Citation Nr: 20053092 Decision Date: 08/11/20 Archive Date: 08/11/20 DOCKET NO. 13-06 060 DATE: August 11, 2020 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT Hypertension was not present during the Veteran’s active service or manifest to a compensable degree within one year of separation from active duty and the most probative evidence reflects that his post-service hypertension is not otherwise causally related to active service nor is it proximately due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran was a member of the U.S. Marine Corps Reserve from April 1999 to April 2005. During this time, he had periods of active duty from August 1999 to February 2000, and from February 2003 to April 2005, including service in the Southwest Asia theater of operations (Iraq) from March to July 2003. This matter comes before the Board of Veterans’ Appeals (Board) from an October 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for hypertension. The Veteran filed a timely notice of disagreement, received by VA in July 2012. In December 2012, the RO issued a statement of the case. The Veteran’s substantive appeal was received by VA in January 2013. In May 2016, July 2017, and July 2019, the Board remanded the matter for further development. Entitlement to service connection for hypertension The Veteran seeks service connection for hypertension which he claims is secondary to medications prescribed to treat his service-connected rhinitis and/or PTSD. See e.g. February 2011 statement. He has also generally contended that all of his claimed disabilities, including hypertension, “were incurred coincidental to my military service or as a result of it,” specifically his combat service in Iraq. See April 2011 Statement. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. “[T]o establish service connection... for a present disability the veteran 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.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, certain specifically enumerated chronic diseases—including hypertension—will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within an applicable presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Hypertension is manifest to a compensable degree (10 percent) when diastolic pressure is predominantly 100 or more, or when systolic pressure is predominantly 160 or more, or as a minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, DC 7101. 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). 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 disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Whether the disability was permanently worsened is not a part of the necessary analysis of these claims, and should not be included. Ward v. Wilkie, 31 Vet. App. 233 (2019). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39–40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). “When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter,” the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert, 1 Vet. App. at 54. The Veteran’s service treatment records are entirely negative for complaints or findings of hypertension. In fact, the service treatment records affirmatively show that multiple blood pressure readings demonstrated that the Veteran’s diastolic blood pressure was not predominantly 90mm. or greater, nor was his systolic blood pressure ever 160mm during any period of active service. The service treatment records show that in September 1998, the Veteran underwent a medical examination for purposes of his enlistment in the Marine Corps Reserve. At that time, his blood pressure was 107/69. He completed a report of medical history in connection with the examination at which he denied having or ever having had high or low blood pressure. Service treatment records corresponding to the Veteran’s first period of active duty show that at a January 2000 clinic visit, his blood pressure was 111/59. Service treatment records corresponding to the period between the Veteran’s two periods of active duty show that in March 2000, he sought treatment for viral gastritis. At that time, his blood pressure was 126/90. At a January 2002 annual examination, his blood pressure was 110/70 and at an October 2002 annual examination, his blood pressure was 116/64. Service personnel records show that during the Veteran’s second period of active duty from February 2003 to April 2005, his military occupational specialty was traffic management specialist. He served in Iraq from March 2003 to July 2003. In pertinent part, service treatment records corresponding to the Veteran’s second period of active duty show that at a July 2003 annual examination, his blood pressure was 120/80. In January 2004, the Veteran specifically denied a history of hypertension. At an August 2004 physical, his blood pressure was 120/90. At a December 2004 Medical Board examination, his blood pressure was 122/80. At a periodic examination in February 2005, his blood pressure was 118/80. In April 2005, the Veteran’s blood pressure was 120/80 and the examiner specifically indicated that the Veteran did not have arterial hypertension. The Board notes that the service dental records also reflect that in August 1999, May 2001, February 2002, and December 2004, the Veteran completed dental health questionnaires on which he denied having or ever having had hypertension. In April 2005, following his separation from active duty, the Veteran submitted an original application for VA compensation benefits, on which he sought service connection for multiple disabilities. His application, however, is silent for any mention of hypertension. Clinical evidence assembled in connection with the claim is similarly negative for complaints or findings of hypertension. That clinical evidence included private treatment records dated from May 2004 to July 2005 and a series of VA medical examinations. The private treatment records during this period note multiple blood pressure readings, all of which are consistently below 140/90. An August 2005 VA general medical examination recorded blood pressure readings in three different positions of 150/85, 145/85, and 150/90. The examiner described these readings as borderline. Hypertension was not diagnosed. The record on appeal also contains VA clinical records dated from June 2005 to October 2019. In pertinent part, these records show that blood pressure readings prior to 2010 did not document persistently elevated blood pressure readings nor do they contain any notations or diagnoses of hypertension. For example, in June 2005, the Veteran’s blood pressure was 126/72 and 125/81. In August 2005, a blood pressure reading of 116/80 was recorded and in December 2005, the Veteran’s blood pressure was 114/68. In September 2006, the Veteran’s blood pressure was 129/75. In February 2007, the Veteran’s blood pressure was 125/89. In July 2007, blood pressure readings of 140/90 and 128/82 were noted. In January 2008, the Veteran’s blood pressure was 138/80. In July 2008, a blood pressure reading of 137/92 was recorded. In February 2009, the Veteran’s blood pressure was 120/80 and 131/87. In May 2009, his blood pressure was 135/80. In July 2009, it was 120/80. In August 2009, a blood pressure reading of 130/70 was noted. In October 2009, a blood pressure reading of 130/85 was noted. In January 2010, a blood pressure reading of 127/82 was noted. In March 2010, VA clinical records show that the Veteran sought treatment for a headache for the past week. He reported that he had been seen by a private provider one week prior who told him that he had high blood pressure and prescribed Benicar. He also indicated that he had undergone a VA examination earlier that day and had had a blood pressure of 150/110, although the examiner noted that the Veteran’s current reading was 126/86. The Veteran was diagnosed as having controlled hypertension. The clinician recommended a low sodium diet and continued antihypertensive medication. During a VA eye examination in July 2010, the Veteran reported having hypertension. At an August 2010 VA psychiatric examination, the Veteran’s significant nonpsychiatric illnesses included hypertension for which he had been prescribed Enalapril. Subsequent clinical records show continued notations of hypertension requiring medication. In February 2011, the Veteran filed additional VA claims, including service connection for hypertension, which he argued was secondary to medications prescribed for his service-connected allergic rhinitis. In connection with the Veteran’s claim, he was afforded a VA examination in July 2011. The Veteran reported that in 2008 or 2009, he was notified of elevated blood pressure readings but had been able to maintain control with exercise and keeping his weight down. He indicated, however, that he subsequently gained weight and his blood pressure increased so he was prescribed antihypertensive medications. After examining the Veteran and reviewing the record, the examiner diagnosed essential hypertension. She concluded that it was less likely than not that the Veteran’s hypertension was caused by or the result of medications prescribed for allergic rhinitis. She explained that in 95 percent of cases, essential hypertension could not be linked to a particular cause. She further explained that although certain medications could temporarily elevate blood pressure after it was ingested, there was no medical literature which indicated that the elevations were more than transient. In May 2016, the Board remanded the matter for an additional medical opinion, noting that although the July 2011 opinion was adequate on the question of whether the Veteran’s hypertension was secondary to his service-connected allergic rhinitis, the opinion was inadequate as it did not address direct service connection, nor did it address the question of whether the Veteran’s hypertension had been caused or aggravated by his service-connected PTSD. Pursuant to the Board’s remand directives, the Veteran was afforded a compensation and pension examination in August 2016. He reported that he had been suffering from hypertension since 2010 and had been on antihypertensive medication since that time. The August 2016 VA examiner opined that the Veteran’s hypertension was not caused by or a result of the Veteran’s service-connected PTSD or allergic rhinitis as there was no pathophysiological relationship between the disabilities. The examiner further noted that the Veteran’s hypertension did not manifest within a year after his discharge from service. In July 2017 the Board remanded once more, finding the August 2016 opinion inadequate on the question of aggravation. In August 2017 and January 2018 opinions, the examiner opined that there was a less than 50 percent chance that the Veteran’s hypertension was aggravated by his service-connected rhinitis or PTSD as the medical literature indicated that there was no pathophysiological relationship between the disabilities. The examiner further explained that the Veteran’s hypertension was responding to medication, and that individuals on the same clinical course, but without PTSD, showed the same responses. Thus, the service-connected PTSD did not aggravate or accelerate the Veteran’s hypertension. Finding the August 2017 and January 2018 addendum opinions insufficient on the question of whether the medications required for the service-connected PTSD caused or aggravated the Veteran’s hypertension, the Board again remanded the matter in July 2019. As the Board explained, the August 2017 and January 2018 medical opinions did not substantially comply with the July 2017 remand directives because neither provided an opinion as to whether the medications prescribed to treat the Veteran’s service-connected PTSD caused or aggravated the Veteran’s hypertension. Pursuant to the July 2019 remand directives, an addendum medical opinion was obtained by VA in August 2019. The opining physician posited that there was less than a 50 percent probability that the Veteran’s hypertension was caused by medication taken for his service-connected PTSD, and also less than a 50 percent probability that the Veteran’s hypertension was aggravated by medication taken for his service-connected PTSD. For both opinions, the physician reasoned that review of medical literature (via UpToDate and Micromedex) did not show that use of bupropion hydrochloride or hydroxyzine pamoate causes, has an adverse effect on, or aggravates hypertension. Applying the facts in this case to the legal criteria set forth above, the Board concludes that the preponderance of the evidence is against the claim. As a preliminary matter, the Board finds that the Veteran’s hypertension did not have its inception during active service, nor was it manifest to a compensable degree within one year of separation from active duty. As delineated in detail above, the Veteran’s service treatment records contain no notations of hypertension, repeated blood pressure testing during active service reflected that, but for a single reading of 90mm, diastolic blood pressure was consistently below 90mm. and diastolic blood pressure was consistently below 160. Moreover, on reports of medical history completed during active service, the Veteran denied having or ever having had hypertension. Based on the foregoing, the Board finds that hypertension did not have its inception during active service, nor was it noted as chronic in service. In reaching this decision, the Board has considered the Veteran’s general statement to the effect that all of his claimed disabilities, including hypertension, were incurred coincident with service, including his combat service in Iraq. The Veteran, however, has never specifically indicated that he was diagnosed as having hypertension during active service, i.e. relayed an in-service diagnosis of hypertension by a medical professional, and he is not competent to attribute any symptoms he experienced during active service to hypertension, nor is he competent to provide an in-service diagnosis in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Moreover, the Board finds that his recent statements that his hypertension had its inception during active service are not consistent with the contemporaneous record which shows that during active service, he specifically denied having or ever having had hypertension and blood pressure readings showed that hypertension was not present. The Board finds that the contemporaneous clinical evidence is more probative than the remote recollections of the Veteran made in the context of a claim for monetary benefits, particularly as in subsequent clinical settings, he dated the onset of his hypertension to 2010. To the extent the Veteran claims that his hypertension was incurred during combat service, the Board finds that the record described above contains clear and convincing evidence that hypertension was not present during active service, including during combat. 38 U.S.C. § 1154(b). Again, multiple blood pressure readings taken during active service affirmatively showed that the Veteran’s blood pressure was predominately below 90mm. and diastolic blood pressure was consistently below 160. Moreover, on reports of medical history completed during active service, including after combat service in Iraq, the Veteran denied having or ever having had hypertension and a military physician affirmatively indicated that hypertension was not present. Accordingly, the Board concludes that there is clear and convincing evidence that the Veteran’s hypertension did not have its inception during active service. The combat presumption of 38 U.S.C. § 1154(b) is rebutted in that respect. The Board further finds that hypertension was not manifest to a compensable degree within one year of separation from active duty. As set forth above, repeated blood pressure readings taken in the year following the Veteran’s separation showed that he was not diagnosed as having hypertension, nor did he exhibit diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, nor did he require medication for the control of his blood pressure. In summary, the Board concludes that the most probative evidence shows that hypertension was not present during active service, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology thereafter. Rather, the record reflects that hypertension was not diagnosed until 2010, approximately five years after the Veteran’s separation from service and well outside of the applicable presumptive period. Moreover, the record contains no indication, nor has the Veteran specifically contended, that his post-service hypertension is otherwise casually related to an in-service disease or injury. Under these circumstances, the Board finds that the preponderance of the evidence is against an award of direct or presumptive service connection. Alternatively, the Veteran has contended that his hypertension is causally related to or aggravated by his service-connected rhinitis or PTSD. As set forth above, however, the medical opinions obtained in connection with the Veteran’s claim reflect that it is less likely than not that his hypertension is causally related to or aggravated by his service-connected allergic rhinitis or PTSD, to include medications prescribed to treat those disabilities. The Board collectively assigns these opinions significant probative weight as they were provided by clinicians with the expertise necessary to render an opinion on the etiology of hypertension. Moreover, the opinions were based on consideration of the Veteran’s medical history as well as the applicable medical literature. Finally, the Board notes that there is no other medical opinion evidence which contradicts the conclusions of the VA clinicians or otherwise suggests an etiological relationship between the Veteran’s hypertension and any service-connected disability. Thus, the Board concludes that the preponderance of the evidence is against the claim. Therefore, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54–56. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hillan Sosa, 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.