Citation Nr: 1604571 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 09-23 451A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for hypertension, including as secondary to posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from rating decisions issued by the Montgomery, Alabama Regional Office (RO) of the Department of Veterans Affairs. In a February 2008 rating decision, the RO denied service connection for hypertension. In a September 2009 rating decision, the RO denied service connection for hypertension, including as secondary to PTSD. In November 2013, the Board remanded the case to the RO for the development of additional evidence. The Board is satisfied that there has been substantial compliance with the remand directives. The Board will proceed with review of the case. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT Symptoms of the Veteran's service-connected PTSD likely increase his blood pressure and worsen his hypertension. CONCLUSION OF LAW The criteria for secondary service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. § 3.310(b) (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2015). Under the notice requirements, VA is to notify the 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, VA will attempt to obtain. 38 C.F.R. § 3.159(b). VA satisfied the duty to notify provisions in letters issued in May 2007 and July 2009. In those letters, VA advised the Veteran what information was needed to substantiate claims for service connection, on direct and secondary bases. VA also advised the Veteran how VA assigns disability ratings and effective dates. In the November 2013 remand, the Board directed that the RO schedule a VA medical examination with file review and opinion. An examination was performed in December 2013. The examiner provided opinions addressing the questions raised in the remand instructions. The Board is satisfied that there has been substantial compliance with the remand directives, such that additional remand is not needed. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran's claims file contains service medical records, post-service medical records, and reports of VA medical examinations. He has had a VA examination that provided adequate information about the issue on appeal. The Board finds that the Veteran was notified and aware of the evidence needed to substantiate the claim, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Hypertension The Veteran contends that he has hypertension that has been aggravated by his service-connected PTSD. Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection for certain chronic diseases, including hypertension, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service of ninety days or more during a period of war. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. 38 C.F.R. § 3.310(b). 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. 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 v. Derwinski, 1 Vet. App. 49, 54 (1990). The Veteran's service treatment records contain readings of blood pressure within normal limits, and do not contain any findings of elevated blood pressure or hypertension. The preponderance of the evidence thus is against onset of hypertension during service. The Veteran has not indicated that he was found to have hypertension during the year following his separation from service, and he has not identified any medical treatment during that year. Therefore there is no basis to presume service connection for hypertension. In December 1999, private primary care physician C. P. R., D.O., found that the Veteran had hypertension. The Veteran reported that he had been told he was hypertensive, but had not been on any medication for hypertension. Dr. R. started him on antihypertensive medication. Records show ongoing treatment for hypertension. From 2005 forward, Dr. R. noted that he had psychiatric symptoms or disorders including PTSD, anxiety, and depression. Dr. R.'s treatment notes do not address whether there is any relationship between the Veteran's PTSD and the onset or course of his hypertension. In March 2008, D. D. C., PA-C, a physician assistant at Dr. R.'s practice, wrote, "It is felt that his diagnosis of Post-traumatic stress disorder is an exacerbating factor of his hypertension." The Veteran submitted in 2012 excerpts of surveys of medical literature. Authors from a university center for psychological studies stated that clinical literature, including a comorbidity survey, increasingly indicates that cardiovascular risk factors, cardiovascular disease, and high blood pressure were more common among individuals with PTSD. The authors noted a study showing that hypertension was found to be associated with PTSD. The authors noted findings that persons with PTSD, when exposed to traumatic triggers, experienced increased blood pressure, increased heart rate, and sweating in the hands. The authors concluded that the body of evidence indicates that there is a link between PTSD and the risk of hypertension. On VA examination in December 2013, the examiner, a certified nurse practitioner, reported having reviewed the Veteran's claims file. The Veteran reported that he was diagnosed with hypertension in the mid 1970s, and that presently he was on medication for hypertension. He related that his PTSD symptoms included nightmares. He stated that he awakened from the nightmares with pounding in his chest and elevated blood pressure. The examiner record blood pressure measurements of 172/83, 158/87, and 144/80. The examiner expressed the opinions that it is less likely than not that the Veteran's PTSD caused his hypertension, and that it is less likely than not that his PTSD aggravated his hypertension beyond its natural progression. The examiner explained that the National Heart, Lung, and Blood Institute stated that PTSD was not a cause of hypertension. The examiner noted that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), by the American Psychiatric Association, did not relate any symptoms of hypertension to PTSD. The examiner reported having consulted a psychiatry unit in reaching the opinions. The primary care practice that treats the Veteran supports the likelihood that his PTSD aggravates his hypertension. The medical article excerpts that the Veteran submitted contain support for PTSD having effects that can lead to or worsen hypertension. The persuasive weight of those views at least approximately balances the persuasive weight of the VA examiner's opinion against the likelihood that the Veteran's PTSD has aggravated his hypertension. Giving the benefit of the doubt to the Veteran, the Board grants service connection for hypertension as aggravated by PTSD. ORDER Entitlement to service connection for hypertension as aggravated by PTSD is granted. ____________________________________________ MATTHEW D. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs