Citation Nr: 21072378 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 17-13 894 DATE: December 3, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected heart and sleep apnea disabilities, is denied. FINDING OF FACT There is no probative medical evidence that indicates the Veteran's current hypertension disability was incurred in service, diagnosed within the presumptive period after discharge, nor is secondary to a service-connected disability. CONCLUSION OF LAW The criteria to establish service connection for hypertension have not been satisfied. 38 U.S.C. §§ 1110, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1968 to December 1969. Effective March 2017, the Veteran has a combined 100 percent service-connected disability rating. The procedural history of this claim is outlined in the April 2020 and July 2021 Board of Veterans' Appeals (Board) remands. Most recently, the claim was remanded for addendum medical opinions. All actions ordered by the remand have been accomplished. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be established 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). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). "Hypertension" refers to persistently high arterial blood pressure. Medical authorities have indicated various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland's Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term "isolated systolic hypertension" means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Certain disorders listed as "chronic" in 38 C.F.R. § 3.309 (a) and 38 C.F.R. § 3.303 (b) are capable of service connection based on a continuity of symptomatology without respect to an established causal nexus to service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Hypertension, as an "organic disease" of the nervous system, is a "chronic disease" listed under 38 C.F.R. § 3.309 (a). Therefore, the presumptive service connection provisions based on "chronic" in-service symptoms and "continuous" post-service symptoms under 38 C.F.R. § 3.303 (b) apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 38 C.F.R. § 3.303 (b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309 (a). While the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The Board must analyze the competency and credibility of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept it means that the person or person who makes the statement is qualified by training, education, an occupation, personal experience, or other reason to make the statement. Credibility is a factual determination it involves deciding whether the testimony or other evidence is believable, and the determination is made after the evidence has been found competent. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities Service treatment records do not indicate any complaints, diagnoses, or treatments for hypertension in service. The Veteran's July 1967 report of medical history at enlistment indicates he denied high or low blood pressure. His clinical heart and vascular evaluations were normal. The Veteran's October 1968 report of medical history at reenlistment indicates he denied high or low blood pressure. His clinical heart and vascular evaluations at reenlistment were normal. The Veteran's separation examination is not in the record. May 2010 VA treatment records indicate the Veteran was self-managing his hypertension disability with a personal blood pressure monitor cuff since at least May 2009. In June 2014 the Veteran presented with chest pain and was found to have severe complex left main coronary artery disease (CAD). He underwent coronary artery bypass graft (CABG) surgery soon after. In October 2015 the Veteran was diagnosed with severe central sleep apnea with Cheyne-Stokes breathing. The Veteran has service-connection for both his heart and sleep apnea disabilities. November 2016 VA treatment records indicate that in assessing the Veteran's complaints of fatigue, a cardiac nurse practitioner noted that the Veteran's pulmonary hypertension and pulmonary vascular resistance (PVR) were likely due to his obstructive sleep apnea (OSA). The nurse practitioner also noted that the Veteran's severe brachycardia could be the etiology of his fatigue. This opinion provides insufficient analysis to consider and weigh her opinion. The nurse practitioner did not provide a factually based explanation for her conclusion. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on incomplete or inaccurate factual premises are not probative). At a January 2018 VA medical examination for hypertension, the examiner reviewed the Veteran's claims file and diagnosed the Veteran with hypertension as of 2010. The examiner noted that the Veteran's recent treatment records indicated he had complained of fatigue, and that he had been diagnosed with sleep apnea. The examiner also noted the Veteran's hypertension was fairly well controlled and not likely causing functional impairments. The examiner did not provide an opinion on etiology or aggravation. At his January 2020 Board hearing, the Veteran testified that he did not have high blood pressure complaints or concerns prior to his cardiac surgery in 2014. At an October 2020 VA medical examination, the examiner conducted an in-person examination and diagnosed the Veteran with hypertension as of 2014 because the Veteran recalled he was diagnosed with hypertension after his 2014 hospitalization for chest pain and subsequent CABG surgery. The examiner opined the Veteran's hypertension was not incurred in service because his service medical records did not show entrance or discharge examinations and that the Veteran denied having hypertension prior to 2014. The examiner also opined there was no plausible secondary relationship between the Veteran's hypertension and his heart condition. This opinion is not probative because it is based on an inaccurate factual premise. The Veteran's treatment records clearly show that he was being monitored for high blood pressure prior to the diagnosis and treatment of his CAD disability. See Reonal v. Brown, supra. Furthermore, the examiner did not provide a sufficient analysis for his opinion that there was no plausible relationship between the Veteran's hypertension and CAD disabilities. See Stefl v. Nicholson, 21 Vet. App. 120, 124-125 (2007) (holding that "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor's opinion"). At a December 2020 VA medical examination, a VA medical examiner reviewed the Veteran's claims file and opined that it was less likely than not that the Veteran's hypertension disability was related to or was being aggravated by his coronary artery disease (CAD). The examiner noted that medical literature did not indicate that CAD was a causal or aggravating factor of hypertension. The examiner also noted that hypertension occurs when there is a peripheral resistance in the vascular system, and that CAD is a condition of the coronary arteries that supply blood to the heart, which is not a part of the peripheral vascular system. The examiner further noted that most patients with essential hypertension have normal cardiac functioning. The examiner explained that given the physiology of hypertension, there was no causal or aggravation nexus to CAD. In a separate May 2021 VA medical opinion, the VA medical examiner noted that the conditions of hypertension and sleep apnea were not medically related, and that a thorough review of medical literature failed to demonstrate a causal relationship between the two medical conditions. At a September 2021 VA medical examination, a different VA examiner reviewed the Veteran's claims file and opined that the Veteran's hypertension was less likely than not due to, the result of, or being aggravated by his service-connected sleep apnea and CAD disabilities. As for sleep apnea, the examiner noted that neither central nor obstructive sleep apnea was a known cause of hypertension; that the Veteran's hypertension had remained stable on two medications throughout his initial diagnosis and treatment for sleep apnea; and that while medical research indicated that OSA was thought to be a risk factor for hypertension, none of the medical research submitted by the Veteran indicated a causal or aggravating relationship between the two disabilities. The examiner also noted that occasional adjustment in dosages or changes in medications were common throughout treatment for essential hypertension and did not represent aggravation beyond the natural course of the disability. The examiner noted that the onset of the Veteran's hypertension pre-dated the diagnosis and treatment of his sleep apnea, and that therefore his OSA was not likely the cause of his hypertension. Finally, the examiner noted that the studies did not establish OSA as a cause of hypertension, but rather that both disabilities warrant screening for the other condition and that treatment for either condition should assess the presence and relationship between both conditions. With regards to the Veteran's CAD disability, the examiner noted that CAD did not cause nor aggravate hypertension. The examiner stated there was no anatomic or physiologic mechanism by which CAD could cause or aggravate hypertension. One exception would be if the Veteran's CAD disability demonstrated with chronic congestive heart failure with elevated resting cardiac pressures, which is not documented in the Veteran's medical history. Therefore, it was less likely than not that the Veteran's CAD caused or aggravated the Veteran's hypertension. The preponderance of the evidence is against finding service connection for hypertension. There is no probative medical evidence that the Veteran's hypertension was incurred in service, diagnosed within the presumptive period after discharge, or is secondary to a service-connected disability. The Veteran has continuously asserted throughout the appeal that his current hypertension disability is a result of his service-connected heart and/or sleep apnea disabilities. The Veteran is competent to report observable symptomatology of his condition and to relate a contemporaneous medical diagnosis. See Layno, 6 Vet. App. 465, 469; see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, while the Veteran has attempted to establish a nexus through his own lay assertions, the Veteran is not competent to offer opinions as to the etiology of his current hypertension disability. See Jandreau, 492 F.3d 1372, 1377 n.4; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Hypertension requires specialized training for determinations as to diagnosis and causation and is therefore not susceptible to lay opinions on etiology. Thus, the Veteran is not competent to render such a nexus opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and its relationship to any of his service-connected disabilities. The claim for service connection is denied. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Anwar, Attorney-Advisor The Board's action is binding only in this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.