Citation Nr: 1622407 Decision Date: 06/03/16 Archive Date: 06/13/16 DOCKET NO. 13-14 219 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected generalized anxiety disorder. 2. Entitlement to service connection for heart disease, to include as secondary to hypertension and secondary to service-connected generalized anxiety disorder. REPRESENTATION Appellant represented by: Daniel Smith, Attorney ATTORNEY FOR THE BOARD J. Tunis, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1975 to August 1976, with additional service in the United States Navy Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The July 2010 rating decision denied the Veteran's claims to reopen service connection for hypertension and heart disease. In a March 2014 decision, the Board reopened the Veteran's claims for service connection for hypertension and heart disease. The Board then remanded the claims for additional development. RO complied with the remand directives, and returned the matters to the Board. The Board then sought expert medical opinion from the Veterans Health Administration (VHA). VHA opinion was received in March 2016., and in March 2016, VA provided these opinions to the Veteran and his representative with a 60-day period of time to provide additional evidence and/or argument. Having fully complied with the remand directives, and having fully developed the claims, the matters are now appropriately before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). Additional evidence has been submitted by the Veteran since the RO last considered the case in a March 2015 supplemental statement of the case. Nevertheless, the Veteran has provided a waiver of RO consideration of this evidence. 38 C.F.R. § 20.1304(c). This appeal was processed using the Veterans Benefits Management System and Virtual VA paperless claims processing systems. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, hypertension is aggravated by the Veteran's service-connected generalized anxiety disorder. 2. Resolving all reasonable doubt in the Veteran's favor, heart disease is aggravated by the Veteran's service-connected generalized anxiety disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 1154(a), (b), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 2. The criteria for service connection for heart disease have been met. 38 U.S.C.A. §§ 1110, 1154(a), (b), 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist (VCAA) The VCAA describes VA's duties to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). As discussed in more detail below, sufficient evidence is of record to grant the Veteran's claims for entitlement to service connection for heart disease and hypertension. Thus, any errors in complying with the notice or assistance requirements with respect to this matter are moot. II. Analysis In general, service connection may be granted for disability or injury incurred in, or aggravated by, active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015). In order to establish service connection for a claimed disorder, there must be (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 current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Where a disease is first diagnosed after discharge, service connection will be granted when all of the evidence, including that pertinent to service, establishes that it was incurred in active service. See 38 C.F.R. § 3.303(d) (2015); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). A disability can be service-connected on a secondary basis if proximately due to, or the result of, a service-connected condition. See 38 C.F.R. § 3.310(a) (2015). In order to establish entitlement to service connection on a secondary basis, there must be (1) a current disability; (2) a service-connected disability; and (3) a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable. 38 C.F.R. § 3.310(a) (2015); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2015). A claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Veteran seeks service connection for hypertension on both a direct basis and a secondary basis related to his service-connected generalized anxiety disorder. See March 2013 Veteran's Application for Compensation or Pension; July 2010 Notice of Disagreement. The Veteran also seeks service connection for heart disease on both a direct basis and a secondary basis related to his hypertension and service-connected generalized anxiety disorder. See March 2013 Veteran's Application for Compensation or Pension; March 2013 Statement in Support of Claim; July 2010 Notice of Disagreement. After a review of the matters, the Board grants service connection for hypertension and heart disease on a secondary basis. As to the first element of entitlement to service connection on a secondary basis, the Veteran has a current disability, having been diagnosed with hypertension. See May 1990VA treatment record; September 2008 private medical treatment records; November 2010, May 2012, November 2012, March 2013, April 2013, May 2013, and November 2013 private treatment records from Dr. P. C. W., M.D.. The Veteran also has a current disability of heart disease. See January to February 1998 private treatment records; September 2008 private medical treatment records. Therefore, as to both claims, hypertension and heart disease, the first element of service connection has been met. As to the second element of entitlement to service connection on a secondary basis, a service-connected disability, the Veteran is currently service connected for generalized anxiety disorder evaluated at 50 percent, effective March 30, 2010. Last, as for the third element of entitlement to service connection on a secondary basis, a nexus between the service-connected disability and the current disability, the Board finds that, resolving reasonable doubt in favor of the Veteran, his hypertension and heart disease have been permanently aggravated by his service-connected generalized anxiety disorder. The Board must observe that the extent of aggravation has not been established by a baseline of disability prior to aggravation and that, pursuant to 38 C.F.R. § 3.310(b), "VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence." In the instant case, the Boards finds that the evidence is at least in equipoise as to whether or not the Veteran's hypertension and heart disease have been aggravated by his service-connected generalized anxiety disorder. In this case, the VHA opinion opined that "it is at least as likely as not that his generalized anxiety disorder contributed to his aggravation of hypertension and heart disease." In support of the opinion, Dr. J. H., M.D., noted that "it is generally accepted that poorly controlled anxiety can lead to increased risk or worsening hypertension and heart disease[;]" and that "[s]upport for this can be found with his development of worsening blood pressure and chest pain in 1990 with documented association with anxiety and subsequent requirement of balloon angioplasty in 1998 followed by repeated episodes of angina requiring further work up with stress testing and repeat heart catheterizations." In addition to the VHA opinion, the record contains private medical opinions submitted by the Veteran to support his claim. In August 2015, registered nurse, A. S., reviewed the Veteran's file and complete medical history, and opined that "there is a greater than 50/50 probability that [the Veteran's] hypertension is directly related to his [generalized anxiety disorder] . . . ." A. S. also opined that "[i]t is also my opinion there is at least a 50/50 probability [the Veteran's] heart disease is caused by years (since acquiring generalized anxiety disorder . . . ) of hypertension as the [V]eteran reports there is no family history of heart disease." A. S. further supports her opinion by stating that the Veteran has demonstrated that anxiety affects his hypertension by providing blood pressure readings at home to compare against his blood pressure readings away from home. The Veteran has also provided a September 2015 opinion from his treating physician, Dr. P. C. W., which states, "[i]t is my opinion that these conditions are at least likely or not (in other words at least a 50% chance) caused or aggravated by anxiety." Dr. P. C. W. supports his opinion with medical knowledge from the JAMA Internal Medicine article, which states that population based studies suggest a causative link between anxiety and depression and the development of heart disease. Yet, the Board considers the entire claims file, including a June 2011 VA opinion. The June 2011 VA opinion found that it is less likely as not (less than 50/50 probability) that the Veteran's current hypertension is due to or aggravated by the Veteran's generalized anxiety disorder. The examiner supported his findings by stating that "there are many patient with anxiety who does not have hypertension." The examiner also opined that "[i]t is less likely as not (less than 50/50 probability) that the [V]eteran's current heart condition or coronary artery disease, is due to or aggravated by the [V]eteran's claimed generalized anxiety disorder . . . ." In an April 2015 addendum opinion, the same examiner noted that there is no evidence of the Veteran developing hypertension within one year from active service, and stated that heart disease is multi-factorial in etiology, but not caused by hypertension. The April 2015 addendum again stated that anxiety is not a cause of hypertension or coronary artery disease. Although the Board considers the VA examiner's June 2011 opinion and April 2015 addendum opinion, the Board finds the VHA and private medical opinions to be probative. Given that the VHA and private medical opinions are supported by specific medical knowledge and point to available medical evidence in the Veteran's file, the Board finds that the evidence is at least in equipoise as to whether the Veteran's hypertension and heart disease have been aggravated by his service-connected generalized anxiety disorder. The Board notes, however, that the extent of aggravation is a rating consideration for the RO in assigning a disability rating. See generally 38 C.F.R. § 4.22. Furthermore, applicable case law precedent instructs that, if the degree of impairment from disease attributable to service-connected versus nonservice-connected disease cannot be medically ascertained, VA must consider the whole of the impairment as service connected. Mittleider v. West, 11 Vet. App. 181 (1998). Thus, the Board resolves reasonable doubt in favor of the Veteran by finding that his diagnosed hypertension and heart disease have been permanently aggravated by his service-connected. 38 U.S.C.A. § 5107(b). The claims of entitlement to service connection for hypertension and heart disease, therefore, are granted. ORDER Entitlement to service connection for hypertension based upon aggravation by service-connected generalized anxiety disorder, is granted. Entitlement to service connection for heart disease based upon aggravation by service-connected generalized anxiety disorder, is granted. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs