Citation Nr: 1808561 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 08-26 523 ) 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 due to herbicide exposure or as secondary to service-connected PTSD. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Whitley, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1963 to October 1983. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from a September 2006 rating decision issued by the Regional Office (RO) in Houston, Texas. In November 2014, the Board reopened the claim of entitlement to service connection for hypertension, and remanded the reopened claim. In September 2015, the Board again remanded the appeal to the RO for further development. In August 2017, the Board sought expert medical opinions from the Veterans Health Administration (VHA). The VHA opinion was received in January 2018. In January 2018, VA provided these opinions to the Veteran and his representative. The case has been returned to the Board for further appellate review. FINDING OF FACT With resolution of all doubt in his favor, the Veteran's hypertension is related to service. CONCLUSION OF LAW The criteria for establishing service connection for hypertension have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. VCAA As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159 (2017). The Board is granting service connection for hypertension, constituting a full grant of the benefit sought on appeal; therefore, no discussion of VA's duty to notify and to assist is necessary. II. Service Connection Service connection will be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2017). Pursuant to 38 C.F.R. § 3.303(b) (2017), when a chronic disease (e.g., hypertension and arthritis) is present, a claimant may establish service connection by demonstrating continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A veteran who, during active military, naval, or air 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 such veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a) (6) (iii) (2017). Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and hypertension or arthritis becomes manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112(a), 1113 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017) The diseases for which service connection may be presumed to be due to an association with herbicide agents do not include hypertension. 38 U.S.C. § 1116 (a) (2) (2012); 38 C.F.R. § 3.309(e) (2017). Even where the criteria for service connection under the provisions of 38 C.F.R. § 3.309(e) are not met, a veteran is not precluded from establishing entitlement to service connection by proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Additionally, service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310 (a) (2017). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (a) (2017). III. Evidence and Analysis The Veteran contends that his hypertension is related to his activity duty service, to include as due to herbicide exposure or alternatively as secondary to his service-connected PTSD. As the evidence is in equipoise as to whether the Veteran's hypertension is related, to service, to include herbicide exposure and his service-connected PTSD, the Veteran's claim for service connection for hypertension will be granted. The Veteran's personnel records confirm that he had service in the Republic of Vietnam during the applicable time period; accordingly, his exposure to herbicides is conceded. Service treatment records (STR's) do not show that the Veteran was diagnosed with hypertension during military service, although the treatment records do indicate the presence of elevated blood pressures, which included readings of 144/90 in January 1966, 156/90 in January 1966, and 140/90 in February 1981. No treatment or diagnosis was reported. The Veteran waved his separation physical and did not indicate, at that time, that he suffered from, or was diagnosed with, hypertension. The Veteran's service treatment records document that the elevated blood pressure in January 1966 was in association with chest pain and pain and numbness radiating down his left arm. He also had an elevated pulse rate and temperature; the provisional diagnosis was pericarditis. The Veteran's STRs from February 1981, show the elevated blood pressure was connected to acute gastroenteritis. The Veteran returned to the clinic approximately two days later for a three-day blood pressure check. The Veteran did not have elevated blood pressure and was released without further follow up. During the reported episodes, the Veteran was not treated for or diagnosed with hypertension. Post service medical records do not show a diagnosis of hypertension within a year of separation. The first time an issue of hypertension was raised in reference to the Veteran was 1993 at Baptist Memorial hospital in San Antonio, Texas. The treatment notes show an impression of mild to borderline hypertension in February 1993. The physician suggested a treatment of reduced salt intake. The treatment note also indicated no previous history of hypertension. In October 2005, the Veteran was diagnosed with essential hypertension. In September 2015, the Veteran was afforded a VA examination. The VA examiner reviewed the Veteran's claims file, interviewed the Veteran, and conducted a physical examination. During the examination, the Veteran reported that he was initially diagnosed with hypertension in 1981 while on active duty; he did not recall the medication he was given. He also reported that his blood pressure is not well controlled and that he was diagnosed with chronic renal failure in 2009. The September 2015 VA examiner acknowledged the February 1981 elevated blood pressure and stated, "The Veteran was not diagnosed with hypertension during this gastrointestinal episode; and there is no nexus to military service for hypertension." The examiner then stated that the Veteran has essential hypertension, which by definition occurs without a known etiology and that; the determinants of blood pressure in the body are blood volume and peripheral vascular resistance. The examiner further stated the Veteran's post-traumatic stress disorder (PTSD) does not affect either of these determinants of blood pressure nor has it been linked to hypertension as a risk factor or associated condition. Finally, he stated that it has not yet been established that hypertension in Vietnam veterans is linked to exposure to Agent Orange. For these reasons, he opined, " it is as less as likely (less than 50% probability) that the Veteran's hypertension is due to, was aggravated or permanently worsened by his service-connected PTSD or that this diagnosed condition (hypertension) is related to a specific exposure event experienced by the Veteran during service in Southwest Asia." A VA addendum opinion was provided in December 2015. In the December 2015 VA opinion, the VA examiner discussed the Veteran's elevated blood pressure in January 1961. The examiner noted that in January 1961 the Veteran was suffering from pericarditis. He defined pericarditis as an inflammation of the pericardium. Pericarditis is usually acute, develops suddenly, and may last up to several months and the patient complains of sharp, stabbing chest pain, which is a common symptom of acute pericarditis. Pericarditis is an inflammatory process that can adversely affect your hemodynamics. He defined hemodynamics as the physical factors that govern blood flow, which affects pulse and blood pressure. He again opined that the Veteran has essential hypertension, which by definition occurs without a known etiology. The determinants of blood pressure in the body are blood volume and peripheral vascular resistance (hemodynamics) and the Veteran's post-traumatic stress disorder (PTSD) does not affect either of these determinants of blood pressure nor has it been linked to hypertension as a risk factor or associated condition. The examiner concluded that based on these facts, it is less likely than not (less than 50 percent probability) that the Veteran's hypertension had onset during his active military service, including as the result of presumed exposure to Agent Orange from Vietnam service; 2) it is less likely than not (less than 50 percent probability) that the Veteran's hypertension first manifested to a compensable degree within one year of separation from military service in October 1983) it is less likely than not (less than 50 percent probability) that the Veteran's hypertension was initially caused by service-connected PTSD; and 4) it is less likely than not (less than 50 percent probability) that the Veteran's hypertension was aggravated, or permanently worsened, by service-connected PTSD. In August 2017 the Board sought expert medical opinions from the Veterans Health Administration (VHA). The VHA opinion was received in January 2018. In the January 2018 opinion, the examiner found that it was as least as likely as not the Veteran's hypertension had its onset within 1 year of separation of service. The VHA examiner actually concluded that based on the Veteran's service treatment records the Veteran met the criteria for a diagnosis of hypertension as early as February 1981, which was two years before the Veteran left active service. The examiner noted that per the Mayo Clinic Stage I hypertension is a systolic pressure ranging from 130 to 139 mm HB or a diastolic pressure ranging from 80 to 89 mm Hg and Stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher. The examiner stated that per the Mayo clinic parameters, the Veteran's hypertensive readings that were as follows: December 1982 BP: 120/82, August 1973 BP-130/82, January 1966 BP: 144/90 and BP l56/90, February 1981 BP 140/98, February 1981 BP 120/80, met the criteria for a diagnosis of hypertension in February 1981. The examiner also noted that there was a plethora of dates that no blood pressure was logged for the Veteran. The examiner also concluded that it is at least as like as not that the Veteran's hypertension is related to service, specifically herbicide exposure. The examiner's stated rationale was that the Veteran has a documented hypertension reading in service and per consideration of the IOM study and November 2016 article conducted by the VA regarding herbicides and hypertension, hypertension can be a result of herbicide exposure. The VHA examiner further noted that it was as least as likely as not that the Veteran's hypertension was secondary to his service connected PTSD. He noted that the Veteran abused alcohol for about 15 years after Vietnam. He stated that the Veteran seems to have used alcohol to manage his PTSD symptoms and excessive alcohol consumption is associated with the development of hypertension. He also noted that per the Mayo clinic high levels of stress could lead to a temporary increase in blood pressure. He then went on to say that the stress associated with PTSD is a known risk factor for hypertension. Moreover, the examiner noted that the medication the Veteran takes for his PTSD, Risperdal and Ariprazola, can cause hypertension. Based on the foregoing, the Board finds that there is an approximate balance of positive and negative evidence on the issue on appeal. Both the positive and negative medical opinions in this case are probative. Both sets of evidence have respective strengths and weaknesses. All medical opinions are from equally competent sources. All clinicians have the requisite training to offer such opinions and provide a rationale in support of their conclusions. As such, their opinions are entitled to equal probative weight. Under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the veteran shall prevail upon the issue. Because a state of relative equipoise has been reached in this case with regard to the Veteran's hypertension, the benefit of the doubt rule will therefore be applied. Therefore, service connection for hypertension is granted. ORDER Entitlement to service connection for hypertension is granted. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs