Citation Nr: 21006053 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 14-12 668 DATE: February 3, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected ischemic heart disease, is granted for accrued benefits purposes. FINDING OF FACT The Veteran’s hypertension was as likely as not aggravated beyond its natural progression by service-connected ischemic heart disease. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to service-connected ischemic heart disease, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1968 to February 1970. The Veteran died during the appeal period, on January 5, 2014, and his surviving spouse has been accepted as the substitute party to complete the appeal. This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for hypertension The Veteran’s notice of disagreement (NOD) was received in May 2012. The RO issued the statement of the case (SOC) in December 2013, and the Veteran’s VA Form 9, substantive appeal was received in February 2014. In March 2018 and October 2019, the Board remanded the case for further development and adjudicative action. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § § 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Additionally, service connection may be established 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). Establishing service connection on a secondary basis requires evidence (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). 1. Service connection for hypertension, to include as secondary to service-connected ischemic heart disease The appellant contends that service connection is warranted for the Veteran’s hypertension, as proximately caused or aggravated by service-connected ischemic heart disease. In that regard, a private chiropractor opined in August 2010 that the Veteran’s hypertension is directly and causally related to his ischemic heart disease, and more likely than not related to the Veteran’s service. No rationale was provided for either opinion. The chiropractor noted difficulty with blood pressure control. Veteran’s blood pressure was 156/70 with medication, which was noted as indicative of “break through systolic hypertension.” In January 2011, a VA examiner opined that the Veteran did not have ischemic heart disease. A November 2011 private cardiology consult note shows that the Veteran was treated by a physician, Dr. R.P., M.D., since January 1996. Dr R.P. reported conducted a complete cardiac evaluation in November 2011, which revealed mitral regurgitation and aortic regurgitation; the physician also noted a longstanding diagnosis of hypertension. An August 2011 VA primary care note shows that because of his hypertension, the Veteran was followed regularly with blood pressure checks and was given blood pressure control education. VA treatment records show numerous blood pressure readings. A September 2010 history and physical note shows blood pressure of 132/62. An August 2013 VA primary care note shows blood pressure of 158/68. An October 2013 VA primary care note shows that blood pressure measured at 139/89, and then 116/78 on a second reading. A January 2014 Death Certificate shows that the Veteran’s causes of death are listed as pericardial tamponade, aortic dissection, and hypertension. In November 2018, a VA examiner found it less likely as not that the hypertension was caused or incurred in service, because there was “no documented medical and/or diagnostic evidence to support” that the hypertension was proximately due to or aggravated by the ischemic heart disease. The examiner cited service treatment records which are silent for any elevated blood pressure or related symptomatology. The examiner then opined that the hypertension is less likely than not proximately due to or the result of ischemic heart disease. The examiner cited the November 2011 letter from Dr. R.P., which indicates that the hypertension was diagnosed well before any cardiac condition; and, found “no documented medical and/or diagnostic evidence to support” that the hypertension is related to the ischemic heart disease. In September 2020, a VA examiner opined that the hypertension was less likely than not incurred in or caused by service. The examiner noted that the Veteran’s high blood pressure was diagnosed prior to the IHD, and that he had essential hypertension controlled with blood pressure medication. The examiner noted occasional highs which would return to reasonable levels, and a review of the records did not demonstrate poorly controlled blood pressure. The examiner found that aortic stenosis more likely as not could contribute to changes in blood pressure, but that the blood pressure would then return to normal ranges and would not remain chronically elevated, which would suggest a secondary factor contributing to the underlying condition. In an addendum opinion dated October 2020, the examiner opinion that the Veteran had aortic dissection, which was at least as likely as not aggravated by ischemic heart disease. The examiner noted that both hypertensive and atherosclerotic heart disease were significant risk factors in the development of aortic dissection and ultimately, the Veteran’s death; and, noted that ischemic heart disease is a contributing factor to hypertension and aortic dissection. The examiner provided another addendum opinion, also in October 2020, in which she indicated that although the aortic dissection was aggravated by the ischemic heart disease, it was not possible to establish a baseline level of severity because aortic dissection occurs acutely and is typically not a slow, progressive condition. Again, in late October 2020, the examiner was asked to provide an opinion as to whether the hypertension was aggravated beyond natural progression by ischemic heart disease. She opined, following a review of the Veteran’s medical records, that the hypertension was at least as likely as not aggravated by the ischemic heart disease. Her opinion cited that ischemic heart disease can aggravate hypertension as the arteries become more resistant with both decreased blood flow from coronary artery disease and increased resistance from hypertension. However, the examiner was unable to determine a baseline level of severity of the hypertension. She noted no objective evidence to demonstrate that the Veteran’s blood pressure was consistently elevated, but noted that the Veteran began taking more blood pressure medication at some point to control his blood pressure. From this, the examiner deduced that the Veteran had worsening blood pressure. However, the medication was discontinued, and thus the examiner could not establish when the worsening began. Turning to whether the evidence demonstrates a link between the hypertension and service, to include service-connected ischemic heart disease, the record contains opinions which are both in favor and against the claim. The November 2018 VA examiner opined against a link between the ischemic heart disease and hypertension, due to a finding that the hypertension pre-existed the ischemic heart disease. In the prior Board remand, the Board found that opinion inadequate to address the issue of aggravation, because the examiner did not discuss the Veteran’s death certificate which includes a note of hypertension; and, in light of his service-connected ischemic heart disease and cause of death. Then, a separate VA examiner reviewed the claims file and opined, in October 2020, that the hypertension was aggravated by ischemic heart disease. The opinion cited hypertensive and atherosclerotic heart disease as significant risk factors in the development of aortic dissection and ultimately, the Veteran’s death; and, the examiner noted that ischemic heart disease is a contributing factor to hypertension. The October 2020 examiner conducted a thorough review of the Veteran’s claims file, including reviewing the death certificate to familiarize herself with the causes of death. Then, she applied her medical expertise and knowledge concerning (i) the nature of the various causes of the Veteran’s death; (ii) the relationship between ischemic heart disease and hypertension; and (iii) the unique nature of the numerous conditions affecting the Veteran’s heart function. The rationale is clearly worded, and clearly relays that the hypertension was aggravated by service-connected ischemic heart disease. For those reasons, the opinion carries substantial probative value. The October 2020 examiner was unable to establish a baseline of disability prior to aggravation by ischemic heart disease. While the extent of aggravation has not been established by a baseline of disability prior to aggravation, pursuant to 38 C.F.R. § 3.310 (b), “VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence.” However, in this case, the Board finds the evidence is at least in equipoise as to whether the Veteran’s hypertension was aggravated by his service-connected ischemic heart disease. The extent of aggravation is a rating consideration for the RO in assigning a disability rating, see generally 38 C.F.R. § 4.22, and relevant case law instructs that, if the degree of impairment from a disability attributable to service-connected versus nonservice-connected disability cannot be medically ascertained, VA must consider the whole of the impairment as service connected. Mittleider v. West, 11 Vet. App. 181 (1998). Weighing the evidence set forth above, the evidence is at least evenly balanced as to whether the Veteran’s hypertension was aggravated beyond its natural progression by ischemic heart disease. When the evidence is at least evenly balanced, all reasonable doubt must be resolved in the Veteran’s favor. The claim is granted. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. KAYS HUKILL 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.