Citation Nr: 21006449 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 12-15 193 DATE: February 4, 2021 REMANDED Entitlement to service connection for hypertension as secondary to posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1984 to April 1987, February 2003 to June 2003, and October 2004 to March 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In March 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In June 2016, the Board remanded the Veteran's claim for additional development and, in August 2017, denied service connection for hypertension. Thereafter, he appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In October 2018, the Court granted the Veteran's and the Secretary of VA's (the parties') Joint Motion for Partial Remand (JMPR), which vacated and remanded the Board's August 2017 decision. In March 2019 and July 2020, the Board remanded the claim for development consistent with the JMPR, and the case now returns for further appellate review. Entitlement to service connection for hypertension as secondary to PTSD. In accordance with the JMPR, the March 2019 remand directed that an addendum opinion addressing whether the Veteran's hypertension was caused or aggravated by his PTSD be obtained. In rendering such opinion, the remand directed that the examiner should consider the fact that the Veteran gained weight while participating in a drug trial of Mirtazapine for his PTSD from February 2009 to July 2009, and offer an opinion as to (1) whether his PTSD, to include as due to his participation in the drug trial, caused him to become obese and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his hypertension and (3) whether his hypertension would not have occurred or worsened but for the obesity caused by his service-connected PTSD. In October 2019, a VA examiner reviewed the record and opined that the Veteran's hypertension was less likely than not secondary to his PTSD. In this regard, she noted that his hypertension was likely essential as the majority of such cases are essential and his records referred to such as essential. The examiner indicated that he had several risk factors for essential hypertension. She further opined that the Veteran's obesity is likely multifactorial and indicated that she could not state that such is due solely to his PTSD. The examiner further stated that she cannot determine the percentage contribution of PTSD to obesity without speculation, and again noted that the Veteran had other risk factors for essential hypertension in addition to obesity. In regard to the Mirtazapine trial, the examiner noted that the record showed that the Veteran discontinued such medication after a short duration, it was unclear whether he was receiving the medication or a placebo, and only gained 4 pounds. Further, his blood pressure was 124/72 when he discontinued the trial, and thus it was less likely that his participation in such contributed to his hypertension. The examiner further indicated that acute exacerbations of PTSD can cause an elevation of blood pressure, but a review of the record did not demonstrate such occurred in the Veteran's case, and his most recent blood pressure reading was 116/82. Thus, she concluded that she could not state that the Veteran's PTSD aggravated his hypertension without resorting to speculation as the available medical evidence was insufficient to support such position. However, the examiner's conclusions as to the level of contribution of the Veteran's PTSD to his obesity and whether such service-connected disability aggravated his hypertension were inconclusive, as she indicated that such determinations could not be reached without resort to speculation. Accordingly, the Board found that it could not rely upon such opinion in adjudicating the Veteran's claim. Furthermore, while she reported that the Veteran had multiple risk factors for hypertension and obesity, she did not identify them. Finally, while the examiner found that the Veteran only gained four pounds during his participation in the Mirtazapine trial, a March 2009 record reflected that he actually gained 7 pounds within the first month. Therefore, the Board remanded the claim in order to obtain another addendum opinion addressing such matters. In this regard, the examiner was also requested to consider the medical treatise evidence from the National Center for Biotechnology Information (NCIB) that suggests a relationship between PTSD and hypertension as cited by the Veteran's representative in his May 2020 Appellant's Post-Remand Brief. Such addendum opinion was obtained in August 2020 and, unfortunately, is also inconclusive. In this regard, the examiner found that the Veteran’s PTSD did not cause or aggravate his hypertension; however, the rationale provided was that (1) no good studies have shown that PTSD caused or aggravated hypertension, and (2) any obesity possibly caused by the Mirtazapine drug trial was not likely to have caused or aggravated hypertension because the Veteran could have lost the weight and, in addition to obesity, race and genetics are other possible causes of hypertension. The Board finds that, once again, this addendum opinion failed to address how the risk factors for hypertension and obesity relate to the specific Veteran in this case and address the medical treatise evidence cited by the Veteran’s representative in May 2020. Furthermore, in January 2021, his new representative provided additional medical treatise, to include “A Review of Posttraumatic Stress Disorder and Obesity: Exploring the Link,” “Know Your Risk Factors for High Blood Pressure,” “Risk for Incident Hypertension Associated with PTSD in Military Veterans, and The Effect of PTSD Treatment,” Stress- and PTSD-associated obesity and metabolic dysfunction: A growing problem requiring further research and novel treatments.” Thus, such should also be considered in the new opinion. The matters are REMANDED for the following action: Forward the record, to include a copy of this remand, to an appropriate VA clinician other than the October 2019 and August 2020 examiners, if possible, for an opinion addressing the etiology of the Veteran’s hypertension. Following a review of the record, the examiner is requested to offer an opinion as to whether it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension is caused or aggravated by his PTSD. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. The examiner should further consider the fact that the Veteran gained weight while participating in a drug trial of Mirtazapine for his PTSD from February 2009 to July 2009, to include a 7 pound weight gain in the first month, and offer an opinion as to (1) whether his PTSD, to include, but not limited to, as due to his participation in the drug trial, caused him to become obese and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his hypertension and (3) whether his hypertension would not have occurred or worsened but for the obesity caused by his service-connected PTSD. In addressing the foregoing, the examiner should specifically address how the risk factors for hypertension and obesity relate to the specific Veteran in this case, and consider the medical treatise evidence cited by the Veteran’s representative in May 2020 and submitted by his representative in January 2021. A rationale for any opinion offered should be provided. If the examiner cannot provide an opinion without resorting to mere speculation, s/he must make clear that s/he has considered all procurable data, but any member of the medical community at large could not provide such an opinion without resorting to speculation. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Breckenridge, 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.