Citation Nr: 1818002 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 09-40 384 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G. Johnson, Associate Counsel INTRODUCTION The Veteran served in the United States Navy from August 1971 to October 1993, and received multiple awards and medals including the Navy Commendation Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran has since moved to Tennessee, and the Nashville, Tennessee RO has assumed jurisdiction over his claim. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in January 2011. A transcript of the hearing has been associated with the claims file. The case was previously before the Board in June 2011, August 2014 and March 2016. In a March 2016 decision, the Board denied a claim for entitlement to service connection for hypertension. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In May 2017, pursuant to a Joint Motion for Remand, the Court vacated the March 2016 decision and remanded the matter to the Board for action consistent with the Joint Motion. FINDING OF FACT It is as likely as not that the Veteran's hypertension is attributable to service. CONCLUSION OF LAW Hypertension was incurred in active service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.326(a). In light of the favorable disposition of the claim for service connection for hypertension, the Board finds that any deficiencies with regard to the duty to notify or assist is non prejudicial, and thus, no further discussion of VA's duties to notify and assist is necessary. II. Service Connection for Hypertension The Veteran seeks service connection for hypertension, which he asserts is related to service or to service-connected posttraumatic stress disorder (PTSD). At a January 2011 Board hearing, the Veteran testified that his hypertension was caused by a psychiatric condition. He testified that he had high blood pressure when he separated from service, and that his first doctor after service opined that his high blood pressure was caused by the stress of being a Navy Master Chief. The Veteran testified that his hypertension was diagnosed in 2002, and he had been taking medication continuously since his diagnosis. In a September 2014 statement, the Veteran asserted that he was diagnosed with hypertension by a private treatment provider in October 1993 in Atsugi, Japan, and was prescribed Lisinopril to treat his hypertension. He stated that in September 1993, upon his return to the United States, he was diagnosed and treated for hypertension in Ohio, and continued to take Lisinopril for eight years. In a December 2014 statement, the Veteran asserted that he did not have elevated blood pressure readings after May 1995, because he had been on medication to control his high blood pressure. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). For Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension, are presumed to have been incurred in or aggravated by service if manifest to a compensable degree (10 percent disabling) within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease, at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Even if service connection is not warranted under one of the presumptive regulations, this does not preclude a claimant from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). Service connection may also be granted for a disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 446-449 (1995) (en banc). The Veteran served in the United States Navy from August 1971 to October 1993. Service treatment records do not reflect a diagnosis of hypertension. Service treatment records reflect elevated systolic blood pressure (SBP) readings and elevated diastolic blood pressure (DBP) readings. The following elevated blood pressure (BP) readings were noted in service: 150/82 in November 1975; 140/92 in June 1986; 140/90 in April 1988; 130/90 in December 1988; 132/86 in April 1993; and 130/88 in June 1993. Post-service treatment records reflect elevated diastolic blood pressure readings from September 1994, elevated blood pressure readings from May 1995, and a diagnosis of hypertension from December 2003. Private treatment records reflect that the Veteran's blood pressure was 116/90 in September 1994, and after it was rechecked, it was 120/86, and it was 134/90 in May 1995. Private treatment records in June 2002 reflect that the Veteran's blood pressure was 152/120, and after it was rechecked, it was 130/90. The treatment provider noted that the plan was for the Veteran to return in two weeks to recheck his blood pressure, which was 132/100 in July 2002. The treatment provider noted that the Veteran's diastolic blood pressure was high, and prescribed Zestril (Lisinopril). VA treatment records in December 2003 reflect a diagnosis of hypertension and the Veteran was taking medication for his hypertension. The Veteran was afforded a VA examination in October 2012, which reflected a diagnosis of hypertension. The Veteran reported he was diagnosed with hypertension in August 1993, and was prescribed Lisinopril. The examiner noted that the Veteran was diagnosed with hypertension by VA in approximately 2002 and was prescribed MiCardis. The Veteran's current blood pressure readings were 130/76, 128/74, and 126/70. The examiner opined that it was less likely than not that hypertension was incurred in or caused by an in-service injury, event, or illness. The examiner also opined that the Veteran had no evidence of diagnosis and treatment for hypertension in service and it was not aggravated by psychiatric disorders. The examiner noted that the Veteran had not been diagnosed with PTSD or an acquired psychiatric condition in the form of depression and anxiety that began in or was aggravated in-service. The examiner noted that high-level anxiety could cause temporary increase in the established hypertension, but opined that anxiety was not the cause of the Veteran's hypertension. An addendum opinion was obtained in September 2014. The examiner opined that the Veteran's hypertension was not due to or the result of a psychiatric disorder initially manifested during his military service. The examiner opined that PTSD and its treatment do not cause hypertension and that that there was no "permanent blood pressure elevation or diagnosis of hypertension due to PTSD." The examiner also opined that the there was no diagnosis of elevated blood pressure or hypertension in service, and there was no record of treatment of hypertension in service. The examiner noted that the four elevated readings in November 1975, January 1986, April 1988, and December 1988 were all taken during visits for acute medical problems and noted that it was not unexpected that blood pressure would have been elevated those days. As outlined in the May 2017 Joint Motion for Remand associated with an appeal of the Board's prior decision to the United States Court of Appeals for Veterans Claims, the September 2014 VA examiner applied the incorrect standard for aggravation when providing the medical opinion as to whether the Veteran's hypertension had been aggravated by his service-connected PTSD. Specifically, the September 2014 VA examiner indicated that there was no "permanent blood pressure elevation." The Court has explained that, "any increase in disability" is the standard to be used. See Allen, supra. In February 2018, a VA Veteran Health Administration (VHA) expert opinion was obtained from a physician who specialized in cardiovascular disease. The examiner opined that the Veteran's hypertension was incurred in active service. The examiner noted that the definition of hypertension was recently updated and fully described in the 2017 ACC/AHA/AAPA/ABC/ ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Guideline for High Blood Pressure). The examiner noted that pertinent aspects from this guideline update include: hypertension stage 1 is defined as 130-139mm Hg or 80-89 mm Hg; individuals with SBP and DBP in 2 categories should be designated to the higher BP category; and BP indicates blood pressure (based on an average of 2 or more careful readings obtained on 2 or more occasions. Specifically, the examiner noted that the Veteran's blood pressure was 132/86 in April 1993 and 130/88 in June 1993. The examiner found that both readings met the definition for hypertension stage 1 based on both SBP and DBP. The February 2018 VHA examiner also opined that the Veteran's hypertension was at least as likely as not aggravated as a result of the Veteran's service-connected PTSD. The examiner noted that clinically, hypertension could be ameliorated by lifestyle modification and exacerbated by lifestyle choices including dietary indiscretion. Psychologic distress, such as PTSD, can impact lifestyle choices including dietary indiscretion; which can aggravate hypertension. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for hypertension have been met. The February 2018 VHA opinion establishes that the Veteran's hypertension is related to service. The examiner found that due to the 2017 Guideline for High Blood Pressure update, the Veteran had met the definition of hypertension in service based upon the Veteran's SBP and DBP measurements in service. The February 2018 opinion is competent, credible and probative, and coupled with the other medical evidence of record including service treatment records, VA treatment records, and lay evidence, supports a conclusion that service connection for hypertension is warranted. ORDER Service connection for hypertension is granted. S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs