Citation Nr: 1809181 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 13-31 696 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for hypertension, to include as due to exposure to Agent Orange, or as secondary to service-connected coronary artery disease (CAD). REPRESENTATION Appellant represented by: Mark W. Breneman, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and L. T. ATTORNEY FOR THE BOARD J. Baker, Associate Counsel INTRODUCTION The Veteran had active service from May 1970 to May 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In May 2016, the Veteran provided testimony at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is associated with the record. This matter was previously before the Board in August 2016 and September 2017, when it was remanded for further development. The matter now returns to the Board for appellate consideration. FINDING OF FACT The most probative evidence of record does not show that it is at least as likely as not that the Veteran's hypertension had its onset during, or is otherwise etiologically related to, his active service, to include herbicide exposure, or that the Veteran's hypertension is caused by, proximately due to, or chronically aggravated by, service-connected coronary artery disease. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as due to exposure to Agent Orange, or as secondary to service-connected CAD, are not met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2015); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Legal Criteria Generally, service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110 (West 2015); 38 C.F.R. § 3.303 (2015). To establish service connection for a disability, the Veteran must show: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established for a disability shown after service when all of the evidence, including that pertinent to service, shows that the disability was incurred in service. 38 C.F.R. § 3.303 (d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. As hypertension is considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for certain diseases, including hypertension, may also be established on a presumptive basis by showing that the disease manifested to a compensable degree within one year from the date of separation from service. 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Certain diseases may be presumed to have been incurred in service where a Veteran was exposed to herbicide agents, such as Agent Orange, while on active service, even when there is no evidence of such exposure during the period of service. 38 U.S.C.A. § 1116 (West 2014); 38 C.F.R. §§ 3.307 (a)(6), 3.309(e) (2014). Veterans who served in the Republic of Vietnam during the Vietnam Era are presumed to have been exposed to herbicide agents. 38 C.F.R. § 3.307 (a)(6)(iii). Generally, the regulation applies where an enumerated disease becomes manifest to a compensable degree at any time after active service. 38 C.F.R. § 3.307 (a)(6)(ii). A disability which is proximately due to or the result of a service-connected disease or injury will also be service connected. When service connection is thus established for a secondary condition, the secondary condition is considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will also be service connected. 38 C.F.R. § 3.310(b). Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). In deciding the Veteran's claim, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Analysis The Board concedes that the Veteran has a current disability of hypertensive heart disease, as shown by VA treatment records. The Veteran contends that his hypertension was caused by his exposure to herbicides in Vietnam, or in the alternative, secondary to his service-connected CAD. The Veteran's service treatment records show that the Veteran's blood pressure was normal at entry, and elevated at 134/100 on separation. The Veteran then had a three day blood pressure evaluation. The record reflects that the Veteran was first diagnosed with hypertension in 2004, many years after service. The Board finds that the Veteran did have service in Vietnam during the requisite period, and, as such, is presumed to have been exposed to herbicide agents. Nonetheless, hypertension is not under the list of enumerated conditions in 38 C.F.R. § 3.309(e). Therefore, service connection due to herbicide exposure is not warranted on a presumptive basis. However, the Veteran is not precluded from presenting evidence that a claimed disability is due to or the result of herbicide exposure to alternatively show entitlement to service connection on a nonpresumptive direct-incurrence basis. Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). The Veteran has contended that a relationship exists between his hypertension and his herbicide exposure. A March 2013 VA examiner opined that it was not at least as likely as not that the Veteran had hypertension in service. The examiner noted the Veteran's three day blood pressure evaluation, but indicated that it was insufficient for a diagnosis of hypertension. Further, the examiner stated that it was not at least as likely as not that the Veteran's condition was caused by, related to, or aggravated by service. A June 2013 disability benefits questionnaire by a private physician states that the Veteran has had elevated systolic pressures since 1998. The physician notes that the Veteran was diagnosed with hypertension in 2004 and started on medication in 2011. A September 2016 VA examination found that hypertension is most likely essential in nature and unrelated to herbicide exposure in service. The examiner noted that medical research is against a direct relationship between hypertension and herbicide exposure, and that there is no medical rationale for latent hypertension due to herbicide exposure. A supplemental VA opinion was obtained in September 2017. The examiner noted the Veteran's 2004 hypertension diagnosis and the Veteran's presumed exposure to herbicides. The examiner concluded that the Veteran's hypertension is less likely than not caused by herbicide exposure. The examiner noted the commonality of the condition amongst the general public. The examiner indicated that the National Academy of Sciences could not clearly identify relevant data that is consistent with a relationship between herbicide exposure and blood pressure. In October 2017, the Veteran submitted a medical journal article entitled "Herbicide Exposure, Vietnam Service, and Hypertension Risk in Army Chemical Corps Veterans." The VA obtained a supplemental medical opinion in October 2017 to consider and address the Veteran's submission. The October 2017 VA opinion notes that the article discusses a study of the hypertensive risk of Army veterans who sprayed defoliant in Vietnam. The examiner noted that the Veteran testified to serving in the Navy, and claiming exposure through cleaning naval vessels. The record does not support the Veteran spraying herbicides. The examiner concluded that because the subpopulation of veterans studied in the article was different from the Veteran, the study results could not be directly applied to the Veteran. The examiner noted that the article also pointed out that causal relationships could not be inferred because the study was cross-sectional. Given the above, the examiner concluded that it was less likely than not that the Veteran's hypertension was caused by herbicide exposure. The examiner also noted the commonality of hypertension in the general population, as well as the Veteran's inherent risk factors such as male gender, age, and strong family history. With regard to the relationship between the Veteran's hypertension and his service-connected CAD, the June 2013 physician indicated that CAD was related to his hypertension, but did not make an assertion or opinion as to a causal relationship or aggravation. It is unclear how the term "related" was interpreted by the physician. A February 2014 VA examiner stated that hypertension was less likely than not proximately due to or the result of his service-connected CAD. The examiner stated that the Veteran had been borderline hypertensive for years prior to the diagnosis of CAD. The examiner stated that while hypertension can contribute to or aggravate CAD, the opposite is not true, and that CAD does not cause hypertension. The examiner also stated that there is no mechanism by which CAD can aggravate hypertension. The Board affords great probative weight to the consistent opinions of VA examiners that the Veteran's hypertension is not due to herbicide exposure, as well as the February 2014 examiner's opinion that as a matter of fact, hypertension is not caused or aggravated by CAD. The examiner's reviewed the Veteran's complete record, and applied their medical expertise in forming their opinions. The Board gives particular weight to the October 2017 medical opinion that determined the study submitted by the Veteran to be inapplicable to the Veteran, as well as her consideration of other risk factors. The Board acknowledges that the Veteran is competent to report a symptom such as shortness of breath or dizziness, but he has not been found to possess the medical expertise to diagnose hypertension or attribute hypertension to a specific cause. Given the above, the Board finds that the most probative evidence of record does not show that it is at least as likely as not that the Veteran's hypertension had its onset during, or is otherwise etiologically related to, his active service, to include herbicide exposure, or that the Veteran's hypertension is caused by, proximately due to, or chronically aggravated by, service-connected coronary artery disease. In light of the above, the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not for application. The claim therefore must be denied. 38 U.S.C.A. § 5107 (b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hypertension, to include as due to exposure to Agent Orange, or as secondary to service-connected CAD, is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs