Citation Nr: 1817100 Decision Date: 03/20/18 Archive Date: 03/30/18 DOCKET NO. 10-13 789A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for hypertension, to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Cheryl E. Handy, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to September 1970, including service in the Republic of Vietnam for which he earned the Combat Action Ribbon. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision issued in March 2009 by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2016, the Board requested an advisory opinion from a Veterans Health Administration (VHA) medical expert with respect to the question of whether the Veteran's hypertension was related to his service, to include as secondary to any service-connected disability. The opinion was received in September 2016 and the Veteran and his representative were provided a copy of it. The Veteran's representative submitted a response to the opinion in December 2016. In January 2017, the Board denied the appeal for service connection for hypertension. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court), which in October 2017 granted a Joint Motion for Remand (JMR) of the parties (VA Secretary and the Veteran), vacated the Board's decision, and remanded the case pursuant to 38 U.S.C. § 7252(a) for readjudication consistent with the Motion. In December 2017, the Board requested another advisory opinion from a VHA medical expert with respect to the question of whether the Veteran's hypertension was related to his service, to include as secondary to any service-connected disability. The opinion was received in February 2018. Inasmuch as this opinion is favorable to the Veteran's claims, the Board will proceed with the adjudication. FINDING OF FACT The evidence shows that the Veteran's hypertension has been aggravated by his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303, 3.304, 3.310(b) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Inasmuch as this decision grants the benefit sought on appeal, there is no reason to belabor the impact of VA's duty to notify or assist on this matter; any notice error or duty to assist failure as to this claim is harmless. The AOJ will assign a rating and effective via a rating decision implementing this Board decision. Principles of Service Connection Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a), (b). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). Facts and Analysis The Veteran seeks service connection for hypertension, which he asserts was caused or aggravated by his service-connected PTSD. The record shows that the Veteran was diagnosed with hypertension in May 2008 based on his blood pressure readings and was placed on prescription medications. He had been diagnosed with PTSD in February 2006; the record shows that the Veteran had symptoms of PTSD for many years before the official diagnosis was given. He was granted service connection for PTSD beginning in February 2006, with a disability rating of 30 percent; the disability rating was increased to 50 percent as of November 2007. The Veteran submitted a statement signed by his treating physician in June 2008 in which he stated that it was "difficult to assess if hypertension is related to PTSD; though it may not be ruled out" (Medical Treatment Record, 06/20/2008). At the VA examination in October 2008, the Veteran reported that his hypertension had been diagnosed six months previously and he had begun taking medication (C&P Exam, 11/03/2008). He reported a history of symptoms such as intermittent headaches and blurred vision since 1970, but noted that these symptoms had not changed since he started on medication to control his blood pressure. He reported no functional impairment resulting from his hypertension and his blood pressure readings at the time of the examination were 138/80, 136/80, and 140/80. On examination, the Veteran's chest X-ray and EKG were both normal. The examiner noted that PTSD had first been diagnosed in February 2006, although the Veteran had been experiencing symptoms for many years prior. The examiner stated that he could not relate the Veteran's current hypertension to his PTSD without speculation, but noted that hypertension could be associated with PTSD. In his Form 9 submitted in April 2010, the Veteran noted that he had submitted a copy of a study by Dr. Joseph A. Boscarino which discussed the results of clinical and epidemiologic studies showing evidence of cardiovascular disease in veterans with traumatic exposure (Form 9, 04/09/2010). The Veteran's former attorney noted that this study had been cited in the Federal Register to support the conclusion that PTSD might be associated with cardiovascular disorders. The Veteran's attorney also noted that the record showed an elevated blood pressure reading shortly after service separation, in March 1971, of 132/82, and an elevated reading since service of 131/87 in August 2005. The Board has reviewed the study by Dr. Joseph A. Boscarino, "Posttraumatic Stress Disorder and Mortality Among U.S. Army Veterans 30 Years After Military Service" (VA Memo, 04/09/2010). The Board notes that the stated conclusion of the study is that "Vietnam veterans with PTSD may be at increased risk of death. The reasons for this increased mortality are unclear but may be related to biological, psychological, or behavioral factors associated with PTSD and warrants further investigation." In August 2016, to assist it with adjudication of this appeal, the Board requested an expert medical opinion through VHA with respect to the cause of the Veteran's hypertension. The expert reviewed the entirety of the file and all medical evidence contained therein before offering an opinion. It was the expert's opinion that the Veteran's hypertension was unlikely to have been cause by his PTSD and symptoms of PTSD (Correspondence, 09/30/2016). The expert cited a study regarding the correlation between blast exposure and prevalence of increased mean systolic blood pressure, diastolic blood pressure, and heart rate. The expert noted that the prevalence of hypertension among those with blast exposure - regardless of any diagnosis of PTSD - was 34.1 percent, as compared to 33.5 percent in the general population, a difference of less than one percent. The expert noted that there was no report in the record that the Veteran had any blast exposure in service. The VHA expert also addressed the study by Dr. Boscarino and noted that it had only shown a suggestion of a possible link and was written to address causes of death rather than causes of hypertension. The VHA expert noted the elevated blood pressure readings in March 1971 and August 2005 which were cited by the Veteran's attorney and noted that these did not meet the medical definition of hypertension, namely, two or more office readings in which the systolic pressure (top number) is greater than 140 or the diastolic pressure (bottom number) is greater than 90. The VHA expert also addressed whether the Veteran's service-connected malaria could have caused or aggravated his hypertension and offered the opinion that it could not have, at least based on existing medical research. After the Court vacated the January 2017 Board decision, the Board sought an additional VHA opinion to address the deficiencies highlighted by the JMR (Correspondence, 12/18/2017). The Board noted that the Veteran was awarded the Combat Action Ribbon and therefore is confirmed to have had blast exposure in service. The VA physician had noted a correlation between blast exposure and hypertension, regardless of whether there was a diagnosis of PTSD, and therefore the Court deemed the opinion inadequate because it did not take into account the Veteran's exposure. In light of this, the Board's December 2017 request for an opinion instructed the new VHA expert to provide information on risk factors for hypertension and to address the medical research included in the record. The VHA expert medical opinion dated in February 2018 contained a review of the entire claims file and of the study by Dr. Boscarino (Medical Opinion, 03/12/2018). The expert also cited a more recent and relevant study showing that the rate of hypertension among veterans with PTSD is approximately double that of veterans without PTSD, or 16.4% compared to 8.1% in those who had served in Iraq and Afghanistan. The expert also listed the risk factors that can cause hypertension, to include age, genetics, race, weight, lifestyle, and medication. The expert stated that hypertension "is the most common medical diagnosis in the" country and PTSD is just one possible cause. As a result, the expert stated that it would be impossible to state that the Veteran's hypertension was caused by his PTSD with greater than 50% probability. However, the expert offered the opinion that the Veteran's hypertension had been aggravated by his PTSD, with a measurable increase, such that 23% of the hypertension is a result of aggravation. The medical opinions of record have all been unable to provide an opinion that the Veteran's hypertension was caused by his service-connected PTSD on an at least as likely as not (probability 50% or greater) basis. However, after considering the entirety of the record, to include the evidence discussed above, the Board finds that service connection for hypertension as a result of aggravation by service-connected PTSD is warranted. 38 C.F.R. § 3.310(b). In this regard, the Board finds that the opinion of the 2018 VHA expert that the Veteran's hypertension was aggravated by his PTSD, along with an opinion of the measurable increase, supported by medical research studies, is sufficient to satisfy the requirements for service connection on a secondary (aggravation) basis. 38 C.F.R. § 3.310(b). As the evidence regarding aggravation by a service-connected disability is at least in equipoise, reasonable doubt is resolved in favor of the Veteran and all the elements necessary for establishing secondary service connection are met. The Veteran's hypertension claim is granted. 38 U.S.C. § 5107(b). ORDER Service connection for hypertension is granted. ____________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs