Citation Nr: 18141265 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 08-28 607 DATE: October 10, 2018 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected headaches, is denied. FINDING OF FACT The Veteran’s hypertension is neither proximately due to nor aggravated beyond natural progression by his service-connected headaches, and is not otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b) (West 2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had qualifying service from September 1972 to November 1978 (active duty) and May 1996 to June 1996 (active duty for training [ACDUTRA]). See DD Form 214s; May 1996 Statement of Medical Examination and Duty Status. In July 2013, the Board remanded for further development. In May 2013, the Veteran testified at a videoconference hearing before a Veterans Law Judge who is no longer employed by the Board. In May 2017, the Board remanded again for further development. In November 2017, the Board requested a medical expert opinion, which was rendered in December 2017. In March 2018, the Veteran was offered another Board hearing, but declined. In May 2018, the Board requested an addendum medical expert opinion, which was rendered in June 2018. 1. Service Connection for Hypertension Direct service connection generally requires evidence showing: (a) the existence of a present disability; (b) in-service incurrence or aggravation of a disease or injury; and (c) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Secondary service connection may be granted for disabilities which were proximately due to, the result of, or aggravated beyond natural progression by a service-connected disability. 38 C.F.R. § 3.310(a). Hypertension means diastolic blood pressure predominantly 90 millimeters of mercury (mmHg) or greater, and isolated systolic hypertension means systolic blood pressure predominantly 160 mmHg or greater with diastolic blood pressure of less than 90mmHg; hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. The Veteran contends that he was diagnosed with and given medication for hypertension during qualifying service, that he has had high blood pressure since an injury while unloading duffle bags, and/or that his hypertension is secondary to his service-connected headaches. See July 2006 VA Form 21-4138; May 2013 hearing transcript. The Veteran has already established that he: (a) has a diagnosis of hypertension (see June 2018 medical expert opinion); (b) had an ACDUTRA, back injury when lifting a duffle bag (see May 1996 service treatment record); and (c) is currently service-connected for post-trauma headaches (see June 2017 Codesheet). Of note, the Veteran also had a head injury while unloading duffle bags in December 1998, but this incident did not occur during qualifying service. See December 1998 service treatment record (non-ACDUTRA, reserve service). Although the Veteran contends that he was diagnosed with and prescribed medication for hypertension in service, the preponderance of the evidence weighs against the finding that hypertension onset occurred during qualifying service. See April 2009 VA neurological disorders examination (reported taking hypertension medication since the 1980s; May 2013 hearing transcript (reported in-service diagnosis and prescription for Lisinopril). Service treatment records show an elevated blood pressure reading of 130/90 mmHg in November 1975; however, multiple blood pressure readings before and after that were within normal limits (see August 1972 reading of 130/82; July 1975 reading of 124/86; July 1978 reading of 120/70; August 1978 reading of 120/70; October 1978 reading of 110/72; October 1983 VA special neuropsychiatric examination readings of 120/90 and 135/95; December 1998 reading of 128/82). The June 2018 medical expert explained that many factors can cause the sporadic elevation of readings (including feet position, caffeine or tobacco consumption, talking, coughing, laughing) and that a single, elevated reading does not constitute a diagnosis of chronic hypertension, nor does it indicate a precursor for the chronic disease. The expert also noted that, during the elevated reading, the Veteran was also reporting chest pain, a potential cause of the mild, transient increase in blood pressure. Service treatment records are also negative for blood pressure control medication, including Lisinopril. See August 1972, September 1972, October 1978, August 1984, December 1998 examinations (indicating no history of high or low blood pressure or pertinent medications). Further, although service treatment records show a possible systolic murmur in July 1975, the June 2018 medical expert explained that this record is isolated, as murmur was not recorded on any entrance or separation physical or upon testing in August 2017. The expert opined that the July 1975 finding was either a transient, innocent murmur or a provider error in auscultation, but that, either way, heart murmurs are not considered a cause of chronic hypertension. Additionally, although service treatment records show borderline first-degree heart block in November 2015, the June 2018 medical expert explained that electrocardiograms (EKGs) are variable and open to interpretation, but that it was essentially normal. The expert stated that the Veteran’s anatomic structure as a tall, thin, male and the lead placement increased the amplitude of the readings because the cardiac muscle would be much closer to the chest wall and increase the amplitude of the wave form. The expert noted that it was a skewed reading due to the high-voltage reading in the leads because an atrioventricular (AV) block, if true, is a fixed anatomical defect and subsequent testing did not demonstrate any type of AV block or left ventricular hypertrophy (see April 2014 EKG [no AV block or history of AV block]; August 2017 EKG [no left ventricular hypertrophy]). Moreover, April 1991 private treatment records from Westside-Urban Health Center of Savannah show borderline hypertension and note that, if it persists, medication may be started at the next visit; however, the expert opined that the blood pressure subsequently normalized, based on no medication being prescribed and the December 1998 examination (indicating no history of high or low blood pressure or pertinent medications). The Veteran does not have the educational background required to competently render an etiological opinion regarding onset because hypertension is not lay-observable; as such, the Veteran’s etiological opinion holds less probative value that the medical expert’s opinion. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). In sum, the preponderance of the evidence weighs against finding onset in service and in favor of finding onset in July 1999, based on the earliest record in the claims file with a diagnosis. See July 1999 Memorial Medical Center record. The preponderance of the evidence also weighs against finding that hypertension was caused or aggravated beyond natural progression by service. As discussed above, the Veteran was never diagnosed with hypertension in service and, even though borderline hypertension was diagnosed in 1991 (between his qualifying active duty and ACDUTRA service), subsequent treatment records indicate normalization, not worsening. Thus, service connection is not warranted on a direct basis. The preponderance of the evidence also weighs against the finding that hypertension is proximately due to or aggravated beyond natural progression by service-connected headaches. The June 2018 medical expert explained that headaches do not cause and are not a manifestation of chronic hypertension. The expert noted that a severe headache may occasionally cause distress, which may cause a transient and very temporary elevation in a blood pressure reading; the expert also noted that headaches may occur during hypertensive emergencies, where end organ damage is potentially imminent and/or the patient is on the verge of having a cerebrovascular event. However, the examiner highlighted that these scenarios are not part of the Veteran’s chronic hypertensive condition. Further, a November 2003 hospitalization record from Savannah Outpatient Clinic shows admission for headache and chest pain after being hit in the head “while on active duty” and a provider note saying “perhaps if [the Veteran’s] BP was controlled, headache frequency would decrease;” however, the provider did not attribute the headaches to hypertension or its treatment. Rather, the provider attributed the chest pain and headaches to stress, nerves, and being hit in the head. As the June 2018 medical expert explained, hypertension was treated with hydrochlorothiazide (HCTZ), which was implicated as part of the cause of the chest pain and spasms, but not the headaches; also, the expert noted that HCTZ was discontinued and replaced with Atenolol, which resolved the symptoms. Again, the Veteran does not have the educational background required to competently render an etiological opinion because hypertension is not lay-observable; as such, the Veteran’s etiological opinion holds less probative value that the medical expert’s opinion. Jandreau, 492 F.3d at 1377; Layno, 6 Vet. App. at 465. In sum, the preponderance of the evidence weighs against finding that hypertension is proximately due to or aggravated beyond natural progression by service-connected headaches. Thus, service connection is not warranted on a secondary basis. Considering the above, the Board must deny the claim. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Daus, Associate Counsel