Citation Nr: 1742425 Decision Date: 09/26/17 Archive Date: 10/04/17 DOCKET NO. 13-10 588 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran, his wife and his nephew ATTORNEY FOR THE BOARD Suzie Gaston, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to August 1969. This matter comes before the Board of Veterans' Appeals (hereinafter Board) on appeal from an August 2010 rating decision of the Phoenix, Arizona, Department of Veterans Affairs (VA) Regional Office (RO) which, denied the Veteran's claim of entitlement to service connection for hypertension. He perfected a timely appeal to that decision. On July 17, 2013, the Veteran, his wife and his nephew appeared and offered testimony at a hearing before the Board, sitting at the RO. A transcript of the hearing is associated with the Veteran's electronic file. In June 2015, the Board remanded the claim for further evidentiary development. Following the requested development, a supplemental statement of the case (SSOC) was issued in December 2015. The case has now been returned to the Board for further appellate review. In June 2015, the Board also remanded an appeal on the issue of entitlement to an increased rating for PTSD. Thereafter, in a December 2015 rating decision, the RO granted a rating of 100 percent for the entire appeal period. Because this grant constituted a full grant of the benefits sought on appeal, this claim is no longer in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). FINDING OF FACT Hypertension did not manifest in service or to a compensable degree within one year thereafter, and has not been shown to be causally or etiologically related to the Veteran's period of active service. Hypertension was not caused or made worse by service-connected diabetes mellitus or PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service-connected diabetes mellitus or PTSD, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1151(a), 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See generally, 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Factual background and Analysis-S/C for hypertension, including as secondary to diabetes mellitus. The Veteran contends, essentially, that he has hypertension that is related to service, or, alternatively, that it is related to his service-connected diabetes mellitus and/or PTSD. Service connection is warranted for a disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110. To establish a right to compensation for a disability, a Veteran must show, "(1) the existence of a present disability; (2) 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); Holton v. Shinseki, 557 F.3d 1362 (2009). Service connection will be presumed for certain chronic diseases, including hypertension, if they were manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a) (2016). Service connection may be granted for a condition on a "secondary" theory of entitlement if the condition is shown to have been caused or aggravated by a condition for which service connection has already been established. See 38 C.F.R. § 3.310 (2016). The term "aggravated" in this context means that, although the secondary condition was not caused by the service-connected condition, the secondary condition was chronically worsened by the service-connected condition. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence that does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102. The Veteran's personnel records indicate that he served in Vietnam from August 1968 to August 1969. His DD Form 214 indicates that his military occupational specialty was as Medical Specialist; he was awarded the Combat Medic Badge, the Republic of Vietnam Campaign Medal with 60 device, and the Republic of Vietnam Gallantry Cross Unit Citation with Palm device. The service treatment records (STRs) are negative for any complaints, findings or diagnosis of hypertension. The induction examination, dated in August 1967, reported a blood pressure reading of 120/64. On the occasion of his separation examination in August 1969, the Veteran denied any high blood pressure in a report of medical history completed at that time. Blood pressure reading was 130/78; clinical evaluation of the heart was normal. Post-service treatment records, including VA as well as private treatment records, dated from October 1994 through July 2006, show that the Veteran received clinical evaluation and treatment primarily for type II diabetes mellitus, PTSD, hearing loss, and back and shoulder pain. These records reflect a history of hypertension in October 1997, with an April 2001 assessment of hypertension, controlled. The Veteran was afforded a VA examination in April 2006. It was noted that hypertension was diagnosed in 1989 when he was living in New Mexico; he has been taking blood pressure medication since that time. The impression was diabetes mellitus, type 2 with normal kidney function, no proteinuria, no report of erectile dysfunction and no evidence for clinical coronary disease. The examiner opined that hypertension predated the diagnosis of diabetes and was not aggravated by diabetes as renal function was normal. By a rating action in June 2006, the RO granted service connection for diabetes mellitus, type 2 and assigned a 20 percent rating, effective March 9, 2006. Subsequently, in October 2006, the RO assigned an effective date of March 9, 2005, for the grant of S/C for type 2, diabetes mellitus. By a rating action in January 2008, the RO granted service connection for PTSD and assigned a 50 percent evaluation, effective February 13, 2007. In April 2010, the Veteran filed a claim for service connection for hypertension secondary to his service-connected PTSD (VA Form 21-4138). Submitted in support of the claim were medical records, VA progress notes as well as private treatment reports, dated from September 2003 through July 2010. These records reflect a diagnosis of hypertension, well-controlled on medication. During a primary care visit in December 2009, the Veteran was diagnosed with hypertension, stable. A DBQ examination was conducted in October 2012. At that time, the Veteran indicated that he was initially diagnosed with hypertension in the early 1990s. He indicated that he has been treated with antihypertensive medications and was currently taking Atenolol and Amlodipine daily. The Veteran reported taking continuous medication for hypertension. The examiner reported blood pressure readings of 114/84, 116/82, and 120/84. The pertinent diagnosis was hypertension. The examiner opined that the Veteran's hypertension was less likely as not caused by diabetes mellitus as onset of hypertension predated the diagnosis of diabetes mellitus by many years. The examiner further noted that the Veteran had normal renal function. Moreover, the examiner stated that there was no evidence in the literature that PTSD causes hypertension; therefore, it is less likely as not that hypertension was caused by the service-connected PTSD. The examiner explained that, although there is some mechanistic plausibility for a causal link between PTSD and hypertension via anxiety induced activation of the autonomic nervous system, it has not been convincingly shown that such activation can truly cause or permanently aggravate hypertension as a chronic medical condition, versus simply causing transient situational elevation of blood pressure. The examiner noted that hypertension is an extremely common medical condition, and its coexistence with PTSD will therefore be commonly found without the need to infer any causal nexus. He further noted that, to date, the weight of scientific evidence is not sufficient to deduce a causal nexus between PTSD and hypertension. The examiner indicated that it should be noted that this Veteran has additional risk factors for hypertension, including age and obesity, which strengthen the argument against a causal nexus in this case. The examiner concluded that, due to the same considerations, it is less likely than not that the hypertension was permanently aggravated by the PTSD. At his personal hearing in July 2013, the Veteran maintained that his high blood pressure is directly related to the effects of his diabetes. In November 2015, the Veteran's file was referred to the DBQ examiner for review and opinion regarding the etiology of the Veteran's hypertension. It was noted that the records were reviewed and the Veteran was examined. The examiner opined that it is unlikely that this Veteran's diabetes has caused or aggravated his hypertension. The examiner observed that it is most likely that this Veteran has essential or primary hypertension. The examiner explained that, in current medical literature such as Harrison's, UpToDate, Cecil's, etc, the consensus opinion is that hypertension, in the large majority of cases, is "essential" or primary hypertension, and is not commonly secondary to other medical conditions. The examiner cited to Harrison's Principles of Internal Medicine, 17th Edition, pages 1553-1554, which states that: "80-95% of hypertensive patients are diagnosed as having 'essential' hypertension (also referred to as primary or idiopathic hypertension). In the remaining 5-20% of patients a specific underlying disorder causing the elevation of blood pressure can be identified." The examiner noted that diabetes is not listed as a Secondary Cause of Systolic and Diastolic Hypertension. Therefore, the examiner concluded that the above reference indicates that diabetes does not cause (or aggravate) hypertension in a patient with normal renal function, and the Veteran's renal function is normal. Upon review of the evidentiary record, the Board concludes that service connection is not warranted for hypertension. The Board observes that there is no evidence of hypertension during the Veteran's military service. STRs do not show any in-service complaints, findings, or diagnoses of hypertension. As noted above, the Veteran denied any high blood pressure in a report of medical history at separation from service in August 1969; and his blood pressure reading was normal. Additionally, there is no indication in the record that hypertension was manifested within one year of the Veteran's discharge from active service. In fact, the first mention of hypertension was in October 1997, more than 28 years after his discharge from active service. The Veteran himself noted that his hypertension was not diagnosed until the 1990s. Although the VA treatment records reflect current diagnoses of hypertension, they do not indicate a link between this condition and the Veteran's period of active military service. There is also no competent evidence of record linking his hypertension to the service-connected disabilities. Rather, following an examination of the Veteran and review of the claims folder in October 2012, an examiner concluded that it was less likely as not caused by diabetes mellitus as the onset of hypertension predated the diagnosis of diabetes mellitus by many years. The examiner also opined that it was less likely than not that the Veteran's hypertension was caused by his service connected PTSD. The examiner explained that, to date, the weight of scientific evidence is not sufficient to deduce a causal nexus between PTSD and hypertension. The examiner indicated that it should be noted that this Veteran has additional risk factors for hypertension, including age and obesity, which strengthen the argument against a causal nexus in this case. The examiner concluded that, due to the same considerations, it is less likely than not that the hypertension was permanently aggravated by the PTSD. The Veteran's claim was again referred to an examiner for an opinion regarding the etiology of the Veteran's hypertension; and, in November 2015, the examiner opined that it is unlikely that this Veteran's diabetes has caused or aggravated his hypertension. The examiner observed that it is most likely that this Veteran has essential or primary hypertension. The examiner explained that, in current medical literature such as Harrison's, UpToDate, Cecil's, etc, the consensus opinion is that hypertension, in the large majority of cases, is "essential" or primary hypertension, and is not commonly secondary to other medical conditions. The examiner noted that diabetes is not listed as a Secondary Cause of Systolic and Diastolic Hypertension. Therefore, the examiner concluded that the above reference indicates that diabetes does not cause (or aggravate) hypertension in a patient with normal renal function, and the Veteran's renal function is normal. The Board has considered the Veteran's assertions that he suffers from hypertension related to his service-connected disabilities. As a layperson, however, the Veteran is not competent to give a medical opinion on the onset of a medically complex issue such as hypertension. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has not been shown to have the requisite expertise or medical knowledge to provide an opinion as to whether his hypertension was caused or aggravated by his diabetes mellitus, type II, or his PTSD, and he did not provide any evidence in support of that contention. Moreover, the Board has found the examiners' opinions to be the most probative than the Veteran's lay assertions. The evidence simply does not establish that the Veteran had hypertension during active service or to a compensable degree within one year of separation from active service, or that his hypertension is otherwise related to active service, to include as due to service-connected diabetes mellitus or PTSD. Accordingly, hypertension was not incurred in or aggravated by service, nor may it be presumed to have so been incurred. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert, 1 Vet. App. at 55. Service connection for hypertension is denied. ORDER Service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II and/or PTSD, is denied. ____________________________________________ James L. March Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs