Citation Nr: 21067673 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 15-25 641 DATE: November 5, 2021 ORDER Service connection for hypertension is denied. FINDING OF FACT The weight of evidence is against a finding that the Veteran's hypertension was incurred in service or within a year after service, or that it was caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension due to service or a service-connected disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1966 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) from a September 2014 rating decision. The Veteran testified at a Board hearing in August 2016. The Board remanded this matter in December 2016, June 2019, December 2019, June 2020, January 2021, and April 2021. *** Generally, to establish service connection, a veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. 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). Regulations define hypertension for VA purposes. Specifically, hypertension exists where diastolic blood pressure is predominantly 90 or more or systolic blood pressure is predominantly 160 or more. Hypertension must be confirmed by readings taken two or more times on three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1); see Gill v. Shinseki, 26 Vet. App. 386, 390 (2013) (holding that "the specified number of readings [in § 4.104, DC 7101, Note 1] applies only to the confirmation of the existence of hypertension, as opposed to the level of hypertension necessary for a particular disability rating"). A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). *** The Veteran seeks service connection for hypertension. Private treatment records submitted by the Veteran show a diagnosis of hypertension since February 2014. 04/25/2014, Medical Treatment Record -Non-Government Facility, at 3. Nonetheless, in his May 2013 claim, the Veteran indicated that his hypertension began in 1970. 05/08/2013, VA 21-526 Veterans Application for Compensation. The Veteran separated from service in December 1969. His December 1969 separation examination shows a blood pressure reading of 138/86 but is negative for any significant medical history. 09/27/2011, STR Medical, at 5. Recent medical records show a history of, and treatment for, hypertension. There is, however, no clear indication of when hypertension was first diagnosed or when treatment for hypertension started. Other than the Veteran's indication that his hypertension started in 1970, he has not submitted any lay or medical evidence to establish that his hypertension was diagnosed in service or within one year after separation of evidence. Regarding the Veteran's assertion that his hypertension started in 1970, while he is competent to report any observable symptoms and history of treatment, he is not competent to diagnose hypertension or provide a medical opinion as to the etiology of his current diagnosis of hypertension. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) The Veteran underwent a VA examination in February 2020. The examiner opined that it was less likely than not that the Veteran's hypertension began in service or manifested within one year of separation from service. The examiner explained that the two blood pressure readings noted in service treatment records were 120/65 in September 1965 and 138/86 at the separation examination, adding that these readings are not hypertensive. The examiner further noted that the earliest documented instance of hypertension was in 2011, at which time he was taking hypertension medication. Regarding secondary service connection, the examiner simply indicated that "[t[here is no evidence in current medical literature to establish anxiety or other mental condition as causative for hypertension. Anxiety may only cause temporary spikes in blood pressure but does not cause hypertensive disease." The opinion, however, did not adequately address the aggravation prong of secondary service connection. For this reason, in June 2020, the Board remanded for a new VA opinion. In October 2020, VA obtained a new opinion regarding the etiology of the Veteran's hypertension. A different VA examiner opined that the Veteran's hypertension was less likely than not incurred in service or within one year after service or caused or aggravated by his service-connected mental health disability. In her rationale, the examiner explained that the Veteran's blood pressure reading at separation did not support a diagnosis of hypertension. The examiner further noted that there was no medical record of a diagnosis of hypertension within one year after separation from service, adding that, according to VA treatment records, the Veteran's hypertension was diagnosed around 2009, decades after service. Regarding secondary service connection, the examiner explained that the Veteran's hypertension was not related to his service-connected mental health disability, as both disabilities are separate and unrelated entities, with no causal relationship shown in the medical literature. As for the aggravation prong of secondary service connection, the examiner's rationale consisted of a detailed explanation of the pathophysiology of hypertension. As discussed in the January 2021 Board remand, this part of the VA opinion is inadequate because it does not explain how a technical description of the pathophysiology supports the conclusion that the Veteran's hypertension is not aggravated by his mental health disability. For this reason, the Board, in January 2021, remanded the Veteran's claim for an addendum opinion as to whether the Veteran's hypertension was at least as likely as not caused or aggravated by his service-connected mental health disability. Shortly thereafter, also in January 2021, VA obtained an addendum opinion, focusing on secondary service connection. A different VA examiner opined that the Veteran's hypertension was not caused or aggravated by his service-connected disability. The examiner's rationale was simply that "there is no evidence in the provided service treatment records indicating that the veteran was diagnosed with hypertension while on active duty or within one year of his discharge from active duty." In April 2021, the Board concluded that this rationale is patently inadequate as it does really address the question of secondary service connection. Consequently, the Board remanded for another VA addendum opinion. In May 2021, the same VA examiner who issued the February 2020 VA opinion issued an addendum opinion. The examiner noted that the Veteran's hypertension was diagnosed around 2008 and that he was service-connected for anxiety. The examiner explained that there is no evidence found in current medical literature to support any causal or aggravation relationship between hypertension and any mental health conditions, including anxiety. The examiner further indicated that risk factors for primary hypertension include advanced age, obesity, family history, race, reduced nephron number, high sodium diet, alcohol consumption, and physical inactivity, and further noted that anxiety is not a primary risk factor for hypertension. The examiner cited health information from the Mayo Clinic, indicating that anxiety does not cause hypertension. The examiner further indicated that she had reviewed the Veteran's current VA medication list and that none of the Veteran's medications used to treat anxiety have the side effect of increasing blood pressure. For these reasons, the VA examiner concluded that it is less likely than not that the Veteran's service-connected mental health disability caused or aggravated his currently diagnosed hypertension. Based on the above, the Board finds that the weight of evidence is against a finding that the Veteran's hypertension was incurred in service or within a year after service, or that it was caused or aggravated by a service-connected disability. As detailed above, the evidence establishes that the Veteran's hypertension was first diagnosed decades after service. While the Veteran has suggested that his hypertension began in service or soon after service, service treatment records do not show blood pressure reading consistent with such a diagnosis, and the Veteran is not competent to establish such a diagnosis through his own lay statements. As such, the Veteran's statement in the record for this purpose lack weight. Furthermore, the Veteran has not submitted any competent evidence that tends to establish that his hypertension was diagnosed in service, shortly after service, or at any point prior to 2009. Various VA examiners have reviewed the Veteran's records and found no evidence of hypertension prior to 2009. The Board has also reviewed the Veteran's medical records and found the competent evidence does not tend to support a finding of hypertension prior to 2009. Regarding secondary service connection, the Veteran has submitted no competent evidence that establishes that his hypertension is secondary to his service-connected mental health disability. This aspect of the claim was recently addressed by a VA examiner, in May 2021, who opined that it is less likely than not that the Veteran's mental health disability caused or aggravated his hypertension. This opinion is supported by a clear medical rationale, to include references to relevant and probative medical literature. The opinion also shows adequate consideration of the relevant evidence, to include consideration of the medications used by the Veteran and its possible side effects. For these reasons, the Board finds that the May 2021 VA opinion is worthy of significant probative weight. In contrast, the Veteran's assertion that his hypertension is secondary to his mental health disability lacks probative value, as he has not been shown to possess the medical expertise required to provide a competent medical opinion in this case. As such, his statement regarding a nexus also lack weight. The weight of the probative and competent evidence does not tend to show the Veteran's hypertension was incurred in service or within one year after service, or that it was caused or aggravated by the Veteran's service-connected mental health disability. As the preponderance of the evidence weighs against the claim, the Veteran's claim of service connection for hypertension is denied. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.