Citation Nr: 21004580 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 11-11 239 DATE: January 27, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to the Veteran’s service-connected posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to service connection for a heart condition is remanded. FINDING OF FACT The Veteran’s hypertension is not proximately due to or aggravated by her service-connected PTSD, did not manifest to a compensable degree within one year of the Veteran’s active service, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for hypertension due to service or the service-connected PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had service in the National Guard and Army Reserve from July 1978 to March 1990, and from January 1998 to January 2001, with active service from June 22, 1979 to June 26, 1979, and additional periods of duty training, to include active duty for training from November 1978 to May 1979. The matters on appeal come before the Board of Veteran’s Appeals (Board) from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran had a hearing before the undersigned in May 2016. The Board then remanded the matters for additional development in August 2016. Following the evidentiary development, the Board then issued a decision in September 2017, which denied service connection for both hypertension and a heart condition. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). In May 2018, the Court issued an Order granting a Joint Motion for Remand (Joint Motion). The Board’s September 2017 decision was vacated and remanded for action in accordance with the Joint Motion. Most recently, the Board remanded the Veteran’s claims in November 2018. The matters are now again before the Board. Service Connection – Hypertension The Veteran contends service connection is warranted for hypertension as she believes her hypertension was caused by or is being aggravated by her service-connected PTSD, to include the stressful in-service circumstances that caused her PTSD. Service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Initially, the Board recognizes the Veteran’s documented diagnosis of hypertension, which is noted in her clinical records, as well as confirmed by the VA examiners. This element for establishing service connection, existence of the disability claimed, is met. Thus, the question for the Board is whether the Veteran’s hypertension is proximately due to or the result of, or aggravated beyond its natural progression, by her service-connected PTSD. During the Board hearing, the Veteran testified that she began receiving treatment for hypertension in 2000. There is no record of such treatment in the claims file. She also testified that in 2007 or 2010, her doctors told her that her hypertension was related to her PTSD diagnosis. The clinical records within the claims file do not include any such finding. The Veteran was afforded a VA examination for hypertension in November 2016. The examiner noted that she was not on continuous medication for hypertension at this time. All VA medications had expired in March 2016 and there were no other records showing new prescriptions. The Veteran’s blood pressure readings at the time of the exam were 159/80, 156/82 and 132/89. The examiner also stated, “There are various studies that have suggested that PTSD has a direct relationship with the risk of developing hypertension but this is not supported by general consensus of current evidenced [sic] based medicine….The associations observed between PTSD, cardiovascular disease, and cardiac disease have implications for medical practice providing insight into possible risk factors for such diseases, their treatment and research, but have yet to be proven to be directly related to PTSD.” Based upon these factors, the examiner opined that the hypertension was not caused by or the result of the Veteran’s PTSD in whole or in part, and was not aggravated by the PTSD “as this theory is not supported by the current medical consensus of evidence based medicine.” The Joint Motion noted that the rationale for the opinion was limited to direct causation and found the reasoning for the aggravation opinion was not adequately explained. The Board, therefore, remanded this matter for a new opinion. Following the remand, and before the opinion was rendered, the Veteran submitted a statement in April 2019 again suggesting her stressors related to her PTSD have impacted her health and she reported ongoing issues with her blood pressure. The Veteran’s file was then sent to a VA examiner and an updated opinion was obtained in August 2019. This examiner reviewed the record and found the Veteran’s hypertension was not aggravated beyond its natural progression by the PTSD symptoms. The examiner noted the Veteran’s suggestion that her hypertension initially had its onset in 2000, but noted the diagnosis first appeared in treatment records in 2003. The examiner went on to note the Veteran’s PTSD was found to be service-connected effective in 2002, but that there was no objective evidence of a PTSD diagnosis until 2007. However, the examiner went on to explain that regardless of the date of diagnosis, the evidence did not show aggravation of hypertension by the PTSD. The examiner noted the 2016 examination report showing an average blood pressure of 149/82 at a time when the Veteran was on no hypertensive medications. The examiner explained that this finding falls within the projected natural history of the condition and does not represent any aggravation beyond natural progression. The Board recognizes the Veteran’s belief that her hypertension is proximately due to or is being aggravated beyond its natural progression by the symptoms of her service-connected PTSD. However, the Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between the Veteran’s PTSD symptoms and her blood pressure readings. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiner’s opinion in this case, which is based upon medical knowledge and literature. Based upon the foregoing, the Board finds that while the Veteran has a current diagnosis of hypertension, the preponderance of the evidence is against finding that the Veteran’s hypertension is proximately due to or the result of, or aggravated beyond its natural progression by, her service-connected PTSD. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Further, although the Veteran has not claimed her hypertension to have had its onset during her active service or within one year of her active service, or otherwise be directly related to her active service, the Board has reviewed the entire record to assess whether direct service connection is warranted on a direct or presumptive basis. Service treatment records are silent as to any diagnosis or treatment of hypertension or increased blood pressure. Various Reports of Medical Examination dated January 1979, February 1988 and December1997 were included in her STRs and showed her blood pressure as 110/62, 106/70, and 127/72, respectively. VA treatment records show the Veteran has a history of hypertension since approximately 2003. Although the Veteran claims that she began receiving treatment for hypertension soon after leaving the service, the first records noting a diagnosis of hypertension are in 2003, and, as noted above, the Veteran is not shown competent to assess questions of medical nature, to include diagnosing hypertension. A search for earlier records was undertaken, but there were none. Therefore, there is no probative evidence confirming a diagnosis within one year of separating from service; thus, service connection on a presumptive basis is not warranted. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Further, based on the foregoing, the Board finds that the evidence does not show a nexus between the Veteran’s hypertension and any in-service injury or disease. The November 2016 VA examiner found no relation between her hypertension and her service. The hypertension began after she left service and there is no medical or otherwise probative evidence showing a causal connection between the current disability and the Veteran’s active service. As the opinion was based on complete review of the record and the conclusion explained, the November 2016 opinion is considered probative medical evidence as to the direct service connection question. There is no other medical evidence of record refuting the opinion. Service connection, therefore, also cannot be awarded on a direct basis. 38 C.F.R. § 3.303. Accordingly, this claim for service connection for hypertension must be denied on a direct, presumptive and secondary basis. The Board has duly considered the benefit-of-the-doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim, so that doctrine is not applicable. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). REASONS FOR REMAND Service Connection – Heart Condition A remand of the Veteran’s heart condition claim is again needed as the questions asked in the Board’s prior remand, which were needed to address the requirements made in the Joint Motion, were not adequately answered. Stegall v. West, 11 Vet. App. 268, 271 (1998). The November 2016 VA examiner and the May 2018 Joint Motion both erroneously suggested the February 1985 report of viral symptoms with weakness was not in the record. The Board remanded the matter in November 2018 for an opinion to adequately address the Veteran’s reported history of symptoms, to include consideration and reference to the February 1985 record. In August 2019, a VA examiner reviewed the Veteran’s claims file. The examiner checked a box reflecting his conclusion the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The rationale, however, did not make clear whether the provider thought there was a current heart disorder to diagnose, and the reasons for thinking so. It begins by stating there is no objective evidence of a chronic condition, but later seems to acknowledge the presence of bradycardia and perhaps angina. While it appears the examiner considers the angina diagnosis to be inaccurate, he did not clearly explain why he thought that to be the case. In addition, the 2019 examiner suggested the November 2016 examiner “determined negative nexus between current heart condition and 1985 for treatment of viral symptoms.” This appears to overstate the 2016 examiner’s conclusion since that person may not have actually believed the 1985 record was in the file. Thus, while additional delay is regrettable, this claim must again be remanded. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether any heart disorder present during the pendency of this claim, which has been pending since July 2008, is at least as likely as not related to the Veteran’s active service. In addressing this, the examiner should identify any all heart disorders present since 2008. If no heart disability is found to exist, the reasons for that conclusion should be explained, and in doing so the examiner should discuss earlier findings of bradycardia and angina, and whether those should be considered accurate diagnoses. In addressing whether any current heart disability is related to service, the examiner’s reasoning should include discussion of the February 1985 Individual Sick Slip reflecting the Veteran’s symptoms as virus like and weakness, which at her 2016 hearing the Veteran recalled also included chest pain. The examiner should discuss whether these complaints were an initial manifestation of any currently diagnosed heart disorder. A rationale should be provided for any opinion expressed. (Continued on the next page)   2. After completing the above action, to include any other development as may be indicated by any response received as a consequence of the action taken in the preceding paragraph, the Veteran’s claim should be readjudicated based on the entirety of the evidence. . MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Adamson, 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.