Citation Nr: 21070409 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 13-18 460 DATE: November 23, 2021 ORDER Service connection for hypertension as secondary to service-connected disabilities, including asthma, obstructive sleep apnea (OSA), and posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for hypertension on a direct or presumptive basis is remanded. FINDING OF FACT The Veteran's hypertension has not been caused or aggravated by her service-connected asthma, including asthma medications, or by her service-connected OSA or PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension on a secondary basis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from November 1988 to June 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter in September 2017, November 2018, August 2020, February 2021, and July 2021. The Board has bifurcated the claim for hypertension into two issues: (1) entitlement service connection as secondary to asthma, OSA, or PTSD and (2) entitlement to service connection on a direct or presumptive basis. The record is sufficiently developed to adjudicate the first issue, but not the second issue. Moreover, further development of the issue of service connection on a direct or presumptive basis will not affect the outcome of whether entitlement to service connection may be established on a secondary basis. Therefore, bifurcation of the claim is appropriate. See Tyrues v. Shinseki, 23 Vet. App. 166, 176 (2009) (en banc), aff'd 631 F.3d 1380 (Fed. Cir. 2011). The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2017. A transcript of the hearing is of record. Service Connection The Veteran seeks to establish service connection for hypertension as secondary to her service-connected asthma. See April 2017 Hearing Transcript. Specifically, she states that medications to treat her asthma have caused her blood pressure to increase. See id. The record also raises the issue of whether her hypertension may be aggravated by her service-connected OSA or PTSD. For the following reasons, the Board finds that service connection for hypertension on a secondary basis is not established. The issue of whether service connection for hypertension may be established on a direct or presumptive basis is being remanded for further development, as discussed below. Service connection may be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be granted for aggravation of a disease or injury by a service-connected disability. Id. For rating purposes, VA regulation defines hypertension as diastolic blood pressure predominantly 90 mm. or greater; isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. The VA treatment records reflect that the Veteran has been diagnosed with hypertension since December 2001, when her diastolic blood pressure was recorded as 109 mm. In April 2010, the Veteran was hospitalized overnight at VA for an acute exacerbation of her asthma. On the day of admission, her systolic blood pressure was recorded as 158 mm, and her diastolic blood pressure recorded as 105 mm. It was noted that her hypertension was elevated at this time, and that this elevation might be caused by distress secondary to her asthma exacerbation. The following day, it was noted that her blood pressure remained elevated. A blood pressure reading showed systolic blood pressure of 165 mm, and diastolic blood pressure of 106 mm. The hospitalization summary notes that the Veteran was hypertensive and tachycardic in the emergency department, and reported that she had not taken her blood pressure medication at home because she was not feeling well. In October 2010, the Veteran was seen again in the emergency room for an exacerbation of her asthma, stating that she had experienced trouble breathing and a cough. Her symptoms began the night before. She also had a fever and sore throat. Her blood pressure at this time was recorded as 167 mm systolic and 95 mm diastolic. Her heart was noted to be "very tachycardic," which was "likely related" to the excessive use of Beta-2 agonists for her asthma. Regarding her "current hypertension," it was noted that it "could be caused by stress of the last 24 hours and [her] current viral infection." At the April 2017 Board hearing, the Veteran stated that every time she took Symbicort or medications for her asthma, her blood pressure would spike and stay up. She would then have to take additional blood pressure pills to stabilize her blood pressure. A VA examination as part of the development of this claim was performed in October 2017. According to the examination report, the Veteran told the examiner that she was not diagnosed or treated for hypertension during service. Rather, she was initially diagnosed and treated for hypertension at VA , and around that time was also having respiratory problems which were later diagnosed as asthma. She felt that the asthma medication increased her blood pressure. In the August 2021 VA medical opinion, the examiner concluded that the Veteran's hypertension is less likely than not caused or aggravated by her asthma or asthma medications. The examiner explained that hypertension is not caused by asthma or the medications used to treat it, including Symbicort or other steroid-like inhalers, which was established medical knowledge. The examiner added that essential hypertension tends to be familial and is due to increased peripheral vascular resistance, while asthma is due to bronchospasm or constriction. Medications for asthma such as Symbicort are used to treat inflammation locally within the lung, and bronchodilators work locally to dilate the bronchial passage. The examiner observed that, if anything, these medications would be neutral or beneficial with regard to hypertension. No medications used to treat asthma are known to chronically impact or cause hypertension, according to the examiner. Therefore, the examiner found it was less likely than not that the Veteran's hypertension was due to her asthma medications. The examiner further found that the Veteran's hypertension was less likely than not aggravated beyond its natural course "due to any cause." The examiner explained that essential hypertension tends to progress and often requires medication changes or dosage adjustments. This did not constitute aggravation beyond its natural course. In a separate August 2021 opinion, the examiner also addressed the issue of whether the Veteran's hypertension may be caused or aggravated by her service-connected obstructive sleep apnea (OSA). The examiner concluded that the Veteran's hypertension was less likely than not caused or aggravated by her OSA. The examiner explained that while studies have suggested a two-way link between hypertension and OSA, OSA has not been established as a cause or aggravating factor. The examiner reiterated that there was no evidence in the Veteran's case that her hypertension had progressed beyond its natural course due to any cause, including OSA. The August 2021 opinion also found that the Veteran's service-connected posttraumatic stress disorder (PTSD) had not caused or aggravated her hypertension. According to the examiner, current and widely accepted peer-reviewed literature has not established PTSD and related psychological comorbidities, including anxiety, depression, and panic disorders, as a cause of essential hypertension. The examiner noted that by definition, essential hypertension is not caused by any other condition. With regard to aggravation, the examiner stated that while some articles found a possible association, the authors of those articles concluded that further research with appropriately designed studies is required to determine the relationship between those psychological conditions and hypertension. The examiner observed that anxiety, stress, activity, panic attacks, a startling event, etc., may temporarily elevate blood pressure, but that the elevation resolves following abatement of the stimulus and the autonomic response. This temporary elevation did not constitute aggravation as it did not impact the baseline condition. The Board finds that the preponderance of the evidence weighs against causation or aggravation of the Veteran's hypertension by medications for her service-connected asthma, or by her service-connected OSA or PTSD. The VA medical opinions are probative on this issue, as they reflect the conclusions of a medical professional based on review of the Veteran's medical history and prior examination, and are supported by explanations sufficient for the Board to make a fully informed decision. The examiner explained that the records did not show an increase in the Veteran's hypertension beyond the ordinary progression of that condition, and that medications for asthma such as Symbicort and other steroid-like inhalers, as well as bronchodilators, do not cause or aggravate hypertension. The Veteran's statements that she has observed her blood pressure to become elevated when taking her asthma medications are competent evidence, as that is a matter of first-hand experience. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, a finding that they are competent does not mean that they are sufficient to prove that her hypertension is aggravated by her asthma medications. There may be other factors that she has not considered. For example, while the April 2010 VA records pertaining to her overnight hospitalization for an acute exacerbation of her asthma show that her blood pressure was elevated, the treating physician observed that such elevation may be caused by distress from her asthma exacerbation. When the Veteran was seen again in October 2010 for an asthma exacerbation with a fever and cough, her elevated blood pressure ("current hypertension") was thought to be due to the stress of the "last 24 hours," in reference to her symptoms that had begun the night before, and her viral infection. As explained in the August 2021 VA medical opinion, stress and anxiety may temporarily elevate blood pressure, but that does not constitute aggravation of the baseline hypertension beyond natural progression. Moreover, the April 2010 VA hospitalization summary notes with regard to the Veteran being "hypertensive" in the emergency department that she stated she had not taken her blood pressure medication at home because she was not feeling well. Thus, her elevated blood pressure at that time may have been due to not taking her blood pressure medication. The October 2010 VA treatment record notes that the Veteran's heart was tachycardic, and attributed this to excessive use of bronchodilators (Beta-2 agonists). The record does not indicate that the Veteran's tachycardia is related to her hypertension, and the present claim does not reasonably encompass that symptom or condition. Cf. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (the scope of a mental health disability claim includes any acquired psychiatric disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Accordingly, the Veteran's statements in themselves are not sufficient to establish that her asthma medications actually cause an increase in her blood pressure, even if she has associated the two together. She has not submitted any supporting evidence for that theory. Significantly, the VA medical opinion explains that asthma medications do not cause or aggravate hypertension. That opinion outweighs the Veteran's statements on the issue of whether her hypertension is secondary to her asthma medications, as the former represents the conclusion of a medical professional and is based on medical knowledge; by contrast, the Veteran, as a lay person in the field of medicine, does not possess such expertise. By the same token, while the Veteran is competent to observe increases in her blood pressure when taking her asthma medications, her statements are not competent to show that the asthma medication in fact is the cause of that increase, as this is a medical determination that is too complex to be made based on lay observation alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). As explained above, there may have been other factors that caused the increased blood pressure that happened to coincide with her taking asthma medication. Significantly, the August 2021 VA medical opinion states that it is established medical knowledge that asthma medications do not cause increased blood pressure. Thus, her opinion on that issue is not probative. See Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). It is thus outweighed by the VA medical opinion, which the Board finds to be probative, as explained above. Finally, the August 2021 VA medical opinion explains that temporary increases in blood pressure do not in themselves establish that her hypertension has increased beyond its natural progression, noting that hypertension tends to progress and often requires medication changes or dosage adjustments. It was thus less likely than not to have been aggravated beyond its natural course "due to any cause." With regard to the Veteran's OSA, the August 2021 VA medical opinion found that while some studies suggested a two-way link between OSA and hypertension, they were not sufficient to conclude that it is at least as likely as not that her OSA caused or aggravated her hypertension. As explained in the opinion, essential hypertension by definition cannot be caused by another condition, and the studies regarding a possible link between OSA and hypertension did not establish that OSA aggravates hypertension. Moreover, the examiner found that in the Veteran's case, review of her medical history did not show a progression of her hypertension beyond the ordinary course of that condition. The August 2021 VA medical opinion provides a similar finding regarding the Veteran's service-connected PTSD and hypertension, stating that while some articles found a possible association, they were not sufficient to show that it was at least as likely as not that her PTSD aggravated her hypertension. The examiner explained in this regard that the authors of those articles concluded that further research with appropriately designed studies is required to determine the relationship between those psychological conditions and hypertension. In other words, the examiner indicated that the findings in those articles were too tentative or inconclusive to support a finding that it is at least as likely as not that the Veteran's PTSD aggravated her hypertension. The examiner also explained that temporary increases in blood pressure due to stress, anxiety, panic attacks, activity, or startling events do not constitute aggravation of the baseline condition. The Board here again notes the examiner's finding that the record did not show a progression of the Veteran's hypertension beyond its natural course. Accordingly, as the preponderance of the evidence weighs against causation or aggravation of the Veteran's hypertension by her service-connected asthmaincluding the medications she takes for that conditionor by her OSA or PTSD, the criteria for service connection on a secondary basis are not met. See 38 C.F.R. § 3.310. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). As the preponderance of the evidence is against service connection for hypertension on a secondary basis, there is not an approximate balance of positive and negative evidence; therefore, the benefit-of-the-doubt rule does not apply. See id. (Continued on following page) REASONS FOR REMAND Entitlement to service connection for hypertension on a direct or presumptive basis is remanded. The issue of entitlement to service connection for hypertension on a direct or presumptive basis must be remanded again for further development. The Board finds that the October 2017 VA medical opinion, which addresses direct service connection, is not adequate to make an informed decision, and does not comply with the Board's prior remand directives. Specifically, the examiner concluded that the Veteran's hypertension is less likely than not incurred in service or caused by an in-service injury, illness, or event, stating that the Veteran's blood pressure readings during service were generally normal. The examiner noted that a December 1994 entry showed an initial reading of 152/78, and that on a repeat reading it was 124/74. The opinion explains that a one-time elevated blood pressure reading is not diagnostic of hypertension. However, the opinion does not address the in-service blood pressure reading of 133/96 in November 1994, or the reading of 137/86 in the February 1995 separation examination report, as instructed by the Board in its September 2017 remand. It thus does not comply with the Board's remand directives. It is also not adequate to make an informed decision, since it was based on the premise of a "one-time" elevated blood pressure reading in December 1994, which does not take into account the other elevated readings during service. Accordingly, a new medical opinion must be obtained that considers all the in-service elevated blood pressure readings. The matter is REMANDED for the following action: Obtain a new VA medical opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's hypertension is related to her elevated blood pressure readings during service. The opinion must address the following readings: 133/96 (November 1994); 152/78, and then 124/74 on repeat reading (December 1994); and 137/86 (February 1995 separation examination report). P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.