Citation Nr: 21003158 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 13-32 690 DATE: January 19, 2021 ORDER Entitlement to service connection for a blood pressure condition as secondary to service-connected ischemic heart disease is denied. FINDING OF FACT It is less likely than not that the Veteran’s blood pressure condition is due to his service-connected ischemic heart disease. CONCLUSION OF LAW The criteria for entitlement to service connection for a blood pressure condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1968 to May 1970. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of March 2012 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. A hearing was previously conducted before the undersigned Veterans Law Judge (VLJ) in August 2018. A transcript of the hearing is of record. The Board previously remanded this issue for further development in March 2020. See March 2020 Board Decision at 14-15. After reviewing the evidence of record, the Board finds that the RO has substantially fulfilled its remand directives and will therefore adjudicate the Veteran’s claim on the merits. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (providing that a remand confers upon the Veteran the right to substantial compliance with remand instructions). 1. Entitlement to service connection for a blood pressure condition as secondary to service-connected ischemic heart disease. Service connection requires the existence of a present disability, the in-service incurrence or aggravation of a disease or injury, and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, disabilities which are “proximately due to or the result of a service-connected disease or injury” are also service connected. 38 C.F.R. § 3.310(a). “When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition.” Id. The Board notes that certain conditions, including hypertension, may be service-connected on a presumptive basis even in the absence of a direct nexus. See 38 C.F.R. §§ 3.307(a), 3.309(a). However, such a condition must generally have manifested to a compensable degree within one year following separation from service. 38 C.F.R. § 3.303(a)(3). Because the Veteran does not assert, and the medical evidence of record does not otherwise support, that his blood pressure condition manifested to a compensable degree within one year of his active-duty service, an extended analysis of his claim under these regulations is moot. Instead, the Veteran asserts that he has a blood pressure condition, variously claimed as both hypertension and hypotension, due to his service-connected ischemic heart disease. See July 2011 VA Form 21-526b (asserting entitlement to service connection for hypertension); see also August 2011 VA Form 21-0820 (asserting that hypertension is secondary to ischemic heart disease); see also August 2018 Transcript at 3-4; cf. November 2013 VA Form 9 (stating that “I disagree with the decision on Hypertension, should have been claimed as Hypotension and it is secondary to heart condition”) (capitalization in original). The Veteran has undergone VA examinations on this issue in March 2012 and July 2015. As previously discussed in the Board’s March 2020 remand, these examinations were too conclusory to support adjudication of the Veteran’s claim on this issue. See March 2020 Board Decision at 14-15. Accordingly, the Veteran’s claims file was reviewed by another VA examiner in March 2020. However, this review addressed only whether the Veteran’s blood pressure condition is due to his service-connected diabetes mellitus. See March 2020 VA Examination Report at 6. As noted above, the Veteran’s assertion is that his blood pressure condition is due to service-connected ischemic heart disease. The Veteran’s claims file was therefore reviewed by a different VA examiner in October 2020. The October 2020 VA examiner diagnosed the Veteran’s blood pressure condition as primary hypertension and noted “numerous risk factors that are strongly and independently associated” with developing this condition. See October 2020 VA Examination Report at 1 (identifying the Veteran’s age, obesity, family history, diet, and prior use of tobacco and alcohol); see also id. at 2-4 (citing to medical literature and associated studies examining risk factors of hypertension). “Relevant points that can be discussed in an examination report include, but are not limited to, why the examiner finds cited studies persuasive or unpersuasive, whether the veteran has other risk factors for developing the claimed condition, and whether the claimed condition has manifested itself in an unusual way.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Because the October 2020 VA examiner discussed the Veteran’s multiple non-service-connected risk factors and their relationship to his blood pressure condition, as well as the medical literature supporting her findings, the Board assigns her conclusion that his blood pressure condition is less likely than not due to or aggravated by his service-connected ischemic heart disease substantial probative weight. See October 2020 VA Examination Report at 1; see also id. at 4 (opining that medication prescribed to treat the Veteran’s service-connected disabilities is also less likely than not to be the cause of, or to aggravate, his blood pressure condition); see also “Overview of Hypertension in Adults: Complications of Hypertension,” UpToDate (accessed via https://www.uptodate.com/contents/overview-of-hypertension-in-adults#H10) (source cited by VA examiner providing that ischemic heart disease is a common complication of hypertension rather than a secondary or contributing cause thereof). The Board notes the Veteran’s assertion that he was prescribed blood pressure medication by the same treating physician who diagnosed his ischemic heart disease. See August 2018 Transcript at 3 (asserting that “[the doctor] said I had the ischemic heart disease and he also said that my blood pressure was up and he wanted it lower… he couldn’t put a stent in there at that time, so he put me on blood pressure medicine”); see also February 2013 VA Form 21-4138 (asserting that “[the doctor] is the one that put me on [blood pressure] medication after doing the [first] heart [catheterization][,] I was diagnosed with Ischemic Heart Disease”). However, this does not satisfy the Veteran’s burden under the applicable regulations, which is to show that it is at least as likely as not that his service-connected conditions caused or aggravated his blood pressure condition, not merely that they occurred or were diagnosed at similar times. 38 C.F.R. § 3.310. The assignment of service connection for a blood pressure condition as secondary to the Veteran’s service-connected ischemic heart disease is therefore not warranted. 38 C.F.R. § 3.310. The Board has considered the doctrine of   reasonable doubt but finds that it is not applicable because the balance of the evidence is against the Veteran’s claim. 38 U.S.C. § 5107. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Blore, 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.