Citation Nr: 21075275 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 18-55 290 DATE: December 20, 2021 ORDER Service connection for residuals of a stroke is granted. Service connection for obstructive sleep apnea (OSA) is granted. FINDINGS OF FACT 1. Residuals of a stroke were caused by the Veteran's service-connected hypertension. 2. OSA was aggravated by the Veteran's service-connected residuals of a stroke. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a stroke have been met. See 38 U.S.C. §§ 501, 1110, 1111, 1131; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 2. The criteria for service connection for OSA have been met. See 38 U.S.C. §§ 501, 1110, 1111, 1131; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1979 to June 2003. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO). The Board denied the Veteran's claims in August 2019, and the Veteran appealed this determination to the United States Court of Appeals for Veterans Claims (Court). In July 2020, pursuant to a Joint Motion for Remand (JMR), the Court vacated the Board's August 2019 denial of service connection for stroke and OSA and remanded these matters to the Board for further action. The Board most recently remanded these matters in April 2021. Service Connection Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183 (1993). To establish service connection on a secondary basis, there must be evidence of a current disability, a service-connected disability, and medical evidence of a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. See 38 C.F.R. § 3.310(b). A finding of aggravation does not require a permanent worsening of the condition. See Ward v. Wilkie, 31 Vet. App. 233 (2019). Instead, aggravation is any incremental increase in disability attributable to the service-connected disability, regardless of its permanence. Id. Service Connection for Residuals of a Stroke The Veteran contends that he experienced an April 2015 stroke and its residual effects as the result of his service-connected hypertension. With both a current disability and a service-connected disability, the remaining question is whether there is a nexus, or relationship, between the Veteran's service-connected hypertension and his current stroke residuals. The record contains medical evidence both favoring and disfavoring such a connection. In favor of such a nexus, in June 2017, Dr. P.T., a private neurologist, stated that the Veteran's stroke was caused by his history of hypertension. In October 2020, Dr. R.D., a private physician, opined that the Veteran's stroke was more likely than not due to his service-connected uncontrolled hypertension. As a rationale for this opinion, Dr. R.D. stated that hypertension had long been a known major risk factor for a stroke. Dr. R.D. observed that the Veteran experienced high blood pressure between 2007 to 2015 despite receiving large dosages of both Lisinopril and Amlodipine. Dr. R.D. found that hypertension was the most important modifiable risk factor for stroke, with a strong, direct, linear, and continuous relationship between elevated blood pressure and stroke risk. In March 2021, C.L., a private nurse practitioner, opined that the Veteran's stroke was at least as likely as not caused by his service-connected hypertension. Following a review of the Veteran's medical history, C.L. noted that "copious amounts" of medical literature supported a finding that elevated blood pressure is the most prevalent risk factor for a stroke. The record additionally contains medical evidence disfavoring a connection between the Veteran's residuals of a stroke and his service-connected hypertension. With that said, the Board places no probative weight in the June 2016 opinion that the Veteran's stroke was less likely than not related to his service-connected hypertension because the Court's July 2020 JMR found such opinion to be inadequate. Similarly, the Board places no probative weight in the January 2021 and February 2021 opinions that the Veteran's stroke was less likely than not proximately due to or the result of his service-connected hypertension because these opinions failed to consider the above-discussed private medical evidence favoring the Veteran's claim. In May 2021, an examiner opined that the Veteran's stroke was less likely than not proximately due to or the result of his service-connected hypertension. The examiner explained that the Veteran's stroke was more likely related to his history of high cholesterol rather than to his service-connected hypertension. The Board finds the opinion to be of approximately equal probative weight to the evidence favoring a connection between the Veteran's service-connected hypertension and his stroke residuals. With the evidence is at least in equipoise as to whether the Veteran's residuals of a stroke are related to his service-connected hypertension, the claim for service connection for residuals of stroke is granted. Service Connection for OSA The Veteran has been diagnosed with OSA, which he contends is related to his service-connected hypertension or stroke residuals. With both a current disability and a service-connected disability, the remaining question is whether there is a nexus, or relationship, between the Veteran's service-connected hypertension or stroke residuals and his OSA. In October 2020, Dr. R.D. opined that the Veteran's OSA was aggravated or worsened by his stroke. As a rationale for this opinion, Dr. R.D. discussed the Veteran's medical history and cited medical literature concluding that strokes worsened OSA. Dr. R.D. found that the Veteran suffered from "an unhealthy cycle of OSA, hypertension, and stroke whereby each element fuels the others." The Board places great probative weight in this opinion, and it finds that the weight of the evidence thus supports a finding that the Veteran's OSA was aggravated by his service-connected residuals of a stroke. Jennifer A. Flynn Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Smith, Associate 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.