Citation Nr: 21003163 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 14-44 401 DATE: January 19, 2021 ORDER Entitlement to service connection for a heart disability, to include hypertension and hypertensive heart disease, to include as being due to herbicide exposure, and as secondary to diabetes mellitus and/or posttraumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The Veteran served in Vietnam and thus was exposed to herbicides. 2. The preponderance of the evidence is against finding that the Veteran’s heart disability, to include hypertension and hypertensive heart disease, was incurred in service, manifested within one year following service discharge, is otherwise related to service, or is caused or aggravated by a service-connected disability or disabilities. CONCLUSION OF LAW The criteria for service connection for a heart disability, to include hypertension and hypertensive heart disease, to include as being due to herbicide exposure, and as secondary to diabetes mellitus and/or PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1116, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served in the U.S. Army from March 1971 to April 1972. The Veteran had a hearing before the Board of Veterans’ Appeals (Board) in June 2018. A copy of the hearing transcript is in the Veteran’s claims file. The Board notes that a formal finding was made by VA in February 2011 that the Veteran’s service treatment records are unavailable. In cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule where applicable. The unavailability of records, however, does not lower the legal standard for substantiating a claim, but rather increases the Board’s obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the claimant. In September 2018, VA received copies of some service treatment records from the Veteran’s service, an October 1971 medical record (which is hardly legible), a possible December 1971 Clinical Record (which appears to be two pages), and the April 1972 Report of Medical Examination from the Veteran’s separation from service. The Veteran’s DD Form 214 shows that he served in the Republic of Vietnam from August 1971 through April 1972, and the Board finds that the Veteran has been exposed to herbicides. In June 2019, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for a medical opinion regarding whether hypertension, to include hypertensive heart disease, is due to service, to include herbicide exposure, and as being secondary to service-connected PTSD. The Board finds there has been substantial compliance with the Board’s directives and will now evaluation the Veteran’s claim on its merits. Entitlement to service connection for a heart disability, to include hypertension and hypertensive heart disease, to include as being due to herbicide exposure and as secondary to diabetes mellitus and/or PTSD The Veteran believes that his heart disability, to include hypertension and hypertensive heart disease, is due to herbicide exposure or his service-connected diabetes mellitus and/or PTSD. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a 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. 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). Service connection may also be granted on a secondary basis given (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a), (b). In this case, the Veteran’s claims for service connection include disabilities which constitute a “chronic disease” as listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. The applicable chronic diseases are heart disease and hypertension. Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, regarding the Veteran’s claim on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a heart disability. The reasons follow. As to evidence of a current disability, a February 2017 private Disability Benefits Questionnaire report shows that the Veteran was diagnosed with hypertensive heart disease. Additionally, a November 2019 VA examination report shows that the Veteran was diagnosed with hypertension. Therefore, the facts establish that the first element of a service-connection claim is met. The Board notes that it denied service connection for ischemic heart disease in the June 2019 decision, and thus that particular diagnosis is not part of the current appeal. As to an in-service disease or injury, the Board is mindful that the Veteran’s service treatment records were found to be unavailable. However, as mentioned above, three service treatment records were located. A December 1971 record shows that the Veteran complained of heart pains and stated that he had a history of a heart murmur. The examiner noted that there was no cardiac pathology, instead it was musculoskeletal pain. Additionally, there is an April 1972 Report of Medical Examination shows that the Veteran was found to be clinically normal in all areas, including in his heart and vascular system. His blood pressure was noted to be 120/88. Although the majority of the Veteran’s service treatment records are not able to be located, which is unfortunate, the appeal must be decided on the evidence of record and, where possible, the Board’s analysis has been undertaken with its heightened duty to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. Although the two service treatment records show that the Veteran did not have a cardiac condition, the Board will concede that the Veteran complained of pain in his heart during service. Furthermore, the Board concedes that the Veteran was exposed to herbicides while serving in Vietnam. The Veteran asserted in his December 2014 VA Form 9, Appeal to the Board, that he reported a heart murmur on his entrance paperwork into service and in March 2020, the Veteran stated that he when to the 85th Hospital in January 1972 for chest pains and that the results of his chest and x-ray were abnormal. Although the service treatment records from the Veteran’s service entrance and January 1972 are unavailable to support the Veteran’s claim, the Board will find that the facts establish that the second element of a service-connection claim is met. As to evidence of a nexus between the current disability and service or a service-connected disability, the Board finds that the preponderance of the evidence is against such a nexus. For instance, within the September 2010 VA examination report, the examiner noted that the Veteran was diagnosed with hypertension in the 1980s. However, the Veteran’s private treatment records show that he was first diagnosed with hypertension in the 1990s. A May 1998 record from Dr. Melton shows that the Veteran had a three-year history of systemic hypertension. This would show that the Veteran was diagnosed with hypertension, at the earliest, eight years following service discharge, which is evidence against a finding that hypertension had its onset in service or that it manifested within one year following service discharge. In the September 2010 VA examination report, the VA examiner documented that the Veteran had a history of hypertension since the 1980s but did not have a history of heart disease, and his heart catheterization was negative. The examiner also noted that the Veteran’s stress test did not show any coronary artery disease, and that the Veteran did not have myocardial infarction, heart failure, or rheumatic heart disease of any type. The examiner concluded that the Veteran had essential hypertension and the Veteran’s hypertension was not caused by or secondary to his service-connected diabetes. The examiner stated that the Veteran did not have chronic kidney disease and did not have nephropathy. The examiner wrote the Veteran’s creatinine, urine, microalbumin, and hemoglobin A1C were all normal and, therefore, the examiner concluded the Veteran did not have any nephropathy from diabetes, which could aggravate or cause hypertension. Furthermore, the examiner stated that the Veteran’s hypertension existed prior to the diagnosis of diabetes and was not connected to his diabetes. This is evidence against a nexus between hypertension and the service-connected diabetes mellitus. The Board finds the September 2010 opinion highly probative, as the examiner had reviewed the evidence and provided a rationale for the opinion that was based upon medical principles and the specific facts of the Veteran’s case. In November 2013, a VA examiner concluded that the Veteran’s hypertension had caused moderate left ventricular hypertrophy, which was due to hypertension and was not worsened by the service-connected diabetes mellitus, as the Veteran had a normal ejection fraction of 65 to 70 percent. This is evidence against a nexus between hypertension and the service-connected diabetes mellitus. This opinion is probative to the extent that it addressed whether the Veteran’s heart disability was caused or aggravated by diabetes mellitus, as the examiner provided a rationale that was based upon medical principles and the specific facts of the Veteran’s case. The Veteran submitted private Disability Benefits Questionnaires in February 2017 and August 2018. Both examiners diagnosed the Veteran with hypertensive heart disease, and the February 2017 private examiner indicated that the Veteran had essential hypertension. However, both examiners did not provide a nexus opinion as to whether the Veteran’s heart disability is related to his service or a service-connected disability, therefore the Board finds this is nonprobative evidence for this element. The Veteran had another VA examination in November 2019. The examiner provided a negative opinion for the Veteran’s hypertension and heart disability on direct and secondary bases. First, the examiner concluded that it is less likely than not that the Veteran’s hypertension was incurred during service. The examiner stated that there was no evidence of sustained hypertension during service. Moreover, the examiner stated that the Veteran’s hypertension treatment was noted in the late 1990s, which was long after the Veteran’s exit from service, thereby negating nexus to service. The examiner went on to conclude that it was less likely than not that the Veteran’s hypertension was caused by his diabetes mellitus. The examiner stated that the Veteran’s hypertension appeared to pre-date his diagnosis of diabetes. In addition, the examiner stated that there was no evidence of end organ pathology from diabetes in the 1990s, which would be needed in order for hypertension to be caused by diabetes (as a secondary cause), thus negating diabetes as the causation of hypertension. The examiner also stated that it is less likely than not that the Veteran’s hypertension was caused by herbicides (Agent Orange). The examiner said that the medical literature does not support this as fact; the isolated study presented by National Academy of Sciences is not confirmed by additional medical research studies. The examiner explained that accepted standard medical literature does not list herbicides as a secondary cause of hypertension. Thus, the examiner concluded that herbicide exposure is not causative of hypertension. In addition, the examiner stated that a review of the record failed to demonstrate end organ pathology from herbicide exposure at the time of hypertension diagnosis, which would be needed in order for hypertension to be related to herbicide exposure. The examiner further concluded that the Veteran’s hypertension is less likely than not caused by his service-connected PTSD. The examiner explained that PTSD is not causative of hypertension, as the Veteran’s hypertension is essential and without secondary cause. The examiner explained that the medical literature does not support PTSD as a primary cause of essential hypertension. Furthermore, the examiner explained that the Veteran’s hypertension has not been aggravated by the service-connected diabetes or PTSD, as review of records demonstrates that the Veteran has been on a fairly stable medication regimen for several years without marked aggravation, thereby negating aggravation of hypertension to service-connected diabetes or PTSD. When addressing the Veteran’s hypertensive heart disease, the examiner concluded that the hypertensive heart disease was less likely than not incurred during service. The examiner stated that the Veteran had musculoskeletal chest pain in service, which is not indicative of a chronic heart condition. Also, the examiner stated that the Veteran had a functional heart murmur noted in service, which is not indicative of a chronic pathologic heart condition or a chronic heart valve condition in service. The examiner also said that it is less likely than not that the Veteran’s heart disability was caused by exposure to herbicides. The examiner explained that a review of accepted standard medical literature does not demonstrate herbicide exposure, such as Agent Orange, as causative of found heart conditions. The examiner stated that the NAS study was an isolated study not confirmed by subsequent clinical research, thereby negating that the Veteran’s heart condition was related to herbicide exposure in service. The examiner then stated that it is less likely than not that a heart condition is related to PTSD. The examiner found that the medical literature does not support PTSD causing hypertensive heart disease. He found no evidence of aggravation of a heart condition from diabetes or PTSD, as a review of the Veteran’s medical treatment records over the years demonstrated no marked change in his cardiac condition that required medication change out of the ordinary. Therefore, the examiner concluded that it was less likely than not that the Veteran’s claimed heart condition was aggravated by the service-connected diabetes or PTSD. Finally, the examiner stated that the Veteran’s heart disability is left ventricular hypertrophy; which is directly caused by longstanding hypertension. The examiner found that after a review of medical literature, diabetes does not cause left ventricular hypertrophy. The examiner wrote that the evidence in this particular case supported the finding that hypertension was the cause of left ventricular hypertrophy. The examiner added that the Veteran has essential hypertension, which means it is without etiology. Thus, the examiner concluded it is less likely than not that the Veteran’s heart disability is related to or aggravated by service-connected diabetes or PTSD; and it is more likely that his heart condition is related to hypertension. The Board finds the November 2019 medical opinion as the most probative opinion of record. The examiner had reviewed the file and provided rationales for the multiple medical opinions, which opinions were based on evidence in the file, medical principles, and medical literature. As explained above, the September 2010 and November 2013 opinions addressing whether the service-connected diabetes mellitus caused or aggravated the Veteran’s hypertension and/or left ventricular hypertrophy were also probative. The opinions by medical professionals show that hypertension and hypertensive heart disease were not caused or aggravated by the Veteran’s service-connected diabetes mellitus and/or PTSD. The 2019 opinion establishes that these diagnoses are also not related to herbicide exposure. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link hypertension and/or hypertensive heart disease to service or a service-connected disability, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. At the present time, there is no competent and probative evidence to weigh against the VA opinions described in detail above. For all the reasons described above, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for a heart disability, to include hypertension and hypertensive heart disease, to include as being due to herbicide exposure, and as secondary to diabetes mellitus and/or PTSD. There is no reasonable doubt to be resolved, and the claim for service connection is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Griffin, 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.