatment, he reported that he had symptoms of difficulty sleeping, nightmares, and intrusive thoughts about his military service "when he first came home from Vietnam, but then they dissipated, and now they have reemerged over the past year or so" (around 2005)].  During a PTSD examination the same month, the Veteran alternatively reported that he has "always been vigilant and has had nightmares with night-sweats and that these have increased ever since 09/11/01..."  In February 2007, he stated that "the symptoms began after attending a military reunion in July 2006."  He "reported that he was depressed for about 1 year after coming back from Vietnam" and that "he felt better until July 2006 when he attended a reunion related to his Vietnam service."  The Board also points out that during a private "comprehensive examination" in October 1998, and again in August 2000, the Veteran denied complaints.  In November 2000, he was even noted to be "doing well."  Based on the foregoing evidence, the Board finds that the lay statements of the Veteran and his friend indicating that the Veteran has had PTSD symptoms since service lack credibility as they are either internally inconsistent or contradicted by other evidence of record.  Further, as those statements were made in support for a claim for benefits, they are afforded less probative weight.  See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (the credibility of a witness can be impeached by a showing of interest, bias, or inconsistent statements).

Given the varying accounts of both onset and exacerbation of symptoms, the 
Board must rely on the objective evidence of record relating to onset of both hypertension and PTSD, and the objective and probative evidence shows a diagnosis of hypertension in 2000 and PTSD in 2006.

Moreover, to the extent that the Veteran and his friend contend that the Veteran's hypertension was caused by or is permanently worsened by his PTSD, neither 
has not been shown to have the requisite training or expertise to offer a medical opinion.  Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis).  Thus, their statements do not constitute competent medical evidence.  In any event, the Board concludes that the most probative medical evidence of record, which 
does not support that the Veteran's hypertension was caused by or is permanently aggravated by his PTSD, is of greater probative value than the lay contentions of the Veteran and his friend.

The Board recognizes that the Veteran, his friend, and his service representative have submitted evidence from various medical journals or treatises in support of an association between PTSD and heart disease or hypertension.  The Board notes that a treatise "can provide important support when combined with an opinion of a medical professional" if the 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 lay 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).  Here, the treatise information included in the claims file does not specifically 
relate to the facts and circumstances surrounding this particular case.  Rather, the information is general.  Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim.  Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996).  Thus, this information, alone, is of little probative value.  

Finally, the Board notes that the treatise evidence supports an association between PTSD and heart disease or hypertension primarily in the form of causation; the articles do not specifically discuss aggravation in the form of permanent worsening of hypertension by PTSD.  The article submitted by the service representative entitled Posttraumatic Stress Disorder and Cardiovascular Disease, has a section dedicated to "STUDIES OF PTSD AND HYPERTENSION," which notes that veterans with mental health diagnoses have a "significantly higher frequency" of hypertension and other cardiovascular risk disease factors.  (The Board observes that the record shows that the Veteran to have other risk factors, including a high body mass index, a family history of coronary artery disease, and daily alcohol use).  That article, however, does not indicate that PTSD causes permanent worsening of hypertension.  The fact sheet from the National Center for PTSD submitted by the Veteran, and the article entitled PTSD Causes Early Death From Heart Disease, Study Suggests submitted by the Veteran's friend, discuss a link between PTSD, physical health, and the likelihood of death from heart disease, but does not specifically discuss aggravation of hypertension by PTSD.  Thus, the treatise evidence of record does not support that PTSD permanently worsens hypertension, and are therefore not probative of aggravation.  Moreover, as the most probative and persuasive objective evidence of record here shows that the Veteran's hypertension was diagnosed six years prior to PTSD, the Board finds that the treatises do not lend support to the Veteran's claim based on causation.

In sum, the Board finds that the most probative evidence indicates is against a link between the Veteran's current hypertension and his PTSD, either by causation or aggravation.  While there is some evidence of record to support a general association between PTSD and hypertension, primarily one of causation, the positive opinion evidence of record is not supported with adequate rationale or clinical findings showing that this Veteran's hypertension was caused by or is permanently worsened by his PTSD.  Accordingly, service connection for hypertension secondary to PTSD is not warranted.  

In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine.  However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal.  See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990).


ORDER

Service connection for hypertension secondary to PTSD is denied.



____________________________________________
K. A. BANFIELD
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs