Citation Nr: 21005998 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 10-09 013 DATE: February 3, 2021 REMANDED The issue of service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or medications taken for service-connected orthopedic disabilities, is remanded, REASONS FOR REMAND The Veteran served on active duty service in the United Stated Army from August 1979 to July 1989. He had additional service in the United States Army National Guard, which service included a verified period of active duty from December 18, 2003, to April 15, 2005. This appeal to the Board of Veterans’ Appeals (Board) arose from a December 2008 rating decision in which a Department of Veterans Affairs (VA) Regional Office (RO), inter alia, denied service connection for hypertension. The Veteran disagreed with that decision and timely perfected an appeal to the Board. In November 2011, the Veteran testified during a Board video-conference hearing before a Veterans Law Judge (VLJ) at the RO; a hearing transcript has been associated with the claims file. In May 2017, the Veteran and his representative were notified that the VLJ who conducted the November 2011 hearing was no longer employed at the Board. The Veteran was informed that he could request another hearing before a different VLJ. In correspondence received in June 2017, the Veteran stated that he did not wish to appear at another Board hearing. The procedural history of this case is a lengthy one that involves multiple actions by the Board and an appeal to and remand from the United Stated Court of Appeals for Veterans Claims (Court). As the procedural history has been detailed at length in the prior actions in the appeal, it will only be repeated herein as needed to explain the state of the matters currently before the Board. In an August 2017 decision, the Board denied service connection for hypertension. Thereafter, the Veteran filed an appeal to the Court and in November 2018, the Court granted a Joint Motion for Partial Remand (Joint Motion) filed by the Veteran’s then-representative and VA’s General Counsel. In order to comply with the terms of the parties Joint Motion, the Board, in April 2019, remanded, for further development, the issue of service connection for hypertension. Specifically, the matter was remanded for the agency of original jurisdiction (AOJ) to obtain a copy of a February 28, 2005, Post-Deployment Health Assessment, which was referred to by a January 2016 VA examiner, but was included in the record (or at least, not in the record before the Court). Additionally, the Board directed the AOJ to obtain an addendum medical opinion addressing the likelihood that the Veteran’s hypertension was caused and/or aggravated by his service-connected PTSD. Unfortunately, upon further review of the record, to include the actions undertaken on remand from the Board, the Board finds that the matter must again be remanded. The Board has extensively reviewed the record and cannot locate the February 28, 2005, Post-Deployment Health Assessment, which was relied upon by the January 2016 VA examiner in opining that the Veteran’s hypertension was not incurred in or otherwise caused by service. Notably, it is not clear that the AOJ undertook specific measures to obtain that document on remand from the Board. The AOJ did, however, request all National Guard treatment records. In response, it was indicated that after searching with due diligence, the Department of Defense had determined that a paper file for the Veteran could not be retrieved and that all electronic medical records available with the Armed Forces Health Longitudinal Technology Application (AHLTA) were made part of the Veteran’s electronic claims file. Based on this response, the Board assumes that the February 28, 2005, Post-Deployment Health Assessment, to the extent that it once existed, has been lost and concludes that further attempts to obtain the February 28, 2005, Post-Deployment Health Assessment would be futile. Accordingly, as a record relied upon by the January 2016 VA examiner is not available for review by the Board, the Board concludes that it cannot rely upon the January 2016 VA examiner’s negative nexus opinion and that a new medical opinion must be obtained. Additionally, upon further review of the January 2016 VA examiner’s opinion, the Board finds that it is lacking in rationale. Specifically, although the examiner noted various in-service blood pressure readings and found that the available service treatment records (STRs) “do not provide documentation of elevated [blood pressure] readings congruent with a diagnosis of hypertension during active service,” the examiner does discuss whether the Veteran’s in-service blood pressure readings are indicative of pre-hypertension. See Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), available at https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf. (Parenthetically, the Board notes that a newer report from the Joint National Committee (JNC 8) does not define prehypertension.) Notably, the JNC 7 defines pre-hypertension as systolic blood pressure 120-139 mm or diastolic blood pressure 80-89 mm. A review of the Veteran’s STRs reveals several blood pressure readings suggestive of pre-hypertension. Here, because the January 2016 VA examiner did not discuss the potential existence of pre-hypertension in service, the Board concludes that the negative nexus opinion cannot be relied upon for adjudication purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that “most of the probative value of a medical opinion comes from its reasoning”). The Board also points out that the January 2016 examiner failed to address any blood pressure readings recorded in private medical records dated between 2005 and 2008. Accordingly, the Board cannot conclude that the examiner’s conclusion was based on all relevant evidence. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (providing that a VA medical examination or opinion is adequate if it is “thorough and contemporaneous” and considers the veteran’s prior medical examinations and treatment). The Board further notes that in a July 2015 remand action, the Board pointed out that the Veteran’s representative had raised the theory of secondary service connection, asserting the possibility that the Veteran’s hypertension was caused or aggravated by his PTSD and/or use of non-steroidal anti-inflammatory drugs (NSAIDS). Although the AOJ has obtained a medical opinion addressing the likelihood that the Veteran’s hypertension was caused and/or aggravated by his PTSD, no opinion has been obtained addressing the likelihood that the Veteran’s use of NSAIDS caused or has aggravated his hypertension. In this regard, the Board notes that in its July 2015 remand action, the Board directed that if service connection was granted for any orthopedic disability, claims for which were also remanded at that time, the AOJ was to obtain a medical opinion regarding whether it was at least as likely as not that the Veteran’s hypertension was due to or aggravated by NSAID use for a service-connected disability. A review of the record shows that the Veteran’s lumbosacral spondylolisthesis and a right elbow disability are now service connected. Additionally, VA treatment records show that the Veteran has been prescribed Naproxen for pain. Accordingly, to ensure compliance with the prior remand actions, the Board finds that, on remand, an opinion addressing the likelihood that the Veteran’s use of NSAIDS caused or has aggravated his hypertension must also be obtained. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliances with the terms of the remand). Additionally, with regard to the Veteran’s argument that his hypertension was caused or has been aggravated by his service-connection PTSD, the Board notes that a new opinion addressing this question was obtained in November 2020. A review of the opinion report shows that the clinician opined that it is less likely than not that the Veteran’s hypertension was caused by and/or aggravated by his service-connected PTSD. As rationale for that opinion, the clinician stated that although mental health conditions such as anxiety or PTSD can cause transient elevation in blood pressure, there is not objective medical or scientific evidence that these mental health conditions cause or aggravate essential hypertension. The clinician also noted that the that the Veteran’s hypertension has been well controlled over time. Contrary to the VA clinician’s stated rationale, the Board notes that medical literature suggests a potential association between PTSD and hypertension. See e.g., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141329/ (providing that “[p]ersons with PTSD have also been reported to be more likely to have hypertension”). Indeed, several studies referenced on VA’s website suggest some association between PTSD and the development of cardiovascular disease. Although this research may not “show a clear cause-and-effect relationship,” it is indicated that “‘[o]verall, the evidence to date seems to point in the direction of a causal relationship.’” https://www.research.va.gov/currents/spring2015/spring2015-8.cfm; see https://www.ptsd.va.gov/professional/newsletters/research-quarterly/V28N1.pdf; https://www.research.va.gov/currents/spring2014/spring2014-1.cfm. Given this contradictory information, the Board finds that it cannot rely on the November 2020 VA clinician’s opinion and that a new opinion must be obtained on remand that includes consideration and discussion on this evidence. The matter is REMANDED for the following action: Arrange to obtain from an appropriate VA clinician a medical opinion based on claims file review (if possible). Only arrange for the Veteran to undergo VA examination, by an appropriate clinician, if one is deemed necessary in the judgment of the physician designated to provide the medical opinion. Upon review of the Veteran’s claim file, the clinician should address the following: (a) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hypertension manifested during or is otherwise related to the Veteran’s periods of active service. In doing so, the clinician must address whether various blood pressure readings during the period of service from December 2003 to April 2005 are indicative of pre-hypertension, and, if so, whether this supports a finding that the Veteran’s hypertension is attributable to service. The clinician must also consider and discuss the relevant blood pressure readings contained in the Veteran’s private treatment records dated from 2006 to 2008. (b) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hypertension is (1) caused, OR (2) is or has been aggravated (worsened beyond natural progression), by any NSAID medication taken for the treatment of any service-connected disability. (c) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hypertension is (1) caused, OR (2) is or has been aggravated (worsened beyond natural progression), by service-connected PTSD. In doing so, the clinician must also give consideration to the published literature identified above that suggests, at a minimum, that persons with PTSD are at an increased risk for the development of heart disease than those without PTSD. In addressing (b) and (c) above, both causation and aggravation must be addressed. The clinician is reminded that that merely stating that it is his/her opinion that the Veteran’s hypertension was not caused or aggravated by PTSD and/or any NSAID medication taken for a service-connected orthopedic disability is not sufficient. An explanation is required that takes into account the record and pertinent medical principles and the clinician’s rationale should include citation to pertinent evidence and/or medical principles relied upon to form that opinion. Additionally, a rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Neilson, 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.