Citation Nr: 21062571 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 10-24 193 DATE: October 8, 2021 ORDER Service connection for hypertension is denied. FINDING OF FACT The Veteran does not have hypertension that was caused by his service, to include as due to presumed exposure to Agent Orange, or was caused 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, 1116 (f), 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1968 to July 1970, with service in the Republic of Vietnam. In April 2016, the Veteran testified at a Board hearing before the undersigned. In July 2016, the Board remanded the claim. In August 2017, the Board denied the claim. The appellant appealed to the U.S. Court of Appeals for Veterans Claims (Court). In March 2018, the Court issued an Order vacating the August 2017 Board decision and remanding the case for compliance with a Joint Motion for Remand (JMR). In July 2018, and May 2021, the Board remanded this claim for additional development. 1. Hypertension. The Veteran asserts that service connection is warranted for hypertension. He primarily argues that service connection is warranted as due to presumed exposure to Agent Orange during service in Vietnam. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted on the basis of a post-service initial diagnosis of a disease, when "all of the evidence, including that pertinent to service, establishes that the disease was incurred during service." See 38 C.F.R. § 3.303 (d). Service connection may be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Hypertension can be service connected on such a basis. Service connection may be granted, on a secondary basis, for a disability, which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. The statutory provision specifically covering Agent Orange is 38 U.S.C. § 1116. Under 38 U.S.C. § 1116 (f), a claimant, who, during active service, served in the Republic of Vietnam during the Vietnam era, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that he was not exposed to any such agent during that service. Disease associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309, will be considered to have been incurred in service under the circumstances outlined in that section even though there is no evidence of such disease during the period of service. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied: chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; type 2 diabetes, non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; multiple myeloma, respiratory cancers (cancers of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma. 38 C.F.R. § 3.309 (e). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit has determined that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), does not preclude establishment of service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran's service treatment records include a pre-induction examination report, dated in April 1968, which shows that his blood pressure was 138/80. In January and October of 1969, he indicated that he did not have a history of high blood pressure. The Veteran's separation examination report, dated in July 1970, shows that his blood pressure was 140/70. There was no notation, finding, or diagnosis of hypertension or high blood pressure. As for the post-service medical evidence, private reports note obesity as early as 1994, and hypertension as early as 2004. Statements from S.I., M.D., dated in July 2009 and August 2014, show that this physician concluded that the Veteran's PTSD "was likely coexistent and contributory to his hypertension." While the doctor listed several symptoms of his PTSD including severe panic attacks, chronic anxiety, hypervigilance, and insomnia, he did not explain why these symptoms would have been expected to have caused or aggravated his hypertension. VA reports include a June 1972 treatment record which indicates that the Veteran's blood pressure was 120/80. Treatment records from January 1987 to March 2004 contain multiple blood pressure readings including systolic blood pressure measurements ranging from 110 to 160 and diastolic blood pressure measurements ranging from 60 to 100. The Veteran denied a history of hypertension in health questionnaires and periodic health assessments in April 1987, February 1990, February 1992, and February 1994. A February 2007 psychiatric report notes that the Veteran is obese, and that he has a history of hypertension and hypercholesterolemia. VA progress notes include notations of obesity, hyperlipidemia, and hypertension, as of 2008. Between 2008 and 2021, the Veteran was noted to weigh between about 320 and 400 pounds. A progress note, received in August 2014, shows that a physician noted that the Veteran has PTSD and depression with prominent irritability symptoms, which likely exacerbate his underlying hypertension. See also August 2014 statement from a VA nurse, L.G., PMNHP, stating that the Veteran has hypertension which is more than likely related to his chronic anxiety, panic, and PTSD. A VA hypertension examination report, dated in January 2010, shows that the Veteran reported having been diagnosed with hypertension 10 years prior to the examination (approximately 2000). The Veteran submitted three days' worth of blood pressure measurements taken in a drug store, but the examiner noted that the blood pressure cuff was likely too small for the Veteran's arm. The examiner opined that the Veteran's hypertension was not caused by his acquired psychiatric disorder, because acquired psychiatric disorders can lead to panic attacks which in turn temporarily increases blood pressure, but do not lead to sustained high blood pressure. A VA hypertension DBQ, dated in June 2019, shows that it was written by I.T., M.D. Dr. I.T. made the following conclusions: It is less likely as not that the Veteran's hypertension either began during or was otherwise caused by his military service, to include as a result of his presumed exposure to herbicide agents. The examiner explained that no diagnosis of hypertension is documented in the service treatment records. The service treatment records do not support a diagnosis of hypertension with onset in service. Service treatment records and medical records post-service through early 2000s document the Veteran was normotensive during those times. Medical documentation from 2003 and 2004 has the earliest diagnosis of hypertension. The Veteran's weight at enlistment is noted to be 200 pounds. At separation from service, the Veteran's weight was noted to be 195 pounds. The Veteran's weight in 2003 and 2004, around the time of the onset of his hypertension (noted to be primarily "diastolic" hypertension by his treating physician) fluctuated between 275 and 300 pounds. Diastolic hypertension is known to be significantly and strongly associated with male sex, inactivity, and body mass index. The Veteran's hypertension is therefore attributed to his weight gain, and not to exposure to herbicide agents, given the time, course, and clinical details listed. It is less likely as not that the Veteran's hypertension was caused by his service-connected PTSD. The examiner explained that although research suggests a relation between PTSD and hypertension, the American Heart Association (2014) maintains that "stress is not a confirmed risk factor for high blood pressure (BP)." The Veteran's weight at enlistment was 200 pounds. At separation from service weight was noted to be 195 pounds. The Veteran's weight in 2003 and 2004, around time of the onset of his hypertension (noted to be primarily "diastolic" hypertension by his treating physician) fluctuated between 275 and 300 pounds. Diastolic hypertension is known to be significantly/strongly associated with male sex, inactivity, and body mass index. The Veteran's hypertension is therefore attributed to his weight gain, and not to his PTSD, given the time, course, and clinical details listed. Additionally, the medication utilized to currently control the Veteran's blood pressure is lisinopril 5 mg daily, which is the lowest (entry level) effective dose for treating hypertension. The Veteran's blood pressure trend over time has improved. An addendum opinion, dated in December 2019, shows that Dr. I.T. stated that no change is warranted in his prior (June 2019) opinions as to secondary service connection and/or aggravation of the Veteran's hypertension by his service-connected PTSD. The examiner explained that, as stated in the June 2019 hypertension DBQ, "Although research suggests a relation between PTSD and hypertension, the American Heart Association (2014) maintains that stress is not a confirmed risk factor for high blood pressure (BP)." The Veteran's weight at enlistment was 200 pounds. At separation from service his weight was noted to be 195 pounds. In 2003 and 2004, around the time of the onset of the Veteran's hypertension (noted to be primarily "diastolic" hypertension by his treating physician) fluctuated between 275 and 300 pounds. Diastolic hypertension is known to be significantly/strongly associated with male sex, inactivity, and body mass index. The Veteran's hypertension is therefore attributed to his weight gain, and not to PTSD, given the time, course, and clinical details listed." In addition, "Although research suggests a relation between PTSD and hypertension, the American Heart Association (2014) maintains that "stress is not a confirmed risk factor for high blood pressure (BP)." Additionally, the medication utilized to currently control the Veteran's blood pressure is lisinopril 5 mg daily, which is the lowest (entry level) effective dose for treating hypertension. The Veteran's blood pressure trend over time has improved." Dr. I.T. further noted that no rationale was provided in the June 2019 opinion from K. M. (Psychiatric Nurse Practitioner). In July 2021, following a May 2021 Board remand, another VA medical opinion was obtained. The examiner, T.D., M.D., concluded that it is less likely than not that the Veteran's hypertension is due to or the result of his conceded herbicide exposure, i.e., exposure to Agent Orange. The examiner acknowledged the recent language of the National Academy of Science "Veterans and Agent Orange Update" of 2018, which provides for sufficient evidence related to at least 1 (one) chemical of interest (COI) to hypertension. The examiner stated that this is based in part by a study by "Cypel and colleagues," which found for a higher incidence of hypertension in a small, defined population of the Army Chemical Corp, in which these service members were directly involved in spraying herbicide. However, this association was not found in non-sprayers. Most importantly, the authors conclude that NO cause and effect of herbicide spraying and hypertension can be made. (emphasis in original). The more likely causes for his hypertension are his advancing age, male gender and morbid obesity. As of May 2021, his weight was 402 pounds and his BMI (body mass index) was 55.40, which demonstrates significant caloric intake that is well beyond metabolic needs. The Veteran was not treated for high blood pressure or hypertension symptoms during service, nor was a chronic condition involving high blood pressure or hypertension noted upon separation from service. 38 C.F.R. § 3.303. There is no evidence of hypertension within one year of separation from service. See 38 C.F.R. §§ 3.307, 3.309. The earliest medical evidence of the claimed condition is dated in 2004, approximately 33 years after separation from service. There is no competent evidence in support of the claim on a direct basis. With regard to the possibility of service connection based on exposure to Agent Orange, although the Veteran is shown to have served in Vietnam, and is therefore presumed to have been exposed to herbicide agents such as Agent Orange, the applicable law does not include hypertension as a condition for which presumptive service connection may be granted. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). The Board has also considered Agent Orange update 11 (2018), which has upgraded the connection between hypertension and herbicide exposure. However, the July 2021 VA opinion weighs against the claim on this basis, and there is no competent evidence of record which associates hypertension with exposure to Agent Orange. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). That is, there is no explanation how in this Veteran's case, his specific level of exposure to herbicide agents impacted him directly so as to cause hypertension. There is no competent opinion of record in favor of the claim, on any basis, to include as due to exposure to Agent Orange. In particular, the 2019 and 2021 VA opinions are shown to have been based on a review of the Veteran's records, and they are accompanied by sufficient explanations. Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Neives-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). With regard to the possibility of service connection on a secondary basis, the July 2019 and December 2019 VA opinions are found to be highly probative evidence against the claim. Id. These opinions are shown to have been based on a review of the Veteran's claims file, and they are accompanied by sufficient explanations. Id. Although the Board has considered the opinions linking the Veteran's PTSD to his hypertension, none of these opinions is accompanied by indicia of reliability such as citation to clinical studies, specific findings in the Veteran's treatment reports, or a significantly detailed discussion in support of the conclusions. Id. Accordingly, this evidence is insufficiently probative to warrant a grant of the clam. In summary, the Board finds that the weight of the evidence is against the claim on any basis, and it is denied. With regard to the Veteran's contentions, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, it falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran is competent to report the presence of blood pressure symptoms, the claimed disability is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that specific findings are needed to properly assess and diagnose this disorder, and determine its etiology. Id. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S.E., 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.