Citation Nr: 21075640 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-54 556 DATE: December 21, 2021 ORDER Service connection for hypertension is granted. FINDINGS OF FACT 1. The Veteran has a present diagnosis of hypertension. 2. The Veteran is service connected for posttraumatic stress disorder with depression and anxiety (PTSD). 3. There is a secondary etiological relationship between the hypertension and the service-connected PTSD. CONCLUSION OF LAW Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for hypertension as secondary to the service-connected PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran, who is the appellant, had active duty service from September 1973 to September 1976. The instant claim is on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision that, in pertinent part, denied service connection for hypertension. In November 2019, the Board of Veterans' Appeals (Board) issued a decision denying the claim for service connection for hypertension. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In a December 2020 Joint Motion for Partial Remand (JMR), the parties agreed to remand the claim based on their conclusion that there was an inadequate medical opinion. While the JMR stated that a Board remand was necessary to procure another VA medical opinion, the Board finds that the record is sufficient based on the medical opinion provided by the Veteran and, in this decision, grants the claim. The Veteran testified at a Board hearing in August 2019. The hearing transcript has been associated with the record. Service Connection Legal Authority Direct Service Connection Service connection can be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38C.F.R. § 3.303(d). Service connection generally requires competent evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Chronic Disease Presumptive Service Connection Hypertension is a "chronic disease" under 38 C.F.R. § 3.309(a) as a cardiovascular-renal disease; accordingly, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For these reasons, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable. Id. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then, generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more of active service, and certain chronic diseases 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. While the disease need not be diagnosed within the presumption 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. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Secondary Service Connection Service connection may be granted for a condition that is caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. 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) nexus evidence establishing a connection between the current disability and the service-connected disability, which relates to either causation or aggravation. See id.; Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Service Connection for Hypertension is Granted. The evidence shows a current diagnosis of hypertension. See September 2017 VA Examination (providing current diagnosis of hypertension and the medications with which the Veteran is treating it). The Veteran is service connected for PTSD. The remaining question for secondary service connection is whether there is an etiological relationship between the hypertension and the service-connected PTSD. After a review of all the evidence, lay and medical, the Board finds that the evidence is at least in equipoise on the question of whether there is an etiological secondary relationship between the hypertension and the service-connected PTSD. In an October 2021 Psychiatric Evaluation Report, Dr. M.C. reviewed the medical record, service record, prior examinations, and lay statements and conducted a psychiatric diagnostic interview with the Veteran. After this evaluation, Dr. M.C. opined that the Veteran had the diagnostic manifestations of PTSD within six to twelve months after discharge but did not immediately present for treatment. Dr. M.C. noted a few times specific to this Veteran where the PTSD seemed associated with increased blood pressure, to include a time in which the blood pressure was mildly elevated at 147/80 despite three blood pressure medications and during a time in which the Veteran asserted that he had right-sided chest pain for several months that increased with stress. See October 2021 Psychiatric Evaluation Report. In the October 2021 Psychiatric Evaluation Report, Dr. M.C. noted that the Veteran was diagnosed with inconsistently controlled hypertension, and opined that, as the PTSD symptomatology escalated, concomitantly, the hypertension became steadily more evident. As a result, the Veteran intermittently had evidence of hypertension, eventually requiring multiple pharmacologic agents to maintain vascular stability. Dr. M.C. cited to medical literature that describes a secondary relationship between PTSD and hypertension. For example, an article by Dr. Steven Coughlin stated that persons with PTSD have been reported to have an increased risk of hypertension, hyperlipidemia, obesity, and cardiovascular disease. A study by Drs. Bedi and Arora demonstrated that multiple studies have shown that patients suffering from PTSD have increased resting heart rate, increased startle response, and increased heart rate and blood pressure as responses to traumatic slides, sounds, and scripts. PTSD was associated with hyperfunctioning of the central noradrenergic system, which might contribute to cardiovascular issues. Dr. M.C. opined that it is as least as likely as not that there is a strong clinical correlation, if not causality, between the hypertension and PTSD, with vascular pathology escalating in conjunction with the mental illness. While the September 2017 VA Opinion provided a negative secondary nexus opinion, the September 2017 VA Opinion did state that anxiety can cause increased high blood pressure during times of anxiety. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran has a present diagnosis of hypertension, that the Veteran is service connected for PTSD, and there is a secondary etiological relationship between the hypertension and the service-connected PTSD; thus, the criteria are met for secondary service connection for hypertension. 38 C.F.R. §§ 3.102, 3.310. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. 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.