Citation Nr: 21063261 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 17-42 296 DATE: October 13, 2021 ORDER Service connection for hypertension is denied. Service connection for a heart disability is denied. Service connection for sleep apnea is denied. Service connection for headaches is granted. REMANDED A total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's hypertension is not secondary to service-connected posttraumatic stress disorder (PTSD) and is not otherwise related to an in-service injury or disease. 2. The Veteran's cardiomyopathy, cardiomegaly, and congestive heart failure are not secondary to a service-connected disability and are not otherwise related to an in-service injury or disease. 3. The Veteran's sleep apnea is not secondary to service-connected PTSD and is not otherwise related to an in-service injury or disease. 4. The Veteran's tension headaches were proximately due to his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension due to service or service-connected PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for a heart disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for sleep apnea due to service or service-connected PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for tension headaches are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Navy from March 1963 to April 1965. He died in May 2019. The appellant is his surviving spouse and has been substituted in his place for the purpose of this appeal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision. It was previously remanded by the Board in April 2019 for additional development. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Hypertension The appellant contends the Veteran's hypertension is related to his period of active service. The Board concludes that, while the Veteran had a diagnosis of hypertension, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. For reference, under 38 C.F.R. § 4.104, Diagnostic Code 7101, hypertension means diastolic blood pressure predominantly 90mm. or greater, or systolic pressure predominantly 160mm. or greater. Service treatment records are negative for any complaints, treatment, or diagnoses of hypertension. During the Veteran's April 1965 separation examination, blood pressure was measured at 122/60. During an October 1989 VA examination, his seated blood pressure was 122/82, recumbent blood pressure was 122/84, and standing blood pressure was 118/90. No diagnosis or finding of hypertension was rendered. The earliest evidence of hypertension is from prescriptions submitted by the Veteran showing he was prescribed atenolol (an anti-hypertensive medication) in February 2000, almost 35 years after his discharge from service. There is no competent medical evidence linking the Veteran's diagnosed hypertension to service. Alternatively, the appellant asserts that the Veteran's hypertension was secondary to his service-connected PTSD. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The Board concludes the preponderance of the evidence is against finding that the Veteran's hypertension was proximately due to or the result of or aggravated beyond its natural progression by service-connected PTSD. A November 2015 private opinion stated that the Veteran's PTSD aided in the development of his hypertension and aggravated his hypertension. The private examiner cited to studies showing that those with PTSD had higher resting heart rates and blood pressure during times of affective distress when compared to non-PTSD survey participants. Given the increased risk for cardiovascular events associated with elevated resting blood pressure and heart rate, PTSD may be a risk factor for cardiovascular disease. In contrast, an August 2020 VA examiner stated that hypertension was not caused or aggravated by PTSD. She stated that the study cited by the private examiner did not suggest a causal relationship between PTSD and hypertension. Rather, it only noted a possible increased prevalence of elevated heart rate and reactivity of blood pressure to stressful situations, which was not the definition of hypertension. Rather, blood pressure was the result of a complex interplay between the cardiovascular system, sympathetic nervous system, renin-angiotensin system, and renal system. Risk factors for hypertension were age, genetics, diet, activity level, smoking, weight gain and alcohol and drug use. The Veteran had multiple risk factors (smoking, weight gain, alcohol abuse, and a high salt diet) which were the likely causes of his hypertension. PTSD was not considered a risk factor for hypertension. The examiner noted that there was a small but increasing body of literature addressing the relationship between PTSD and hypertension. However, these studies were all retrospective, and prospective studies were needed to establish PTSD as a causative factor for hypertension rather than a coexisting condition. Based on the above, the Board finds that service connection for hypertension is not warranted because the VA examiner's opinion is more probative than the private opinion. Specifically, the VA examiner addressed the Veteran's multiple known risk factors for hypertension and explained why the studies cited by the private examiner did not show a causal relationship between PTSD and hypertension. In contrast, the private opinion concluded that PTSD "may" be a risk factor for cardiovascular disease, and service connection may not be based on speculation or remote possibility. See 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. at 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a plausible claim). The private examiner also did not address the Veteran's other risk factors for hypertension, including his history of smoking, weight gain, alcohol abuse, and a high salt diet. For these reasons, the competent medical evidence is against finding that service-connected PTSD caused or aggravated the Veteran's hypertension. To the extent that the Veteran and appellant asserted that hypertension was incurred in service or secondary to PTSD, they have not shown the necessary medical knowledge or expertise to render competent medical opinions regarding the etiology of hypertension. Therefore, service connection is not warranted. Heart disability The Veteran had been diagnosed with cardiomyopathy, cardiomegaly, and congestive heart failure. He underwent a heart transplant in July 2001. Regarding "direct" service connection, service treatment records are negative for any complaints, treatment, or diagnoses related to the heart. Neither the Veteran nor the appellant have asserted that any heart condition had its onset during his period of service. Rather, the Veteran had submitted a November 2015 private opinion which stated that his cardiomegaly was due to his hypertension. As discussed above, hypertension has not been service-connected, and therefore no disability, including cardiomegaly, can be service-connected on a secondary basis to hypertension. There is no other competent medical opinion linking the Veteran's diagnosed heart conditions to service or a service-connected disability. Moreover, the August 2020 VA examiner stated that service-connected PTSD was not a risk factor for the non-ischemic cardiomyopathy diagnosed before the Veteran's heart transplant, and that his other heart conditions developed later as complications of the transplant. Therefore, service connection is not warranted. Sleep apnea The Veteran was diagnosed with obstructive sleep apnea in 2009. Regarding "direct" service connection, service treatment records are negative for any complaints, treatment, or diagnoses related to sleep apnea. Neither the Veteran nor the appellant have asserted that the condition had its onset during his period of service. In addition, there is no competent medical evidence linking sleep apnea to the Veteran's service-connected PTSD. The August 2020 VA examiner noted that PTSD is associated with disordered sleep and can overlap with many symptoms of obstructive sleep apnea. However, PTSD was not an established risk factor for sleep apnea, and there was no association between the two conditions in the peer-reviewed literature and no basis to establish a causal relationship. Because the preponderance of the evidence is against a finding that sleep apnea was incurred in service or secondary to a service-connected disability, service connection is not warranted. Headaches The Veteran had been diagnosed with tension headaches. The November 2015 private examiner opined that it is at least as likely as not that the Veteran's headaches were caused by his PTSD, noting that Veteran had tension headaches brought on by stress or tension. The Veteran reported that, when his PTSD was really bothering him, he noticed that it brought on a headache. He cited to a medical study showing that symptoms consistent with a PTSD diagnosis appeared to be more frequent in patients with recurring headaches. The Board notes that this suggests that headaches can cause or aggravate PTSD, rather than PTSD causing or aggravating headaches. In contrast, the August 2020 VA examiner stated that PTSD had not been established as a cause of tension or migraine headaches. Rather, the Veteran had untreated sleep apnea, which was a known, and the most likely, cause of the Veteran's headaches. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's headaches were proximately due to his service-connected PTSD. While the medical literature cited by the private examiner was not on point, the Board nonetheless finds his rationale to be persuasive. Accordingly, after resolving all doubt in favor of the appellant, the Board finds that service connection for tension headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND TDIU As discussed above, the Board has granted service connection for tension headaches. The Agency of Original Jurisdiction (AOJ) must now assign an initial rating and effective for this disability. Because that rating and effective date is relevant to the pending TDIU claim, including whether the Veteran met the TDIU schedular criteria, a decision on the TDIU claim cannot be made at this time. The matter is REMANDED for the following action: After implementing the grant of service connection for tension headaches, and any additionally indicated development has been completed, readjudicate the issue of entitlement to a TDIU. If the benefit sought is not granted to the appellant's satisfaction, send the appellant and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shamil Patel, 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.