Citation Nr: 21067841 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 15-06 080 DATE: November 5, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The Veteran's hypertension was not shown as chronic in service and did not manifest to a compensable degree within one year after discharge; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease or a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 2003 to December 2003 and October 2004 to December 2005, including service in Southwest Asia during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This case was most recently before the Board in May 2021 when it was remanded for additional development. The Veteran testified before the undersigned Veterans Law Judge (VLJ) during a February 2018 videoconference hearing. A transcript of that hearing is associated with the claims file. 1. Entitlement to service connection for hypertension The Veteran contends that service connection is warranted for hypertension. Specifically, the Veteran testified that he believes his hypertension began within one year of service discharge or, alternatively, that it is related to a service-connected disability. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, such as hypertension, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). An alternative method of establishing the second and third Shedden elements for disabilities identified as chronic diseases in 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown if "the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology." Savage v. Gober, 10 Vet. App. 488, 498 (1997). Service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multi-symptom illness. 38 C.F.R. § 3.317(a)(2)(i). Service connection may finally be awarded on secondary basis for a disability which is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran's post-service treatment records reflect a current diagnosis of hypertension. Accordingly, the requirements of Shedden and Wallin element (1) have been satisfied. The Veteran's service treatment records are grossly unremarkable for any diagnosis, symptoms, or treatment of hypertension. Indeed, throughout the Veteran's period of service, the recorded blood pressure readings were largely within normal limits. See 38 C.F.R. § 4.104, Diagnostic Code 7101. Even considering the one-time blood pressure reading of 160/88 in September 2005, the records do not indicate that such a reading was "predominant" to satisfy the criteria for isolated systolic hypertension. Notably, the first evidence of a diagnosis of or treatment for hypertension is dated in September 2007. At that time, the Veteran was directed to begin taking Atenolol for his "persistently high blood pressure" as it could aggravate his reported headaches, which were linked to his seizures. Notwithstanding, the Veteran served in Southwest Asia and his service treatment records reflect that he was exposed to burn pits and other contaminants during his deployment. Accordingly, the requirements for Shedden element (2) have been satisfied. The Veteran does not assert that his hypertension was diagnosed during active service. During the February 2018 Board hearing, the Veteran specifically testified that he first started noticing difficulty with his blood pressure when he came home from service or shortly thereafter. Rather, the Veteran asserts that service connection is warranted for hypertension as secondary to a service-connected disability. As the Veteran is currently service connected for depressive disorder, seizure disorder, and kidney stones, the requirements of Wallin element (2) have been satisfied. The question for the Board is whether the Veteran's hypertension manifested during an applicable presumptive period, is at least as likely as not etiologically related to an in-service injury or disease, or is at least as likely as not caused or aggravated by a service-connected disability. The Veteran's post-service treatment records reflect that during an initial visit in March 2007 for seizures, the Veteran's blood pressure was recorded as 113/76. Notes from September 2007 indicate that the Veteran's blood pressure was currently 143/61 and in April 2007, it was 147/79. At that time, he was directed to begin taking Atenolol to control his blood pressure. The remainder of the records reflect ongoing medication management for hypertension without complication. The Veteran was afforded a VA examination in January 2020. At that time, the examiner noted that the Veteran was started on Atenolol for hypertension in August 2007 since the neurologist believed hypertension would aggravate his chronic headaches. The Veteran has been on the medication since that time and his blood pressure has been controlled. After a review of the Veteran's claims file, the examiner stated that there is insufficient data to connect hypertension with the Veteran's Gulf War and burn pit exposure based on current medical literature. However, in a February 2020 addendum opinion, the VA examiner pointed to medical literature indicating that seizures and kidney stone pain can cause elevations of blood pressure when symptomatic and that antidepressants can cause or aggravate high blood pressure in some people. An addendum opinion was obtained in June 2021 regarding secondary service connection. After a review of the claims file, to include the Veteran's treatment records and VA examinations, the examiner opined that the Veteran's hypertension is less likely than not due to or the result of the Veteran's service-connected seizure disorder. The rationale was that during a seizure, fluctuations in blood pressure readings can occur but that such normalize after the seizure. The seizures are less likely than not a cause of sustained elevations of blood pressure. Additionally, the examiner found no evidence of aggravation, indicating that the temporary elevation and fluctuations of blood pressure during a seizure are consistent with the natural progression of hypertension. The examiner further found that the Veteran's hypertension was less likely than not caused by his service-connected depressive disorder or medication taken therefor. The rationale was that temporary elevations of blood pressure are associated with emotional stress, but the medical literature has not shown a direct causal relationship between depressive disorder and hypertension. Additionally, medical literature indicates that an uncommon side effect of Paroxetine, the Veteran's depressive disorder medication, is hypertension but that the Veteran's hypertension was diagnosed and stabilized before he began Paroxetine. The examiner also found no evidence of aggravation, indicating that the hypertension was well controlled by the time the Veteran began medication for depressive disorder. Temporary elevation and fluctuations of blood pressure are consistent with the natural progression of hypertension. Notably, the Veteran's hypertension has not shown evidence of clinical manifestations of hypertensive end organ damage, which would be reflective of aggravation. The examiner also found that the Veteran's hypertension was less likely than not caused by the Veteran's service-connected kidney stones. The rationale was that while acute exacerbations of kidney stones are associated with pain that would cause temporary elevation and fluctuations of blood pressure, the nephrolithiasis condition would not cause chronic and sustained elevations of blood pressure. The examiner additionally did not find that the Veteran's hypertension was aggravated beyond its natural progression because there were no clinical manifestations of hypertensive end organ damage in the treatment records. After consideration of the evidence of record, the Board finds that the weight of the evidence is against finding that service connection for hypertension is warranted. With respect to direct and secondary service connection, the Board finds the VA opinions noted herein to be the most probative evidence of record. Notably, the VA examiners based their opinions on a review of the Veteran's treatment records in light of current medical literature. They provided thorough rationales for their negative opinions that are consistent with the remaining evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). There is no probative medical evidence to the contrary. As to presumptive service connection for a chronic condition, the Veteran's hypertension did not manifest until over a year after his discharge from service, and continuity of symptomatology is not established. As noted above, despite blood pressure readings that do not meet the definition of hypertension for VA compensation purposes, the Veteran began medication for hypertension in September 2007, nearly 2 years after his discharge. Further, the current evidence of record does not indicate that his hypertension manifested to a compensable degree within one year of his service. While the Veteran testified that he began having trouble with his blood pressure shortly after service, the medical records first reflect that he met the criteria for a compensable disability rating in 2007 when he began continuous medication for blood pressure control. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317 as the Veteran's hypertension has a known clinical diagnosis and has not been shown to be part of a medically unexplained chronic multi-symptom illness. In making its determination, the Board has considered the Veteran's lay statements, including that his hypertension is related to his service or his service-connected disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the Veteran is not competent to provide evidence as to more complex medical questions, like the etiology of his hypertension. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran is not shown to possess the medical knowledge or training required to competently attribute his hypertension to his military service or his service-connected disabilities. Therefore, the Veteran's lay statements are not probative in this regard. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim of entitlement to service connection for hypertension is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). CAROLINE B. FLEMING Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Connor, 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.