Citation Nr: 18156259 Decision Date: 12/07/18 Archive Date: 12/07/18 DOCKET NO. 09-00 177 DATE: December 7, 2018 ORDER 1. Entitlement so service connection for hypertension is denied. 2. Entitlement to service connection for heart disease, to include coronary artery disease (CAD), cardiomyopathy and congestive heart failure (CHF) is denied. 3. Entitlement to service connection for residuals of a cerebrovascular accident (CVA) is denied. 4. Entitlement to service connection for peripheral artery disease (PAD) is denied. FINDINGS OF FACT 1. Hypertension was not manifested in service or for many years thereafter, and is not shown to be etiologically related to the Veteran’s service. 2. Heart disease, to include CAD, cardiomyopathy and CHF, was first manifested many years after, and the preponderance of the evidence is against a finding that it is etiologically related to, the Veteran’s active service or was caused or aggravated by a service connected disability. 3. The Veteran suffered a stroke many years after, and the preponderance of the evidence is against a finding that its residuals are etiologically related to, his active service, or were caused or aggravated by a service connected disability 4. PAD was not manifested in service or for many years thereafter, and is not shown to be etiologically related to the Veteran’s service. CONCLUSIONS OF LAW 1. Service connection for hypertension is not warranted. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. Service connection for heart disease, to include CAD, cardiomyopathy and CHF is not warranted; the claim of service connection for a heart disease as secondary to hypertension lacks legal merit. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. Service connection for residuals of a CVA is not warranted; the claim of service connection for residuals of a CVA as secondary to hypertension lacks legal merit. 38 U.S.C. §§ 1101, 1110, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. Service connection for PAD is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R.§ 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from March 1972 to June 1975. These matters are before the Board of Veterans' Appeals (the Board) on appeal from a June 2007 rating decision. In April 2012, August 2015 and July 2017, these matters were remanded by the Board. [The July 2017 Board decision also denied service connection for diabetes mellitus.] Service Connection The Veteran’s service treatment records (STRs) show that on induction in March 1972 a history of transient high blood pressure prior to service was noted, and it was further noted that he had lost weight and his blood pressure returned to normal. His blood pressure was 130/75, and he was not on anti-hypertensive medication. The impression was that he was normotensive. Except for a blood pressure reading of 120/90 in May 1974, all other blood pressure readings in service were in the normal range. In June 1974, the Veteran was seen for a complaint of headaches. It was noted that he had high blood pressure in the past. In a January 1975 report of medical history, he reported having cramps in his legs and chest pain, but denied having high blood pressure. On the January 1975 service separation examination, the heart and vascular system and a neurological evaluation were normal. The Veteran’s blood pressure was 120/80. A chest X-ray was normal. It was noted that he had leg cramps after exercise and when relaxed, and that his chest pain was caused by exercise or over-exertion. On May 1976 VA general medical examination, the Veteran's cardiovascular system was normal. lood pressure was 145/90; a chest X-ray was normal. Private medical records show that in November 1991, when the Veteran was seen for unrelated complaints, his blood pressure was 164/98. It was noted that he was to be seen for follow-up for elevated blood pressure. He had complaints of left leg pain in April and May 1996. In April 1996, the Veteran was admitted to a private hospital for dyspnea. Onset of edema in both legs was also noted. A chest X-ray found cardiomegaly and congestive failure. The diagnoses were CHF, hypertension and cardiomyopathy. In June 1996, an arterial duplex ultrasound was normal on the right and inconclusive on the left due to a cast on the left ankle. In March 1997, a history of hypertension was noted. In July 2003, the Veteran was hospitalized in a private facility and reported a one-week history of slurred speech, facial droop and right-sided weakness. It was noted that he had a 20-pack year history of tobacco use. The diagnosis was right parietal CVA. VA outpatient treatment records show that in November 2006, a limb pressure study found bilateral mild to moderate infrapopliteal disease. On June 2009 VA examination, the Veteran stated that he had headaches in service that were related to hypertension. The examiner stated that he reviewed the Veteran's STRs and found no evidence that he had hypertension in service. He noted that on the two occasions when he was seen for headaches (both times diagnosed as tension headaches) his blood pressure was normal. He observed that the Veteran had been treated for hypertension for approximately ten years, and noted that the Veteran had a normal electrocardiogram in service. He found no documentation whatsoever of any PAD in the STRs, and that the only mention of cramps was on service separation examination. The examiner stated that since it was noted at that time that the cramps were not exercised-induced (since they also occurred at rest), this was very different from his current symptoms. He noted that while the Veteran had PAD, and that smoking contributed to it, he stated that it was as likely as not that some component of his peripheral artery insufficiency was related to his diabetes. He also opined that there was no evidence that the Veteran had hypertension in service, and no evidence that he had peripheral vascular disease in service. He further opined that there was no evidence that the Veteran's CAD, cardiomyopathy and CHF could be connected to any condition documented in service. In June 2009, a VA physician noted that the Veteran's hypertension appeared to have started in service. He stated that his stroke occurred many years after service. He opined that it was at least as likely as not that hypertension was a contributing factor to the stroke. On June 2012 VA examination, the examiner reviewed the record and opined that she found no evidence that the Veteran was treated for high blood pressure in service. She opined that it was less likely than not that hypertension was related to the Veteran's service. She noted that at least three elevated blood pressure readings are required to diagnose hypertension. On November 2016 VA heart examination, the diagnosis was CAD. It was also noted that the Veteran had CHF. In November 2016, a VA physician reviewed the record and opined that it was at least as likely as not that the Veteran's hypertension was incurred in or caused by service. He noted that the Veteran had a documented history of high blood pressure and had borderline blood pressure in 1974. He stated that hypertension was a likely continuation of the condition. On January 2017 VA hypertension examination, the diagnosis was hypertension. The examiner, who reviewed the record, opined that it was less likely as not that the Veteran's hypertension is related to his service. She noted that per the American Heart Association’s (AHA) guidelines, hypertension is when the blood pressure reading is consistently ranging from 140-159/90-99. She noted a blood pressure reading of 140/76 (on May `12, 1974, and that the Veteran’s blood pressure on January 1975 service separation examination was 120/80, and observed that such readings do not, per AHA guidelines, translate into the Veteran having hypertension during his military service. She noted that STRs are silent for a diagnosis of hypertension. On August 2017 VA hypertension examination, the Veteran stated that he had had hypertension since service. The diagnosis was hypertension. The examiner, who reviewed the record, opined that it was less likely than not that the Veteran's hypertension was related to service. He noted that there was no evidence that the Veteran's blood pressure meets the VA criteria for hypertension. He addressed the comment of the VA examiner who stated in November 2016 that the Veteran's hypertension was present in service, noting that such was not documented. He observed that the March 1972 entrance examination noted the Veteran had a history of transient hypertension, but that blood pressure was normal at that time. He stated that there was no evidence in the Veteran's STRs that he had diastolic pressure that was predominantly 90 or higher, noting that the only elevated blood pressure in service was in May 1974 (120/90), and that a single diastolic pressure of 90 does not meet the VA criteria for diastolic pressure 90 or greater. The examiner also disputed the statement by the November 2016 VA examiner that the Veteran had a documented history of high blood pressure. The August 2017 VA examiner stated that the record contains no documentation that meets VA criteria for high blood pressure. He noted that the blood pressure of 140/76 in May 1974 was not borderline, as indicated by the examiner in November 2016. The August 2017 VA opinion provider stated that for hypertension to be diagnosed, blood pressure must be consistently elevated. He further noted that there was no evidence of hypertension on entrance that could be aggravated in service. The August 2017 examiner further stated that the single documented diastolic pressure of 90 was not repeated (as required by VA guidelines to establish a diagnosis). He concurred with the comment by the January 2017 VA examiner regarding that consistency of elevation of blood pressure was required, and that a conclusion that the Veteran had hypertension meeting VA guidelines in service was not supported by documentation in his STRs. He concurred with the January 2017 opinion which noted the presence of multiple normal blood pressures, noting that this served as a sound basis for a conclusion that the Veteran's hypertension is less likely as not related to service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 38 C.F.R. § 3.303(a). To substantiate a claim of service connection there must be evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the claimed disability and the disease or injury in service. See Shedden v, Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). Certain chronic diseases, to include hypertension, CAD and CVA, may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period of time postservice (one year for hypertension, CAD and CVA). 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. 1. Service connection for hypertension is denied. The Veteran’s STRs show one elevated blood pressure reading (120/90) in May 1974. His blood pressure was normal on all other occasions in service, to include on January 1975 service separation examination. The record also shows that on initial VA examination following his discharge from service, in May 1976, blood pressure was 145/90. He then again had an elevated blood pressure documented in November 1991. From the record that the criteria for a diagnosis of hypertension were first met many years following service. The critical question in this case is whether the elevated blood pressure in service or on the May 1976 VA examination represented an initial manifestation of hypertension. There is medical support in the record for the Veteran’s claim. In June 2009 and November 2016, VA physicians opined that it was at least as likely as not that the Veteran’s hypertension is related to service. There are also opinions against claim. Accordingly, the Board’s July 2017 remand requested a clarifying medical opinion. In August 2017, a consulting VA physician who reviewed the record, found that it was less likely than not that the Veteran’s hypertension is related to service. He noted that a diagnosis of hypertension requires multiple elevated (greater than 90) diastolic pressures on several different days. Thus, the fact that there was one elevated blood pressure in service, and one on the VA examination about a year following the Veteran’s separation from service, did not establish that he had hypertension either in service, or within one year of separation. As this is the only opinion in the record that adequately explains what is needed to establish a diagnosis of hypertension, the Board finds the opinion persuasive. As the evidence does not show that hypertension was manifested in service, or for many years thereafter, service connection for such disability on the basis that it became manifest in service, or on a presumptive basis (as a chronic disease under 38 U.S.C. § 1112) is not warranted. As hypertension was not shown for many years after service, service connection for such disability based on continuity of symptomatology (under 38 C.F.R. § 3.303(b)) is also not warranted. Whether an insidious process such as hypertension may be related to remote events in service is a medical question, beyond the scope of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the August 2017 VA consulting provider’s opinion (against the Veteran’s claim) to warrant greater probative value than the opinions supporting the claim. It reflects familiarity with the factual record, and includes rationale that cites to supporting clinical data and governing medical principles. Accordingly, the Board finds that the preponderance of the evidence is against this claim, and that the appeal in the matter must be denied. 2. Service connection for heart disease, to include CAD, cardiomyopathy and CHF is denied. 3. Service connection for residuals of a CVA is denied. Secondary service connection is warranted for a disability which is caused or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. To substantiate a claim of secondary service connection there must be evidence of: A disability for which service connection is sought; a disability that is already service connected; and that the already service connected disability caused or aggravated the disability for which service connection is sought. Regarding heart disease, the Board notes that during the February 2012 hearing before the undersigned, the Veteran testified that he was exposed to Agent Orange in Thailand and asserted that service connection for such disease on a presumptive basis (as due to such exposure) is warranted. His service discharge certificate shows that he had no foreign service. In June 2012, the National Personnel Records Center confirmed that there was no evidence to establish that he served in Thailand. As the alleged exposure to Agent Orange is not shown, service connection for heart disease on a presumptive basis as due to such exposure is not warranted. The Veteran's STRs are silent for complaints or findings concerning heart disease or a CVA. The record shows that heart disease was first noted in 1996, and that the Veteran suffered a stroke in 2003. It is not alleged (or suggested by the record) that heart disease, to include CAD, cardiomyopathy and CHF, is directly related to (was incurred in) the Veteran’s active military service (other than by the rejected theory that it is due to exposure to herbicide agents in Thailand). His sole theory of entitlement to service connection for such disabilities is one of secondary service connection, that his heart disease or CVA is secondary to his hypertension. A threshold legal requirement in a claim of secondary service connection, is that the underlying disability (claimed to have caused or aggravated the disability for which service connection is sought) must be service-connected. If it is not, the claim of secondary service connection lacks legal merit. This decision has (above) denied service connection for hypertension. Accordingly, the claims of service connection for heart disease, to include CAD, cardiomyopathy and CHF, and residuals of a CVA lack legal merit, and the appeal in these matters must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 4. Service connection for PAD is denied. The Veteran's STRs show that in January 1975 the Veteran reporting leg cramps both after exercise and when relaxed. Physical examination on the January 1975 service separation examination was negative for any pertinent abnormality. PAD was initially manifested many years after the Veteran's discharge from service. Whether an insidious process such as PAD may be related to remote service is a medical question, beyond the scope of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). On the June 2009 VA examination, the examiner noted that there was no indication in the Veteran's STRs of PAD and that it was associated with his smoking and diabetes. He specifically distinguished the Veteran's complaints in service of leg cramps from those associated with PAD. That opinion was based on a review of the record and included rationale that cites to factual data and medical principles. It is probative evidence in the matter, and the Board finds it persuasive. Regarding any assertion that PAD was caused or aggravated by diabetes or hypertension, service connection has not been established for either of those disabilities, and such secondary service connection theories of entitlement lack legal merit. The preponderance of the evidence is against this claim also. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Siegel, Counsel