Citation Nr: 1727439 Decision Date: 07/14/17 Archive Date: 07/25/17 DOCKET NO. 09- 23 134 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for hypertension, to include as secondary to major depressive disorder, or as due to exposure to herbicides. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to September 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio which, in part, denied service connection for hypertension to include as secondary to a service-connected disability. The Veteran appealed, and in December 2012, the Board denied the claim. The appellant appealed to the U.S. Court of Appeals for Veterans Claims (Court). In February 2014, while his case was pending at the Court, the VA's Office of General Counsel and Veteran's representative filed a Joint Motion requesting that the Court vacate the Board's December 2012 decision. That same month, the Court issued an Order vacating the December 2012 Board decision. In July 2014, and January 2015, the Board remanded the claim for additional development. Jurisdiction in this matter has been transferred to the RO in Houston, Texas. FINDINGS OF FACT 1. The Veteran served in Vietnam during the Vietnam War and is presumed to have been exposed to herbicides such as Agent Orange. 2. The Veteran's hypertension neither began during nor was otherwise caused by his military service, and it was neither caused nor aggravated by a service-connected disability. CONCLUSION OF LAW Criteria for service connection for hypertension have not been met. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Service Connection The Veteran asserts that service connection is warranted for his clinically diagnosed hypertension, to include as secondary to his service-connected major depressive disorder, or as due to exposure to herbicide exposure. The Board first notes that additional medical evidence has been received following the April 2015 supplemental statement of the case, that it is not accompanied by a waiver of RO review. However, the Board has determined that this evidence is not "pertinent" as defined at 38 C.F.R. § 20.1304 (c), since it does not relate to the etiology of the Veteran's hypertension. Accordingly, a remand for RO consideration is not required. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). 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. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a), to include hypertension. See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). A grant of service connection under 38 C.F.R. § 3.303(b) does not require proof of the nexus element; it is presumed. Id. The statutory provision specifically covering Agent Orange is 38 U.S.C.A. § 1116. Under 38 U.S.C.A. § 1116 (f), a claimant, who, during active service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that he was not exposed to any such agent during that service. Disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309, will be considered to have been incurred in service under the circumstances outlined in that section even though there is no evidence of such disease during the period of service. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; type 2 diabetes, non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; multiple myeloma, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma. 38 C.F.R. § 3.309 (e). Hypertension is not among the diseases in the presumptive list. The Secretary of VA has determined there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341 -46 (1994); see also Notice, 61 Fed. Reg. 41, 442-49 (1996). The Secretary has clarified that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam Era is not warranted for any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 72 Fed. Reg. 32,395 -32,407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258 -21260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), does not preclude establishment of service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Title 38, section 1116(b)(1), United States Code, directs the Secretary of VA to "prescribe regulations providing that a presumption of service connection is warranted for [a] disease" when a positive statistical association exists between Agent Orange exposure and the occurrence of that disease in humans. The statute further provides that a positive association exists when "the credible evidence for the association is equal to or outweighs the credible evidence against the association." In making this determination the Secretary is to take into account reports from the National Academy of Sciences (NAS) under section 3 of the Agent Orange Act of 1991 as well as all other available sound medical and scientific information. 38 U.S.C. § 1116 (b)(3). To carry out this directive, the NAS convened an Institutes of Medicine (IOM) committee to answer "whether a statistical association with herbicide exposure exists." Agent Orange Act of 1991, Pub.L. No. 102-4, 105 Stat. 11 § 3(d)(1)(A) (codified as amended at 38 U.S.C. § 1116 ). The IOM provides an answer to the question of statistical association in its biannual "Agent Orange Updates." The Agent Orange Updates recommend that section 1116(a) include a disease on its list of diseases to which the presumption applies when that disease is placed in the "Sufficient Evidence of an Association" category, but recommend against inclusion if the disease is placed in any of the Updates' remaining three categories. See Comm. to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides, Inst. of Medicine of the Nat'l Academies, Veterans and Agent Orange: Update 2002 (Fourth Biennial Update 2003) (noting that the remaining three categories are "Limited or Suggestive Evidence of an Association," "Inadequate or Insufficient Evidence to Determine Whether an Association Exists," and "Limited or Suggestive Evidence of No Association"). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (2016). Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran's personnel records include his discharge (DD Form 214), which shows that his awards include the Vietnam Service Medal, and the Vietnam Campaign Medal; service in Vietnam has been presumed. The Veteran's service treatment records do not show any treatment, complaints, or diagnoses involving hypertension or high blood pressure. The Veteran's entrance examination report, dated in July 1967, shows that his blood pressure was 130/78. The Veteran's separation examination report, dated in September 1969, shows that his blood pressure was 130/78. In the associated "report of medical history," which the Veteran completed, he specifically denied having a history of high or low blood pressure. As for the post-service medical evidence, it includes private treatment reports, dated beginning in 1986, which note use of the anti-hypertension drug Lopressor, and high blood pressure. Thereafter, VA and private treatment records note hypertension. Reports associated with the Veteran's employment, dated between 1986 and 2005, show that be was using as many as four medications to manage his high blood pressure. This evidence also includes a number of indications of a family history of high blood pressure. Other than one time, in 2004, the Veteran consistently denied having depression or anxiety on medical history survey completed in conjunction with medical appointments. VA progress notes, dated between 2009 and 2016, contain multiple notations that the Veteran was recommended for the MOVE program (a national weight management and exercise program designed by VA). A VA hypertension examination report, dated in April 2012, shows that the examiner indicated that the Veteran's claims file had been reviewed. The examination report shows the following: the Veteran reported that he was diagnosed with hypertension in the 1970 s and that he was treated in the mid-1970s. He stated that he had been on different medications. The examiner determined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of his service-connected condition. The examiner explained that emotional stress in the short term can elevate blood pressure. However, it does not cause a persistent elevation in blood pressure and therefore does not cause true hypertension with its associated consequences. The examiner stated that hypertension was not caused by or a result of his acquired psychiatric disability, and that it was not aggravated or worsened by his service-connected acquired psychiatric disability. In July 2014, the Board remanded the claim, in part, for supplemental opinions. A VA hypertension disability benefits questionnaire (DBQ), dated in August 2014, shows that the examiner indicated that the Veteran's claims file had been reviewed. The DBQ shows the following: the Veteran reported that he was diagnosed with hypertension early in the 1970s and that he was started on Lopressor. The earliest documentation he has is from the 1980s. The Veteran stated that he has been on different medications over time. He denied elevated blood pressure during service. His current medications included Bisoprolol, Diltiazem, Indapamide, and Losartan. The diagnosis was hypertension. The examiner concluded that the Veteran's hypertension was not caused by his active duty service. The examiner explained that the Veteran's only in-service blood pressure readings were 130/78 (in July 1967 and September 1969). Following service, the next medical evidence of hypertension is dated in January 1986 (use of Lopressor, 50 milligrams (mg.) QD (every day)). The Veteran's CPRS (Computerized Patient Record System) records note essential hypertension. The exact causes of essential hypertension are usually unknown. The examiner allowed that the Veteran's acquired psychiatric disability could cause temporary spikes in blood pressure, but that such a condition was not known to cause long-term high blood pressure (hypertension) or aggravate the hypertension. Hypertension is not a presumptively service-connected condition for veterans presumed to have been exposed to Agent Orange. In January 2015, the Board again remanded the claim, in part, for a supplemental opinion on the issue of whether or not the Veteran's hypertension is related to exposure to Agent Orange. In February 2015, a supplemental opinion was obtained. The opinion notes the following: Records dated beginning in January 1986 note a history of hypertension, with use of Lopressor. A July 2009 VA report (BOPC PCP) (Beaumont outpatient clinic primary care provider) notes a history of hypertension and a BMI (body mass index) of 30. The Veteran's other post-service medical history was summarized. It was concluded that it is less likely than not that the Veteran's hypertension was caused by Agent Orange or other herbicide exposure during active military service. It was explained that a review of objective records showed that the Veteran had multiple, well-documented risk factors for hypertension, including family history, advancing age, obesity, and excessive alcohol use over a prolonged period of time. Peer-reviewed medical references show that these are all well-established risk factors. Exposure to toxic chemicals is not among the recognized risk factors for development of primary or secondary hypertension. The medical professional noted that a review of IOM (Institute of Medicine) and 2012 Agent Orange updates notes there was limited or suggestive evidence to support an association between exposure to the herbicides used in Vietnam and hypertension. The 2010 update also noted that while the VA did not find hypertension to be presumptively related to service in Vietnam, on the basis of the total weight of available evidence, the current committee reaffirmed the conclusion of the Committees for Update 2006 and Update 2008 to categorize hypertension has having/limited suggestive evidence of association. The 2010 report went on to say that limited or suggestive evidence was defined as "epidemiologic evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence." It is this examiner's opinion that it is more than 50 percent likely that the presence of multiple risk factors noted above, which are well-recognized in peer-reviewed literature, led to the Veteran's hypertension. As noted, the IOM report only contains suggestive evidence linking herbicide exposure to hypertension. Since this evidence did not lead to a firm conclusion because confounding factors and chance and bias could not be eliminated, it is less likely than not that the Veteran's hypertension was caused by Agent Orange or other herbicide exposure during active military duty. (citations omitted other than as noted). In July 2015, the Board requested a medical opinion addressing the Veteran's claim from a specialist within the VHA. See 38 C.F.R. § 20.901 (a) (2016). The Board requested that an opinion be provided as to: whether it is at least as likely as not that the Veteran's service-connected depressive disorder and dysthymic disorder with sleep impairment and mood swings either a) caused his hypertension, or b) chronically worsened (aggravated) his hypertension. The expert was requested to address the Veteran's assertions that sleep impairment can lead to hypertension, as well as a September 2012 statement from a private physician (Dr. K.P.) (discussed infra). In April 2016, an opinion was received from the clinical director, C&P (VA's compensation and pension service) CAVHCS (Central Alabama Veterans Health Care System). She stated the following: the most recent version of the "Veteran's and Agent Orange" report is Update 2012, which does not contain any relevant changes from Update 2010, as there is ongoing reference to "limited or suggestive evidence" of an association between exposure to Agent Orange (herbicides) and hypertension. Update 2012 states that on meta-analysis there was only limited or suggestive evidence of an association, but this association has been only intermittently demonstrated in medical studies in limited career fields and does not apply to the Agent Orange (herbicide)-exposed population as a whole. There are also studies showing no association between Agent Orange exposure and the later development of hypertension. The limited or suggestive evidence of an association between Agent Orange (herbicide) exposure only applies to those who were directly involved in the active spraying of Agent Orange as their primary military duty (MOS) as a member of the U.S. Army Chemical Corps. A 2006 study by Kang, et al ("Health status of Army Chemical Corps Vietnam veterans who sprayed defoliant in Vietnam) ("2006 study") compared veterans assigned to the U.S. Army Chemical Corps along with "regular Vietnam veterans," and the standard non-exposed population. The relative risk of developing hypertension in Vietnam veterans not assigned to the U.S. Army Chemical Corps was calculated at 0.96, and this indicates that most Vietnam veterans are not at increased risk for hypertension based on Agent Orange (herbicide) exposure. The only data showing a positive nexus between Agent Orange (herbicide) exposure and hypertension occurred in the "herbicide sprayer" group who specifically served in the U.S. Army Chemical Corps. The doctor stated that the 2006 study noted that another study, by the National Institute of Occupational Safety and Health (NIOSH), of workers exposed to chemicals contaminated with dioxin, did not find an elevated prevalence of cardiovascular diseases, including hypertension (citation omitted). He stated that even for veterans who served in the U.S. Army Chemical Corps, the evidence of a link between hypertension and exposure to Agent Orange was "still less than conclusive." The doctor concluded that the Veteran's hypertension is less likely than not due to exposure to Agent Orange during service. She explained that the Veteran was not shown to have served in the U.S. Army Chemical Corps as an herbicide sprayer, that the 2006 study showed that there was no increased risk for hypertension in Vietnam veterans not included in the "herbicide sprayer" group, and that several other studies showed no correlation between Agent Orange exposure and the later development of hypertension. In April 2016, the Board requested an addendum opinion, noting that, contrary to the Board's July 2015 request, the April 2016 opinion only discussed the aspect of the claim based on exposure to Agent Orange. In February 2017, a follow-up opinion was received from the same medical expert. She indicated that the Veteran's VBMS file had been reviewed, before concluding that it was less likely than not that the Veteran's depressive disorder and dysthymic disorder with sleep impairment and mood swings caused his hypertension. She explained that the Veteran had (per documentation with a receipt date in December 2008 in VBMS) medical appointments in 1996, 1997, 1999, and 2002 (i.e., treatment records associated with the Veteran's employer), where he had documented hypertension under treatment with multiple blood pressure medications, but he denied "depression or anxiety," by which time he had well-established hypertension independent of the service-connected depressive disorder and dysthymic disorder with sleep impairment and mood swings. In regard to the possibility that the Veteran's service connected depressive disorder and dysthymic disorder with sleep impairment and mood swings caused aggravation of his hypertension, it is less likely than not that this disability worsened or aggravated his hypertension beyond its natural course, based on his documented course of need for additional blood pressure medicines over time. She noted that in 2002, while the Veteran was denying depression and anxiety, he had already severe hypertension and he was already on four blood pressure medications (Bisoprolol, hydrochlorothiazide (HCTZ), Indapamide, and Tiazac/Diltiazem); and that in 2005, after the Veteran reported depression and anxiety, he was on five medications (the four previously noted, as well as Diovan). She explained that the addition of one blood pressure medication over three years' time did not show progression of the Veteran's blood pressure beyond its natural course, as it is normal that hypertension requires increasing doses and additional medications over time. Based on 20 years of clinical practice treating hypertension, she concluded this does not represent aggravation. The remainder of his record again does not demonstrate that his already severe hypertension was aggravated over time by his service connected acquired psychiatric disability, as his hypertension followed expected natural progression. As an initial matter, in his claim, received in May 2007, the Veteran indicated that his hypertension began in 1970. In a statement, dated in May 2012, the Veteran asserted that he has had hypertension since the early 1970s. See also VA examination report, dated in August 2014 (same). In his notice of disagreement, received in December 2008, he stated that he has had hypertension since 1986. See also Veteran's statement, received in December 2010 (same). Given the significant variations in the claimed date of onset of hypertension, the probative value of his testimony has been reduced. See Wilson v. Derwinski, 2 Vet. App. 16, 19-20 (1991); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) The Board finds that the claim must be denied. With regard to the possibility of service connection on a direct basis, the Veteran was not treated for any hypertension or high blood pressure symptoms during service, and there are no findings of hypertension or high blood pressure during service. Hypertension or high blood pressure was not shown upon separation from service. Therefore a chronic disorder is not shown during service. See 38 C.F.R. § 3.303 (a), (b). There is no evidence to show hypertension was manifest, let alone to a compensable degree, within one year of separation from service. See 38 C.F.R. § § 3.307, 3.309. The earliest post-service medical evidence of hypertension is dated no earlier than 1986, which is approximately 16 years after separation from service. There is no competent opinion of record in support of the claim on a direct basis. In this regard, the VA opinions, dated in August 2012 and February 2017 both weigh against the claim. In particular the February 2017 opinion is considered highly probative evidence against the claim, as the examiner indicated that the Veteran's VBMS files had been reviewed, and as the opinion is accompanied by a sufficiently detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000); Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, the claim must be denied on a direct and presumptive basis. With regard to the possibility of service connection under 38 C.F.R. § 3.310, this claim must also be denied. Other than Dr. K.P.'s opinions, discussed infra, there is no competent opinion of record in support of the claim on a secondary basis. The VA opinions, dated in April 2012, August 2014, and February 2017, all weigh against the claim. In particular, for the previously noted reasons, the February 2017 opinion is considered highly probative evidence against the claim. Prejean; Neives- Rodriguez. In reaching this decision, the Board has considered that the February 2017 opinion appears to have omitted mention of a two-month period of treatment for psychiatric symptoms by Dr. R.W. in 1999, with diagnoses of major depressive disorder and dysthymic disorder. However, the Veteran denied having depression or anxiety prior to, and after this treatment. In addition, the reports from Dr. R.W. state that this was a "single episode" and indicate that it was related to the Veteran's son leaving for college. There is no subsequent evidence of complaints of psychiatric symptoms until 2004. Dr. J.L.'s opinion is shown to have been based on a comprehensive review of the Veteran's records, to include a review of records for many years subsequent to this treatment in 1999. Accordingly, when viewed in context, there is no basis to find that any error was both significant and material, to find that Dr. J.L.'s conclusion would have been different but for this error, or that it resulted in any prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 393 (1993); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). Moreover, even if the doctor's timeline was slightly off, her conclusion and rationale still holds water. Specifically, the medical professional concluded that the Veteran's hypertension pre-existed the onset of his acquired psychiatric disability. Clearly this is the case as anti-hypertensive medication was prescribed as early as 1986, which greatly predates the acquired psychiatric disability regardless of whether this is looked at as 2004 or 1999. The claim must therefore be denied on a secondary basis. In reaching this decision, the Board has considered two statements from a private physician, Dr. K.P., received in December 2010 and September 2012. In the December 2010 statement, Dr. K.P. states, "[The Veteran's] hypertension is most likely caused by or a result of PTSD." In the September 2012 statement, Dr. K.P. reported the following: the Veteran has been her patient since 2005. He was diagnosed with PTSD and hypertension at the time he was established as a patient at her clinic. He has had "routine follow-ups" for both PTSD and hypertension since the 1980s. The stresses the Veteran has been under has been consistent, and "continued to keep his blood pressure elevated." He is required to stay on blood pressure medications to maintain a normal blood pressure because of the increased stress and anxiety. According to the Veteran, he had a normal blood pressure before entering into the service and being diagnosed with PTSD. Currently we are unable to obtain any of the original records from the military. The Veteran also has insomnia and sleep disturbances due to hypnagogic hallucinations as a result of his PTSD. The inability to get good sleep cycles will contribute to increased anxiety, moodiness, and blood pressure. These opinions are insufficiently probative to warrant a grant of the claim. Dr. K.P.'s opinions are not shown to have been based on review of the Veteran's claims file, or any other detailed and reliable history. Prejean. In addition, her December 2010 opinion is one sentence long; it is summary in nature, and it is unaccompanied by any explanation. Neives-Rodriguez. In her September 2012 opinion, she does not cite to any medical findings or facts to show that the Veteran's hypertension has been aggravated. Id.; Madden; Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). This evidence is therefore insufficiently probative to warrant a grant of the claim. Finally, although the Veteran is shown to have served in Vietnam, and is therefore presumed to have been exposed to Agent Orange, hypertension is not a condition for which presumptive service connection may be granted. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). In addition, there is no competent evidence of record which associates hypertension with exposure to Agent Orange. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The only competent opinions are found in the VA opinions, dated in August 2012, February 2015, and April 2016, and all of these opinions weigh against the claim. Accordingly, service connection is not warranted on this basis. As a lay person, the Veteran is competent to report what comes to him through his senses, but he lacks the medical training and expertise to provide a complex medical opinion as to the etiology of the claimed condition. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). In Jandreau, the Federal Circuit specifically determined that a lay person is not considered competent to testify when the issue was medically complex. As such, his opinion is insufficient to provide the requisite nexus. Furthermore, for the reasons previously explained, the Board has afforded his testimony reduced probative value. Given the foregoing, the Board finds that the medical evidence outweighs the appellant's contentions to the effect that he has the claimed condition due to his service, or a service-connected disability, to include as due to exposure to Agent Orange. For the reasons described above, service connection for hypertension is denied. Duties to Notify and Assist There is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A (c)(2). All records pertaining to the disability in issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159 (c)(3)). In this case, the Veteran has not identified any such records, and it appears that all pertinent records have been obtained. The Veteran has been afforded examinations, and an etiological opinion has been obtained in association with the claim for service connection. In January 2015, the Board remanded the service connection claim. The Board directed that the Veteran be contacted and requested to identify all updated treatment records from health care providers who have treated him for his hypertension. In January 2015, this was done, and additional VA and non-VA medical evidence was subsequently obtained. The Board further directed that additional VA opinions be obtained on a secondary basis, and on the basis of exposure to Agent Orange. This has been done. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER Service connection for hypertension is denied. ____________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs