Citation Nr: 20021794 Decision Date: 03/27/20 Archive Date: 03/27/20 DOCKET NO. 09-39 889 DATE: March 27, 2020 ORDER Service connection for hypertension is denied. FINDINGS OF FACT 1. The Veteran had active service from February 1970 to September 1971, to include service in the Republic of Vietnam. He is presumed to have been exposed to herbicides during his Vietnam service. 2. Hypertension was not shown in service, was not shown to a compensable degree within one year of service, and symptoms were not continuous since service; the current diagnosis of hypertension is not causally or etiologically related to service, to include herbicide exposure, and was not caused by or permanently worsened in severity by a service-connected disability. CONCLUSION OF LAW Hypertension was not incurred in service, is not presumed to have been incurred in service, and is not proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may be granted on a presumptive basis for certain diseases resulting from exposure to an herbicide agent (including Agent Orange) for veterans who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307 (a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). Service records confirm that the Veteran served in the Republic of Vietnam and is therefore presumed to have been exposed to herbicides, but hypertension is no a disorder presumed to be associated with herbicide exposure. Nevertheless, the availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a veteran from establishing service connection with proof of direct causation, or on any other recognized basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Turning to the evidence, the first element of direct service connection – a current disability – is met. The Veteran was diagnosed with hypertension in 2003 and has been treated for the disorder throughout the appeal period. As such, the first element of service connection is met. However, the second element of direct service connection – an in-service incurrence – is not met. Service treatment records are silent for complaint, treatment, or diagnosis of hypertension or any elevated blood pressure readings. Thus, the second element of service connection is not met and the medical evidence does not support direct service connection. To the extent that the Veteran asserts a medical nexus between hypertension and service, the medical evidence does not support the claim. Initially, hypertension is not on the list of diseases presumed to be associated with herbicide exposure. Therefore, the evidence does not support the claim on a presumptive basis. Next, in accordance with the January 2018 remand, an opinion was obtained in January 2020 with regard to direct and presumptive service connection. The examiner reviewed the most recent update to the Veterans and Agent Orange publication by the National Academies of Sciences, Engineering, and Medicine and found that six new studies since 2014 prompted authors to find that there was no longer “limited or suggestive” but “sufficient” evidence of a positive association between hypertension and herbicide exposure; however, the examiner also indicated that the new studies neither proved nor disproved a causal relationship, and that only one of the studies reviewed was done in Vietnam veterans. The examiner further observed that that study was a survey and involved little records review, rendering it less reliable than studies involving direct measurement. Additionally, the examiner emphasized that the Veteran had several risk factors for the development of essential hypertension including gender, age at diagnosis, history of tobacco use, obesity, and a family history of heart disease and hypertension. The examiner also noted that hypertension was common in the general population. Therefore, the examiner concluded that the Veteran’s hypertension was not at least as likely as not related to presumed exposure to herbicide agents during service. As such, the medical evidence does not support the claim on a presumed or direct exposure to herbicides. Next, hypertension is a chronic disease under 38 C.F.R. § 3.309 and presumptive service connection will be considered. However, no chronic disease or injury was shown in service. As noted above, STRs are silent for complaints of, treatment for, or a diagnosis of hypertension. Therefore, the medical evidence does not support presumptive service connection on a “chronic disease or injury shown in service” basis. Next, the medical evidence does not support presumptive service connection based on continuity of symptomatology since service. Specifically, the medical evidence shows that the Veteran was first diagnosed with hypertension in 2003, and a July 2001 VA examiner for diabetes mellitus (DM) found a normal blood pressure reading and did not document any complaint, treatment, or diagnosis related to hypertension. The Veteran separated from service in August 1971. The medical evidence shows that symptoms of his current disability developed over thirty years after service. As such, the medical evidence does not support service connection on a “continuity of symptomatology” basis. Further, the disorder did not manifest itself to a degree of 10 percent or more within one year from the date of separation of service. The Veteran separated from service in 1971 but treatment notes did not note symptoms until 2003 at the earliest. This evidence does not support presumptive service connection on a “manifest within one-year from separation” basis. Therefore, presumptive service connection on any basis is not supported by the medical evidence. The Veteran’s primary argument is that his hypertension is secondary to service-connected DM. A July 2001 VA examination reflects that DM was diagnosed a year-and-a-half earlier, and service connection has been in effect for DM since December 2000. A November 2006 VA examiner stated that DM did not cause hypertension and was not secondary to hypertension. The examiner indicated that hypertension develops in DM when there is organ damage such as nephropathy or renal failure. Thus, the examiner concluded that the hypertension was not secondary to DM, but essential in nature. A June 2013 VA examiner opined that essential hypertension was not caused or aggravated by DM. The examiner reasoned that the essential hypertension was well-controlled by medication and that there was no end-organ damage. An April 2017 VA examiner reviewed medical literature submitted by the Veteran identifying insulin resistance, central obesity, and dyslipidemia as factors for increased risk of hypertension and indicated that these factors together are known as Metabolic Syndrome or Syndrome X. However, the examiner found that the Veteran did not have this syndrome as DM was diagnosed in 2001 and essential hypertension was diagnosed in 2003. The examiner also noted that, even though the Veteran had had DM for 16 years, he did not require insulin and showed no evidence of end-organ damage to kidneys or eyes, which would indicate severe DM. The examiner concurred with the November 2006 examiner in describing that hypertension develops with DM most commonly when there is end-stage renal disease, and reviewing the Veteran’s laboratory work since 2001, reported that there was no evidence of renal disease in the Veteran. The examiner stated that while there is a greater frequency of hypertension among people with DM, such is not an indicator of causality but of an association and risk factors common between the two disorders. Finally, the examiner observed that the Veteran had several independent risk factors for hypertension—his gender, age at diagnosis, a history of tobacco use, obesity, and a family history of hypertension and heart disease. In conclusion, the examiner found that the Veteran’s hypertension was not caused or aggravated by DM. Therefore, the medical evidence does not support the claim on a secondary basis. The Board has considered the Veteran’s lay statements that his hypertension was caused by service or service-connected disability. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. Considering the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. M. Schaefer, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.