Citation Nr: 19123748 Decision Date: 03/29/19 Archive Date: 03/29/19 DOCKET NO. 17-50 071A DATE: March 29, 2019 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to service connection for hypertension is granted. Entitlement to service connection for cardiomyopathy and hypertensive heart disease with congestive heart failure as secondary to hypertension is granted. Entitlement to service connection for aortic aneurysm as secondary to hypertension is granted. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression and generalized anxiety disorder, as secondary to hypertension is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his OSA began during active service. 2. The evidence is in equipoise as to whether the Veteran’s hypertension is related to service. 3. Resolving reasonable doubt in the Veteran’s favor, his heart disability is proximately due to his service-connected hypertension. 4. Resolving reasonable doubt in the Veteran’s favor, his aortic aneurysm began during active service. 5. Resolving reasonable doubt in the Veteran’s favor, his depression and generalized anxiety disorder are proximately due to his service-connected hypertension CONCLUSIONS OF LAW 1. The criteria for service connection for OSA are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a heart disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for aortic aneurysm are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for depression and generalized anxiety disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2013 to November 2013. Service Connection To obtain service connection, the evidence must show: (1) the existence of a present disability; (2) 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, i.e., a “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. See 38 C.F.R. § 3.310(a). 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). Entitlement to service connection for OSA The Veteran contends that his current OSA is the result of active service. As an initial matter, the Board notes that the Veteran’s complete service treatment records (STRs) are unavailable and all efforts to obtain said records has been exhausted. Of the STRs available, none contain complaints, treatment, or diagnosis of OSA. In March 2015, the Veteran attended a VA OSA Disability Benefits Questionnaire (DBQ) examination. The examiner diagnosed OSA as of “2014.” Further, the examiner opined that the Veteran’s OSA was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that “his sleep apnea is documented in his records and predisposed to currently noted sleep apnea.” Subsequent VA treatment records indicate continued complaints and treatment of OSA. The Board finds the positive March 2015 opinion the most probative evidence of record and together with the lack of negative evidence against the Veteran’s claim, finds that service connection is warranted for OSA. Entitlement to service connection for hypertension The Veteran contends that his current hypertension is the result of his active service. As noted above, the Veteran’s complete STRs are unavailable and all efforts to obtain said records has been exhausted. Of the STRs available, an October 2013 record notes the Veteran was hospitalized for five days for hypertension and hypertensive heart disease. An accompanying echocardiogram revealed left ventricular long-standing undiagnosed/uncontrolled hypertension. In March 2015, the Veteran attended a VA Hypertension DBQ examination. The examiner diagnosed hypertension as of “2013.” Further, the examiner opined that the Veteran’s hypertension was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that “his hypertension is documented in his records in multiple areas and predisposed to current hypertension.” In a subsequent May 2015 opinion, a VA examiner noted: The claims file is reviewed. Severe concentric left ventricular hypertrophy, dilation, and cardiomegaly findings in the heart would take years to develop, in the presence of uncontrolled hypertension. It is not medically or physically possible for these findings to have developed in the period of 3 weeks, between entrance on 9/10/13, and the echocardiogram of 10/1/13. As the echo report stated, these findings would reflect "LONGSTANDING undiagnosed/uncontrolled hypertension." These findings represent the natural course of the condition, and would have already been well in place, at the time of entrance. Based on the objective evidence in the file, it is more likely than not that the Veteran's hypertension was indeed longstanding and preexisted service, by years. It is less likely as not that the veteran's hypertension was permanently aggravated by service, but that the findings represented the natural course of the disease. In an April 2018 private opinion, Dr. W.B. Md. noted: In reviewing his medical record, it is noted that he was seen and admitted for a hypertensive emergency on the night of 09/30/2013-10/01/2013. At that time, he was complaining of chest pain and his BP was noted to be 220/120. Nowhere in the medical records available to me was there any indication of a prior history or problem with hypertension or cardiac complaints. [The Veteran] had been active in high school and had been active in pre-enlistment physical training. He was able to pass an entry physical and meet the demands of basic training without incident until 09/30/2013. He provided attestation to "complete, detailed, and accurate background information in regard to my controlled drug and alcohol abuse, financial, moral, and physical history.” Missing from his medical assessment was any mention of pre-existing anemia. He was found to be anemic on 10/07/2013. Included with this report of anemia was the statement "soldier did demonstrate mild anemia, most likely from training." Anemia is known to cause worsening of heart failure. A heart-failure review shows "Iron deficiency, with or without anemia, confers increased risk of mortality and morbidity.” …. Given the history, records and research data, I find it to be at least as likely as not that [The Veteran] hypertension and cardiovascular complaints are related. Hypertensive related concerns with [the Veteran] include cardiomyopathy, congestive heart failure and thoracic aortic aneurysm. According to the Framingham Study, hypertension accounts for about one quarter of heart failure cases. Also, given the fact that [the Veteran] was able to pass an entry exam and participate in basic training that it is at least as likely as not that his service time contributed to the worsening of his medical conditions. VA treatment records indicate continued complaints and treatment for hypertension but no discussion on its etiology. The Board has considered the medical and lay evidence of record. There are conflicting medical opinions of record all provided by competent and credible clinicians. The most probative evidence of record is at least in equipoise as to whether the claimed hypertension was incurred in service. After resolving all doubt in the Veteran’s favor, service connection for hypertension is granted. Entitlement to service connection for cardiomyopathy and hypertensive heart disease with congestive heart failure as secondary to hypertension The Veteran contends that his cardiomyopathy and hypertensive heart disease with congestive heart failure is secondary to his hypertension. As noted above, the Veteran’s complete STRs are unavailable and all efforts to obtain said records has been exhausted. Of the STRs available, an October 2013 record notes the Veteran was hospitalized for five days for hypertension and hypertensive heart disease. In March 2015, the Veteran attended a Heart Conditions DBQ examination. The examiner diagnosed congestive heart failure, cardiomyopathy, and hypertensive heart disease. Further, the examiner opined that the Veteran’s congestive heart failure was at least as likely as not proximately due to or the result of the Veteran’s service connected hypertension. The rationale provided was that “His CHF is documented resulting from noted severe uncontrolled hypertension.” In an April 2018 private opinion, Dr. W.B. Md. noted: In reviewing his medical record, it is noted that he was seen and admitted for a hypertensive emergency on the night of 09/30/2013-10/01/2013. At that time, he was complaining of chest pain and his BP was noted to be 220/120. Nowhere in the medical records available to me was there any indication of a prior history or problem with hypertension or cardiac complaints. [The Veteran] had been active in high school and had been active in pre-enlistment physical training. He was able to pass an entry physical and meet the demands of basic training without incident until 09/30/2013. He provided attestation to “complete, detailed, and accurate background information in regard to my controlled drug and alcohol abuse, financial, moral, and physical history.” Missing from his medical assessment was any mention of pre-existing anemia. He was found to be anemic on 10/07/2013. Included with this report of anemia was the statement “soldier did demonstrate mild anemia, most likely from training.” Anemia is known to cause worsening of heart failure. A heart-failure review shows “Iron deficiency, with or without anemia, confers increased risk of mortality and morbidity.” …. Given the history, records and research data, I find it to be at least as likely as not that [The Veteran] hypertension and cardiovascular complaints are related. Hypertensive related concerns with [the Veteran] include cardiomyopathy, congestive heart failure and thoracic aortic aneurysm. According to the Framingham Study, hypertension accounts for about one quarter of heart failure cases. Also, given the fact that [the Veteran] was able to pass an entry exam and participate in basic training that it is at least as likely as not that his service time contributed to the worsening of his medical conditions. VA treatment records indicate continued complaints and treatment for a heart condition but no discussion on its etiology. The Board finds the positive March 2015 opinion the most probative evidence of record and together with the lack of negative evidence against the Veteran’s claim, finds that service connection is warranted for a heart condition. Entitlement to service connection for aortic aneurysm as secondary to hypertension The Veteran contends that his aortic aneurysm is secondary to his hypertension. As noted above, the Veteran’s complete STRs are unavailable and all efforts to obtain said records has been exhausted. Of the STRs available, none contain complaints, treatment, or diagnosis of an aortic aneurysm. In March 2015, the Veteran attended an Artery and Vein Conditions DBQ examination. The examiner diagnosed aortic aneurysm. Further, the examiner opined that the Veteran’s aortic aneurysm was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that “His aortic aneurysm is documented in his records in chest CT report of 2014and predisposed to current aneurysm.” Subsequent VA treatment records indicate continued complaints of aortic aneurysm related symptoms. The Board finds the positive March 2015 opinion the most probative evidence of record and together with the lack of negative evidence against the Veteran’s claim, finds that service connection is warranted for aortic aneurysm. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression and generalized anxiety disorder, as secondary to hypertension The Veteran contends that his acquired psychiatric disorder, claimed as depression and generalized anxiety disorder is secondary to his hypertension. As noted above, the Veteran’s complete STRs are unavailable and all efforts to obtain said records has been exhausted. Of the STRs available, none contain complaints, treatment, or diagnosis of a mental condition. In March 2015, the Veteran attended a Mental Disorders DBQ examination. The examiner diagnosed recurrent moderate depression and generalized anxiety disorder. Further, the examiner opined that the Veteran’s anxiety and depression was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided was that: I believe his anxiety and depression IS AT LEAST AS LIKELY AS NOT (50 PERCENT OR GREATER PROBABILITY) PROXIMATELY DUE TO OR THE RESULT OF THE VETERAN’S CLAIMED HYPERTENSION. Massive loss of physical capabilities is always associated with severe depression. Unpredicted and unexplained loss of physical capabilities is always associated with severe anxiety. Subsequent VA treatment records indicate continued complaints and treatment of mental related symptoms. The Board finds the positive March 2015 opinion the most probative evidence of record and together with the lack of negative evidence against the Veteran’s claim, finds that service connection is warranted for depression and generalized anxiety disorder. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R.A. Elliott II, Associate Counsel