Citation Nr: 18157508 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 16-60 259 DATE: December 12, 2018 REMAND Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), and to include as due to exposure to herbicide agents, is remanded. The Veteran had active military service from November 1967 to October 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), and to include as due to exposure to herbicide agents, is remanded. In this case, the Veteran argued that he is entitled to service connection for his hypertension as his hypertension has been a chronic issue since his first work physical after returning from Vietnam. See December 2016 Form 9. The Veteran contends that his hypertension manifested due to his service-connected PTSD, or in the alternative, due to his exposure to herbicide agents. Id. The May 2017 VA examiner opined it is less likely than not that the Veteran’s hypertension is due to his presumed exposure to herbicide agents during his service in Vietnam. The examiner explained that environment exposure to herbicide agents of any type are not reported as a risk factor for developing hypertension. While a National Academy of Science (NAS) report indicated that there was ‘limited or suggestive evidence of an association between herbicide exposure and hypertension,’ it did not report that hypertension is caused by herbicide exposure, including exposure to Agent Orange. In fact, the examiner referenced three peer-reviewed medical articles that stated that there are no compelling scientific studies demonstrating a causal relationship between Agent Orange and disease development. Based on the collective evidence, the examiner opined that it is less likely than not that the Veteran’s hypertension was caused by or due to the conceded exposure to herbicide agents. Since the May 2017 VA examination, as noted in Veterans and Agent Orange: Update 11 (2018), the NAS found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. Hypertension has been upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. Accordingly, a remand is necessary for the VA examiner to consider this new scientific evidence. The Board recognizes the medical literature referenced in the representative’s December 2017 brief from the Open Cardiovascular Medicine Journal. The November 2011 article stated, in part, that PTSD is associated with an increased risk of hypertension in the National Comorbidity Survey. The study found that veterans with mental health diagnoses had a significantly higher frequency of hypertension and other cardiovascular disease risk factors. This should also be considered by the VA examiner on remand. The claim is remanded for the following action: Obtain an addendum to the May 2017 VA examination. In particular, the examiner should opine as to whether it is at least as likely as not that hypertension was caused by, or is otherwise etiologically related to, his presumed herbicide exposure. The examiner should consider the NAS 2018 conclusion that hypertension has been upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. The examiner should also opine as to whether it is at least as likely as not that the Veteran’s service-connected PTSD (a) caused or (b) aggravated his hypertension. In answering this question, the examiner should consider the medical articles referenced in the December 2017 representative’s brief, PTSD and Cardiovascular Disease, The Open Cardiovascular Medicine Journal. A complete rationale for all opinions is requested. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Noh, Associate Counsel