Citation Nr: 21073875 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 14-20 001A DATE: December 13, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from November 1966 to October 1970, including service in the Republic of Vietnam. His exposure to herbicide agents has been conceded. This matter comes before the Board of Veterans Appeals (Board) on appeal from a July 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded for further development in June 2020 and May 2021. While the Board regrets additional delay, a third remand is necessary, as the August 2021 VA medical examination was inadequate. VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In August 2021, the Veteran was afforded a VA medical examination for his hypertension. The examiner gave the following opinion: There is no evidence of hypertension while in service. The separation exam notes a blood pressure of 124/78. Hypertension was not diagnosed and treated until 2000. The current, widely accepted, peer-reviewed literature has not established Agent Orange as a cause of hypertension. A review of the literature, including Up-to-Date, a respected, professional medical resource wherein one may access current professional treatises and studies, fails to return articles supporting a causal link between Agent Orange and hypertension. The 2018 NAS study suggested an association between Agent Orange and the development of hypertension but did not establish cause. Therefore, it is less likely than not that Veteran's hypertension had its nexus in service or is due to conceded Agent Orange exposure There are a few problems with this opinion. First, while the examiner notes that the Veteran was not "diagnosed and treated" for hypertension until after separation, they do not discuss the significance of elevated blood pressure readings during service. An August 2016 private physician opinion noted that the Veteran exhibited elevated blood pressure (or "hypertensive tendencies") on all available blood pressure readings taken during service; while his blood pressure may not have been high enough to warrant a diagnosis of hypertension, the examiner should nonetheless have discussed if this elevated blood pressure was related to his current hypertension. Second, the examiner did not address the August 2016 private physician's conclusion that there was "ample evidence to indicate that Agent Orange causes [hypertension]... regardless of latency." The August 2016 opinion, among other things, addressed the correlation/causation point made by the August 2021 examiner about the existing medical literature: [Hypertension] is the only condition listed in the limited or suggestive evidence of association that is not presumptively service-connected to exposure to Agent Orange, despite earlier and stronger evidence of an association than [ischemic heart disease, which is presumptively service-connected]... In addition to all of the above, in November 2016, a new study published by VA researchers shows definitively that both occupational exposure to Agent Orange and service in Vietnam are independently associated with the development of [hypertension]. For occupational exposure to Agent Orange, the risk is more than doubled for developing hypertension. This is in spite of controlling for smoking and alcohol intake... There are limits to what epidemiology can prove, especially when it comes to rare disorders or newly emerging disorders that are variants of more classical disease. It takes way too much time for longitudinal studies to determine a 'causal relationship,' and in some cases due to the rarity of the disease would never be enough statistical power in any study to show a 'significant finding.' Toxicology must fill in the gap. While the Board found in June 2020 that the August 2016 physician opinion was not on its own sufficient to establish the Veteran's entitlement to service connection, (because the examiner's analysis was focused on a general link between herbicide agents and hypertension, and did not contain adequate analysis of facts specific to the Veteran,) it is nonetheless part of the evidence of record, and must be acknowledged and dealt with in an adequate VA medical opinion. It is not enough for the examiner to simply wave away the medical literature associating Agent Orange exposure and hypertension with a general statement that association does not necessarily establish a causal relationship. The examiner must explain why, despite the correlation between Agent Orange exposure and hypertension, they believe a causal relationship is less likely than not in this case. Does the medical literature suggest a separate causative factor that is associated with both herbicide agent exposure and hypertension? Is there no plausible mechanism by which herbicide agent exposure would cause hypertension? Does the failure to establish a causal link between herbicide agent exposure and hypertension constitute evidence that such a link does not exist, or does it simply reflect limitations of the studies? The examiner must also address the specific facts of the Veteran's case; if his hypertension was less likely than not caused by herbicide agent exposure, what are the more likely causes? Finally, the Board notes that none of the medical opinions of record adequately address the issue of secondary service connection. While the Veteran's medical records show (and a March 2009 VA examiner pointed out) that his diagnosis of hypertension preceded his diagnosis of diabetes mellitus, no examiner thus far has opined on whether the Veteran's hypertension was at least as likely as not worsened beyond its natural progression (aggravated) by his diabetes mellitus. Similarly, a June 2017 VA examiner opined that the Veteran's hypertension was less likely than not caused by his coronary artery disease because his hypertension existed prior to his hospitalization for a myocardial infarctionbut did not analyze the issue of aggravation. On remand, the new examiner must address both direct and secondary service connection. The matters are REMANDED for the following action: Obtain an opinion from an appropriate clinician, who has not already provided an opinion in this case, regarding the nature and etiology of the Veteran's hypertension. If the clinician believes an in-person or telehealth examination is necessary, one should be scheduled. The examiner shall be provided with the complete claims file, including a copy of this remand. After certifying that they have reviewed the entire claims file, the examiner should answer the following: (a) Is it at least as likely as not that the Veteran's hypertension had its onset during active service? The examiner should address the significance of the Veteran's blood pressure readings during service. (b) Is it at least as likely as not that the Veteran's hypertension was caused or aggravated by his military service, including his conceded exposure to herbicide agents and exposure to asbestos? The examiner must specifically address the National Academy of Sciences, Engineering and Medicine's (NAS) Update 2018 regarding hypertension and Agent Orange exposure, and the August 2016 private medical opinion regarding the link between Agent Orange exposure and the Veteran's hypertension. (c) Is it at least as likely as not that the Veteran's hypertension was caused or aggravated by any service-connected condition, including diabetes mellitus type II, coronary artery disease, and asbestosis? (d) If the Veteran's hypertension is unrelated to his military service, or to any service-connected condition, what is its likely etiology? The examiner must offer a complete rationale for every conclusion reached, citing any record evidence or medical literature relied upon. If the examiner cannot reach a conclusion on an issue without resorting to speculation, the examiner must explain why. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Shermila Sundquist 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.