Citation Nr: 1818191 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 10-43 165 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUE Entitlement to service connection for hypertension, to include as secondary to service-connected unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder). REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law ATTORNEY FOR THE BOARD Hammad Rasul, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1979 to March 1983. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2008 decision of a Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, denied service connection for hypertension and for anxiety. The Board remanded these claims in April 2014 for further development. The Board granted service connection for an acquired psychiatric disorder to include anxiety disorder in July 2015 and again remanded the hypertension claim at that time. The Board remanded the claim again in October 2017 for further development. As indicated in the discussion below, the RO complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). As reflected on the title page, based on the evidence submitted by the Veteran, and through his representative, the Board has re-characterized his hypertension claim to include as secondary to his service-connected unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder). See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant's description of the claim, the symptoms described, and the information submitted or developed in support of the claim). FINDINGS OF FACT 1. Hypertension did not manifest in service or within the one year presumptive period and is unrelated to service. 2. The Veteran's service-connected unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder) did not cause or aggravate his hypertension. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to his service-connected unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder), have not been met on a direct or secondary basis. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist 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. §§ 5103, 5103A; 38 C.F.R. § 3.159. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159 (b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In its October 2017 remand, the Board instructed that an addendum opinion be obtained that specifically discussed the Veteran's in-service nose bleeding incident in March 1980 and blood pressure reading of 142/94 as a possible early manifestation of hypertension. As shown in the discussion below, an opinion was obtained that discussed these facts. The RO thus complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Neither the Veteran nor his attorney has raised any other issues with regard to the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. II. Service connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Service connection generally requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (1995). Service connection may also be granted for any injury or disease diagnosed after service, 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). Service connection may also be granted for listed chronic diseases, including hypertension, when the disease is manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Under § 3.303(b), an alternative method of establishing the second and/or third elements of service connection for a listed chronic disease is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a)). In this regard, the Board notes that lay persons may provide evidence of diagnosis and nexus under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In addition to the regulations noted above, service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). For VA compensation purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm. or greater, or systolic blood pressure is predominantly 160 or more. 38 C.F.R. § 4.104, DC 7101 n.1 (2017). A diagnosis of hypertension "must be confirmed by readings two or more times on at least three different days." Id. The requirement of multiple blood pressure readings to be taken over multiple days as specified in Note (1) of DC 7101 applies to confirming the existence of hypertension. Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). Service treatment records (STRs) do not report a hypertension diagnosis. However, a November 1980 note reflects an elevated blood pressure reading of 142/94. Another November 1980 STR reflects an elevated blood pressure reading of 132/92. May 2006 VA treatment records included a blood pressure reading of 110/60. June 2006 VA treatment records included a blood pressure reading of 120/90. August 2006 VA treatment records included a blood pressure reading of 140/90 April 2007 VA treatment records included a blood pressure reading of 140/100. In a February 2009 statement, the Veteran stated that he developed high blood pressure because during service, he was trained to be an extremely aggressive individual and had to push himself beyond physical and mental limits. On a November 2014 VA examination, the examiner noted that the Veteran was diagnosed with hypertension in 2007. The examiner also noted that the Veteran's treatment plan include continuous medication for hypertension or isolated systolic hypertension. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that a review of medical records during and after military service showed isolated elevated blood pressure readings that did not meet the criteria for hypertension until 2007. The examiner further explained that despite the Veteran attributing his hypertension on his in-service training and stress, the medical literature notes that stress causes temporary elevation in blood pressure but that it does not cause sustained elevated blood pressure consistent with hypertension. The examiner also opined that the Veteran's hypertension is less likely as not aggravated beyond its natural progression by a service-connected disability, to include the Veteran's psychiatric disability on appeal at the time. The examiner noted that he was able determine a baseline level of severity based on the Veteran's treatment records from 2006 and 2007. The examiner also noted that the Veteran was prescribed medication for his psychiatric disability and noted that there is no indication that the Veteran's hypertension was aggravated beyond natural progression. In May 2015, the Veteran provided medical literature that stated that stress can momentarily increase blood pressure. However, the article stated that it was not certain if there is a strong link between stress and long-term high blood pressure. The article also stated that stress can lead to hypertension as people who are stressed tend deal with their stress by engaging in unhealthy eating habits, smoking, and drinking. The article also stated that medications used to treat anxiety can lead to higher blood pressure. In an October 2015 VA addendum medical opinion, the VA physician opined that the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service connected anxiety disorder. The VA examiner noted that review of medical literature shows that anxiety does not cause long-term blood pressure or hypertension. The examiner also noted that review of the Veteran's medications show that none of his prescribed medication causes hypertension. In a November 2017 VA medical opinion, the examiner opined that the Veteran's hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The physician noted that the Veteran's STR show that the Veteran was treated for one episode of nosebleed with elevated blood pressure reading. The physician reasoned that according to medically accepted knowledge, hypertension must show a sustained elevation of blood pressure over time on at least three to five different occasions. The physician also noted that the Veteran's nosebleed alone is not indicative of whether the Veteran had or did have hypertension. The physician also noted that the Veteran separated from service in 1983 and was not diagnosed with hypertension until 2007. The Veteran contends service connection for hypertension is warranted. For the following reasons, the Board finds that the evidence preponderates against the claim. The evidence in support of the claim is limited to the Veteran's general contention. He does not assert a continuity of symptomatology and it is not suggested by the evidence of record. Thus, neither the lay nor medical evidence suggest that hypertension manifested in service or within the one year presumptive period for chronic diseases. The issue of establishing a nexus to service or service-connected disease or injury for post-service hypertension is a complex medical question since it is beyond any readily observable cause and effect relationship. Jandreau, 492 F.3d at 1377, n. 4. Thus, to the extent the Veteran asserts a nexus for post service hypertension, his statements in this regard are not competent. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). The record contains several negative nexus opinions provided by VA examiners and there is no positive nexus opinion of record. As the examiners explained the reasons for their conclusions that the Veteran's hypertension is not related to his military service based on an accurate characterization of the evidence of record, their opinions are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). As to whether the Veteran's hypertension was caused or aggravated by his service-connected unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder), the physician who provided the October 2010 opined the Veteran's hypertension is less likely than not proximately due to or the result of the Veteran's service connected anxiety disorder. Additionally, the November 2014 VA examiner opined that there was no evidence of aggravation or worsening beyond natural progression by any of the Veteran's service-connected disabilities, to include unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder). As the physicians explained the reasons for their conclusions based on an accurate characterization of the evidence of record, their opinions, addressing both causation and aggravation, is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board must weigh this opinion against the medical literature submitted by the Veteran. The Court has indicated that treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). Significantly however, the Court has also held that treatise materials generally are not specific enough to show nexus, Id. at 317, and that medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet.App. 122, 123 (1993). In this case, the above described reasoned opinions by the physicians specifically indicating a lack of causation or aggravation in this case are of greater probative weight than the medical literature submitted by the Veteran indicating generally that stress can momentarily increase blood pressure and medications used to treat anxiety can lead to higher blood pressure. For the above stated reasons, the preponderance of the evidence weighs against a relationship between hypertension and service or a service connected disease or injury. The benefit-of-the-doubt doctrine is therefore not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for hypertension, to include as secondary to service-connected unspecified depressive disorder (acquired psychiatric disorder to include anxiety disorder), is denied. ____________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs