Citation Nr: 20032541 Decision Date: 05/08/20 Archive Date: 05/08/20 DOCKET NO. 11-24 024 DATE: May 8, 2020 ORDER Service connection for hypertension, to include as due to herbicide agent exposure and as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The Veteran’s hypertension was not incurred in or caused by military service and was not caused or aggravated by service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension have not been satisfied. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1966 to April 1972, to include service in the Republic of Vietnam. The Veteran was awarded two Purple Hearts, two Bronze Stars, and a Combat Infantryman Badge, among other decorations. The Veteran died in May 2016. In December 2016 the Veteran’s surviving spouse was properly substituted as the appellant. In September 2015, the Veteran testified during a video conference hearing before the undersigned Veterans Law Judge. The appellant was also present at the hearing as an observer. A transcript of the hearing is of record. In February 2016 and May 2019, the Board of Veterans’ Appeals (Board) remanded the issue on appeal for additional development. The issue has now been returned to the Board for appellate review. Generally, to establish service connection, a claimant 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. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Department of Veterans Affairs (VA) has established certain rules and presumptions for chronic diseases, such as hypertension. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). By nature of his service in the Republic of Vietnam, the Veteran is presumed to have been exposed to herbicide agents. 38 C.F.R. § 3.307(a)(6)(iii). Certain diseases are presumed by VA to be caused by herbicide agent exposure. 38 C.F.R. §§ 3.307, 3.309(e). Hypertension is not one of those diseases. Id. However, service connection can still be awarded if the evidence shows that the Veteran developed hypertension as a result of an in-service event, injury, or disease, to include exposure to herbicide agents. The Veteran was diagnosed with hypertension during his lifetime. Thus, the remaining question is whether the Veteran’s disability is caused or aggravated by military service or service-connected PTSD. Service treatment records show no complaints, diagnosis, or treatment related to hypertension. During the March 1972 separation examination, evaluation was normal. The Veteran presented for a VA examination in December 2010, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The examiner noted the Veteran had a history of hypertension with multiple blood pressure medications. He reported the Veteran had hypertension which onset after service in 1973 and was currently asymptomatic. The Regional Office (RO) obtained a medical opinion in February 2019. The examiner reviewed the Veteran’s medical history and diagnosis of hypertension. He reported the Veteran’s hypertension was controlled by medication and was less likely than not caused by or incurred in service, to include as due to herbicide agent exposure. He explained the Veteran’s service treatment records and immediate post-service treatment records are silent for hypertension and/or residuals. He reported the January 1976 compensation and pension examination is absent hypertension. The examiner explained essential hypertension is clearly acquired and diagnosed many years after service, although the exact date is unknown and cannot be ascertained without resorting to mere speculation. The examiner reported that based on the National Academy of Science (NAS) reports from 2006, 2008, 2010, and 2012, there is limited or suggestive evidence that essential hypertension is associated with herbicide agent exposure, and this does not represent a clearly identified nexus of causality. He reported the Veteran has multiple risk factors for his hypertension and extrapolating these risk factors makes his hypertension less likely than not related to military service, to include exposure to herbicide agents. He explained that for the foregoing reasons the Veteran’s hypertension was not caused or aggravated by his service-connected PTSD either. In May 2019 the appellant responded that the 2018 NAS update concluded that there is sufficient evidence of an association between the chemicals of interest and hypertension and explained the study’s findings on the relationship between dioxin and hypertension. In December 2019 a supplemental medical opinion was obtained to address the NAS 2018 update. The examiner stated that he reviewed the February 2019 VA medical opinion and the subsequent evidence regarding the 2018 NAS update that concluded that there is sufficient evidence of an association between chemicals of interest and hypertension. He noted that the press release also stated that “a firm conclusion is limited because chance, bias, and confounding factors could not be ruled out with confidence.” The examiner reviewed the evidence of record and reported there was no mention of hypertension during service. He stated that records regarding hypertension started to appear in the 2000’s. The examiner explained that the February 2019 VA examiner’s opinion is also scientifically correct when stating association is not equivalent to causation or a clearly identified nexus of causality. He explained that this means that this new data is a data point and should be taken in account with all other data points, but by itself does not constitute proof of causation. The examiner explained that in looking at the complete picture, about the time the Veteran was diagnosed he had several significant risk factors for developing hypertension, including being greater than 50 years of age, of African American race, a long smoking history, excessive alcohol consumption history, distant cocaine use, and obesity. He reported a number of these are considered major risk factors for hypertension. The examiner explained that all of this significantly overshadows an association between herbicides and hypertension. He stated that if one looks at the prevalence of hypertension in the United States for African American men 55 to 64 years old, the prevalence is 60 percent, according to the medical literature and accounting for age and race only. The examiner explained that given all the major risk factors that lead the Veteran to develop hypertension, it would make herbicide agent exposure less likely as not the cause of the Veteran’s hypertension. The Board finds the opinions with respect to whether hypertension is caused or aggravated by PTSD, and whether hypertension is due to herbicide agent exposure highly probative as they were made by medical professionals with consideration of the specific facts in this case and after examination of the Veteran and review of the current medical literature. For example, the February 2019 clearly explained after review of the evidence of record that the Veteran’s multiple risk factors make it less likely than not that PTSD caused or aggravated his hypertension. The December 2019 VA examiner reviewed the 2018 NAS update and with consideration with current medical literature and the evidence of record explained that the Veteran had several significant risk factors for developing hypertension. He explained that in light of the 2018 NAS update the new data is a data point and should be taken into account with all other data points, but by itself does not constitute proof of causation. Looking at the complete picture he opined that herbicide agent exposure is less likely as not the cause of the Veteran’s hypertension. There is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinions. The Board has considered the Veteran’s statements, to include his assertions that symptoms began during service/are aggravated by his service-connected disability. As the Veteran and the appellant are not shown to have medical education or experience, they are lay persons and are competent to report (1) symptoms that are observable; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). They are not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues. Thus, the lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection is denied. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Gonzalez, Associate 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.