Citation Nr: 20060292 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 12-29 356 DATE: September 14, 2020 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The preponderance of the evidence is against a finding that the Veteran’s hypertension had its onset in service or was proximately caused or aggravated by a service-connected condition. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.103, 3.303, 3.304, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1974 to November 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified by videoconference in May 2013 before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the file. In August 2017, the Board issued a decision denying entitlement to hypertension. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). By a May 2018 Order, the Court, pursuant to a Joint Motion for Remand (JMR), vacated the Board's August 2017 decision and remanded the case for action consistent with the JMR. The Board remanded the case in February 2019 for further development to address service connection on a secondary basis. A review of the record reveals that there has been substantial compliance with the Board’s prior remand directives, and the case has now been returned to the Board. Service Connection Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In general, service connection requires competent evidence showing: (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). Additionally, where a veteran served for at least 90 days during a period of war, or after December 31, 1946, and manifests certain chronic diseases, such as hypertension, to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service-connected. 38 C.F.R. § 3.310(b). 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). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm. (millimeters of mercury) 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. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101. 1. Entitlement to service connection for hypertension The Veteran contends his hypertension began in service or in the alternative, is secondary to his service-connected bilateral knee condition. Service treatment records show the first blood pressure reading, dated September 1974 of 134/70. The remainder of the blood pressure readings dated between May 1975 to October 1994, indicate blood pressure readings between 110 and 143 for systolic and between 62 and 98 for diastolic. At his retirement examination in October 1994, there were no complaints of high blood pressure, hypertension or any other chest or heart related issues. The Veteran’s blood pressure was 130/76 at the time. The Veteran contends after his retirement, he went to the Brooke Army Medical Center emergency room for heart palpations and they identified a series of hypertensive blood pressure readings during service and indicated it was a medical diagnosis that could have led to his current palpations. He was started on medication and monitored on a constant basis. See June 2020 Correspondence. The Veteran submitted a medical opinion from the Brooke Army Medical Center in January 2012. The examiner stated that he reviewed the Veteran’s medical records and found it was likely that his hypertension is related to complaints or symptoms while in service as his hypertension was undiagnosed and untreated for many years. The Board affords this opinion little probative value as no further rationale or explanation was provided, including addressing the Veteran’s normal blood pressure at discharge. In the August 2012 VA hypertension examination, the examiner found the Veteran was not diagnosed with hypertension until 2005. He also noted the Veteran’s retirement physical blood pressure reading was normal. The noted elevated blood pressures were taken at the time when the chief complaint was joint pain. The examiner explained that blood pressure decreases and increases throughout the day and elevates when someone is in pain. The examiner identified other risk factors for hypertension and opined that it is less likely than not the Veteran’s hypertension was incurred in or caused by isolated elevated blood pressure readings while in service. The Veteran was afforded another hypertension VA examination in March 2015. The examiner also opined that the Veteran’s hypertension was less likely than not incurred in or caused by service. The examiner added that an accurate measurement of blood pressure should be done when the person is not in pain. Further, if the Veteran had hypertension at the time he was discharged from the military, it would have been expected that his retirement physical blood pressure would be elevated. The May 2018 JMR noted that the record reasonably raised the issue of entitlement to service connection for hypertension secondary to Veteran’s bilateral knee condition based on the August 2012 VA examiner’s opinion that blood pressure can elevate when someone is in pain and, and the December 2014 medical record that shows Veteran stated that his knee pain increases his blood pressure. The Veteran was afforded a VA examination in January 2020 for a secondary service connection opinion. The examiner stated that there can be transient or non-sustained brief elevation of blood pressure during an acutely painful event. There is no evidence, however, that chronic pain is causatively related to hypertension or chronic high blood pressure. The examiner also noted that people with elevated blood pressure may have associated decreased sensitivity to acute pain. Those with chronic pain and increased blood pressure can have associated increased acute pain responsiveness, but the converse is not true, chronic or acute pain is not associated with causing or aggravating elevated blood pressure over the long term. Thus, as pain itself does not cause or aggravate hypertension, the Veteran’s knee conditions, including instability, chondromalacia of the patellar and associated pain is not causative of hypertension. The examiner also found the Veteran’s hypertension was not aggravated beyond its natural progression by his knee condition or any other service-connected disabilities. The Veteran has several service-connected conditions involving pain, but pain is not a causative or aggravating factor for hypertension. The examiner stated that there is evidence that hypertension can affect the pain perception, but there is no definitive evidence where chronic pain affects chronic high blood pressure or hypertension. Thus, the examiner concluded that it is less likely than not the Veteran’s hypertension is proximately due to or the result of the Veteran’s service-connected conditions, including pain. In addition, the Veteran’s hypertension was not aggravated beyond its natural progression by an in-service injury, event or illness, including any pain from other service-connected disabilities. The Board finds this opinion highly probative as the examiner provided clear rationale for his conclusions. The Veteran believes his hypertension is related to service or his bilateral knee condition. The Veteran also submitted lay statements from fellow servicemembers who attested the Veteran had increased heart rate during service while trying to pass his cycle ergometry testing. The Veteran and his fellow service members, in this case are not competent to provide a nexus opinion regarding this issue. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Consequently, the Board gives more probative weight to the medical opinions of record, which, in this case, are the August 2012, March 2015 and January 2020 VA examinations. The Board finds the Veteran’s hypertension is not directly connected to service, not presumed to be connected to service as a chronic disease arising within one year of separation, and not secondary to his service-connected disabilities, to include his knee condition. STRs are silent for a diagnosis of hypertension in service and post service medical records do not show a diagnosis of hypertension within a year of separation from service. The most probative medical evidence indicates the Veteran’s hypertension is not related to service or secondarily to his knee condition. (Continued on the next page)   Based on the above, the Board concludes that the preponderance of the evidence is against the claim of entitlement to service connection for hypertension on a direct, presumptive or secondary basis. The appeal must therefore be denied. There is no reasonable doubt to be resolved in this case. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jaigirdar, 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.