Citation Nr: 21009058 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 10-45 552 DATE: February 18, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities, is denied. FINDING OF FACT The preponderance of probative evidence is against finding that the Veteran’s hypertension had its onset during active service or within the year following discharge, is related to active service, or was caused or aggravated by service-connected disabilities. CONCLUSION OF LAW The criteria to establish entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1983 to November 1986 with additional Army Reserve service, which included active duty from September 1990 to May 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2012, the Board reopened the claim for service connection for hypertension and remanded the matter for further evidentiary development. In an August 2015 decision, the Board denied entitlement to service connection for hypertension, to include as secondary to service-connected disabilities. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claim (Court). In a June 2016 Order, pursuant to a June 2016 Joint Motion for Partial Remand (Joint Motion), the Court vacated the portion of the August 2015 Board decision denying entitlement to service connection for hypertension and returned the matter to the Board for further action consistent with the Joint Motion. In November 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The case was last before the Board in August 2020, the Board remanded the claim for further evidentiary development. 1. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303 (b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Where a veteran served continuously for 90 days or more during a period of active service or during peacetime service after December 31, 1946 and hypertension becomes manifest to a degree of 10 percent within one year from date of termination of 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. 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). A disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran seeks service connection for hypertension, asserting, in essence, that his hypertension began during active service, has been continuous since active service, or, alternatively, was caused or aggravated by his service-connected posttraumatic stress disorder (PTSD), low back disability and radiculopathy of the lower extremities and pain and stress associated with those conditions. In his June 1991 initial claim for service connection for hypertension, the Veteran asserted that he was treated for and diagnosed with hypertension during service. In a June 2009 statement, the Veteran asserted that he had elevated high blood pressure readings during service; that he sought treatment for his low back and was told at that time that his blood pressure was high and that back pain will elevate his blood pressure; and that, after service, he sought treatment for back pain and was immediately prescribed medication to control his blood pressure and has been on medication since. In an October 2010 statement, the Veteran stated that the only medication he was given during service was to address low back pain. During the February 2013 Board hearing, the Veteran additionally stated that he had elevated blood pressure readings while seeking treatment for back pain during service; that he was first diagnosed with hypertension in 2005; that an earlier diagnosis was overlooked during and in the years following service because his elevated blood pressure was attributed to pain related to his other medical conditions, rather than being diagnosed as hypertension; and that after service he did not seek medical treatment for high blood pressure until the early 2000’s because he did not have medical coverage. The Veteran is service-connected for posttraumatic stress disorder (PTSD), degenerative disc disease of the lumbar spine (IVDS) and radiculopathy of the bilateral lower extremities. See May 1994, October 1999 and November 2007 rating decisions. The medical evidence shows a current diagnosis of hypertension. See December 2019 VA examination report and VA treatment records. Thus, the question for the Board is whether the Veteran’s hypertension was incurred in or is related to active service, or caused or aggravated by service-connected disabilities. After reviewing the record, the Board finds that the preponderance of competent and probative evidence is the claim. The Veteran’s service treatment records do not show a diagnosis of hypertension during service. Blood pressure was within normal limits during his October 1992 entrance examination and on examinations in 1983, 1984, 1985, January 1986. Service treatment records in February, April and June 1986 document intermittent, elevated blood pressure readings, some prompting follow-up blood pressure checks. However, none of the treating clinicians diagnosed hypertension and he was not placed on medication. During the Veteran’s September 1986 discharge examination, the Veteran’s blood pressure was within normal limits. While the Veteran noted a history of high/low blood pressure in the accompanying September 1986 report of medical history, the examining clinician specifically noted that a mild increase in blood pressure in 1986 was now normotensive. Two years after the Veteran’s first period of active duty, during a March 1989 reserve reenlistment examination, the Veteran’s blood pressure was recorded at 130/80, which is within normal limits; and the Veteran denied a history of high/low blood pressure on the accompanying report of medical history. At his April 1991 demobilization examination for his second period of active duty, the report of medical history indicates the Veteran reported a history of high blood pressure, that he was ‘informed that [his] blood pressure was high,” and that he was not taking any medication. During examination, his blood pressure was recorded at 138/86, which is within normal limits. Thus, based on the evidence above, the Board concludes that the Veteran’s service treatment records do not show a diagnosis of hypertension or reasonably reflect a chronic hypertensive condition during active service. During a May 1993 VA General Medical examination, the Veteran reported a history of hypertension for the past 8 to 10 years and that he had been taking medication for several years but was not currently taking any medications. The examiner indicated the Veteran’s blood pressure was norma. A January 1997 VA Gulf War examiner diagnosed a history of labile hypertension, untreated, but concluded the Veteran did not currently have hypertension. While the Veteran is competent to report a history of hypertension and prior medication to control it, the Board finds the Veteran’s contention that he was diagnosed with hypertension during service and had continuous symptoms since service is not consistent with the evidence of record and thus, not credible. Hypertension is a clinical diagnosis. The post-service medical evidence does not show a medical diagnosis of hypertension or use of medication for control until approximately 2003-2004, which is more than a decade after active duty discharge. In this regard, a September 2003 VA treatment record notes the use of the medication hydrochlorothiazide; an April 2004 VA treatment record notes a diagnosis of hypertension and prescribed medication for control. The Board finds the medical evidence is more probative as to the presence of hypertension diagnosis and prescribed medication than the Veteran’s reported medical history. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (finding that in weighing credibility, VA may consider inconsistent statements, internal inconsistency, and consistency with other evidence of record). As hypertension was not diagnosed in service or shown within one year of his November 1986 or May 1991 discharges from active duty, competent evidence linking the current hypertension to service or a service-connected disability is needed to establish service connection. On this question, the preponderance of probative evidence is against the claim. With respect to direct service connection, a May 2012 VA opinion weighs against the claim. During the May 2012 VA examination, the examiner diagnosed hypertension and noted continuous medication was prescribed to control the condition. The examiner opined that the currently diagnosed hypertension was less likely than not related to service. He reasoned that a diagnosis of hypertension is associated with a persistent elevation of blood pressure and, while the Veteran’s service treatment records show elevated blood pressure from time to time, it was usually associated with some stress such as pain. The examiner further noted that pain or stress can cause transient elevations in blood pressure but if blood pressure normalizes when the pain resolves, then this is not consistent with a diagnosis of hypertension. The Board finds the May 2012 VA opinion probative and entitled to significant weight. The opinion was based on a thorough review of the medical evidence and medical history, including the service treatment records, and is supported by an articulated rationale for the conclusion reached that is consistent with the evidence. The examiner reviewed and addressed the elevated blood pressure in 1986 but concluded that it was transient and not consistent with a diagnosis of hypertension. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Thus, the opinion is probative and persuasive. There is no positive nexus opinion of record, and the VA treatment records do not suggest an association or link between the Veteran’s current hypertension and service. In the absence of a probative opinion linking the Veteran’s hypertension to active duty service, service connection is not warranted on a direct basis. The preponderance of the evidence is also against the claim for service connection on a secondary basis. VA opinions addressing secondary service connection in June 2012, September 2017, December 2019 and November 2020 weigh against the claim. A June 2012 VA examiner opined that the Veteran’s hypertension was less likely than not caused or aggravated by the service-connected disabilities. He reasoned that the medical literature does not support PTSD or degenerative disease of the spine as the direct cause of hypertension; that the etiology of hypertension in a vast majority of case is unknown; and that, while stress/anxiety and pain may cause transient elevation of blood pressure, it does not cause persistent elevation seen in people diagnosed with hypertension. A September 2017 VA examiner opined that the Veteran’s hypertension was less likely than not caused or aggravated by service-connected disabilities. She reasoned that the current medical literature does not support a direct cause and effect relationship between hypertension and the Veteran’s service-connected PTSD, spine with radiculopathy disabilities, or pain associated with these disabilities. She further reasoned that there is no identifiable cause of high blood pressure; that primary (essential) hypertension tends to develop gradually over many years; and that stress/anxiety is a risk factor for temporary elevation in blood pressure but not for the persistent elevation seen in people who have hypertension. The examiner noted that the Veteran’s blood pressure was controlled with three daily antihypertensive medications, namely hydrochlorothiazide, lisinopril and metoprolol. During examination, blood pressure was recorded at 113/79, 118/84 and 127/87, which is within normal limits. A December 2019 VA examiner opined that the Veteran’s hypertension was less likely than not proximately due to, the result of, or aggravated by the service-connected disabilities. He reasoned that there is no documentation in the medical literature to establish PTSD or IVDS with radiculopathy as a direct cause of, or as an aggravating factor of, hypertension. During the examination, blood pressure was recorded at 149/104, 148/101 and 171/101. A November 2020 VA examiner opined that the Veteran’s hypertension was less likely than not proximately due to, caused by, or aggravated beyond its natural progression by the Veteran’s service-connected PTSD, spine and radiculopathy disabilities. Regarding causation, the examiner reasoned that the pathogenesis of primary hypertension (formerly called “essential” hypertension) is poorly understood but is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function. She identified risk factors for the development of hypertension, including age, obesity, family history, race, reduced nephron, high-sodium diet, excessive alcohol consumption and physical inactivity, and stated that the medical evidence shows that the Veteran has several of these risk factors, notably, advancing age, family history of diabetes mellitus and early coronary artery disease, race, excessive alcohol consumption, tobacco use, physical inactivity, dyslipidemia, diabetes, personal history of coronary artery disease, status-post non-ST-elevation myocardial infarction (STEMI) in August 2013, status-post percutaneous transluminal coronary angioplasty (PTCA) and stent to left internal mammary artery (LAD). The examiner explained that multiple treatment records refer to the Veteran’s repeated noncompliance to lifestyle modifications to treat his high blood pressure, such as weight loss, diet and exercise, and that the Veteran continues to smoke, drink alcohol, is unable to lose weight or control blood sugar, and is non-compliant to medications, appointments and recommendations. Addressing the Veteran’s contention that chronic pain is medically shown to have an effect on blood pressure and that PTSD is a factor, the examiner noted that the Veteran did not cite to a medical reference as the source of the statement. She explained that her review of cited medical literature suggests that, while chronic pain may be associated with an increased risk of hypertension, pain and PTSD are not among the numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function that can lead to atherosclerosis. She concluded that the Veteran has multiple factors that remained uncontrolled even with medication and that these risk factors more likely than not contributed to his hypertension. Regarding aggravation, the examiner opined that his hypertension was less likely than not aggravated beyond its natural progression by stress or the PTSD, spine or radiculopathy disabilities. She reasoned that the Veteran has several risk factors and comorbid conditions that aggravate his hypertension, notably obesity, diabetes, smoking, alcohol use, dyslipidemia and coronary artery disease; that the Veteran’s diabetes is not controlled; that he remains a smoker and alcohol drinker; and that these comorbid conditions negatively impact the control of his blood pressure. She explained that, while the Veteran’s pains due to cervical spondylitis myelopathy with recent repeat surgery (not service-connected) and back pain (service-connected) may contribute to temporarily elevate his blood pressure, the Veteran’s medical treatment records do not show high blood pressure readings that are consistently elevated. She noted that, while the evidence shows some elevated blood pressure readings over the past two years, the majority of the blood pressure readings are within the normal range. She also explained that the Veteran has not been admitted or treated for a hypertensive crisis; his blood pressure medications remain the same; and there is no objective evidence that his blood pressure is consistently elevated or not responsive to his current medications. The Board finds the combined June 2012, September 2017, December 2019 and January 2020 VA opinions are highly probative and entitled to significant weight. The examiners reviewed the record and relevant facts, considered the medical history and medical treatment records, and supported the opinions with a rationale that is consistent with the evidence. See Nieves-Rodriguez, 22 Vet. App. at 304. Taken together, the VA examiner’s opinions establish that the Veteran’s hypertension was less likely than not caused or worsened beyond natural progression by the service-connected PTSD, back and radiculopathy disabilities. Accordingly, the Board finds the combined VA opinions probative and persuasive as to causation and aggravation. The Board acknowledges the evidence submitted by the Veteran to support his contention that his hypertension was caused or aggravated by his service-connected disabilities and the pain and stress associated with those conditions. However, while the December 2008 letter from a VA physician states that the Veteran has chronic cervical and lumbar pain that possibly contributed to the development of his hypertension, this opinion is not afforded high probative weight, as it is conclusory and speculative in nature and does not provide a rationale for the conclusions reached. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (noting that the use of the term “could” without other rationale or supporting data is speculative); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weight against contrary opinions.”). Further, the Board finds the January 2020 article submitted to support the Veteran’s contention that his hypertension is secondary to his PTSD is not persuasive. While the article suggests that individuals with PTSD are more likely to experience various health problems that include heart-related problems and disease, the article is not specific to the Veteran or his medical history, nor does it link the Veteran’s hypertension to his PTSD. See, e.g. Sacks v. West, 11 Vet. App. 314, 316-17 (1998) (holding that a general medical journal article that did not specifically opine as to the causal relationship between the veteran’s condition and active service was too general to satisfy the nexus element of a service connection claim). The Board finds the combined VA medical opinions, which concluded the Veteran’s hypertension was less likely caused or aggravated by his service-connected disabilities are significantly more probative than the December 2008 physician’s statement and January 2020 article submission. Although the Veteran believes his hypertension began during active service or is related to service or a service-connected disability, he has not been shown to have the specialized training sufficient to diagnose hypertension or determine its etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of hypertension, to include whether elevated blood pressure constitutes a diagnosis of hypertension, are matters not capable of lay observation and require medical expertise to determine. See Clyburn, 12 Vet. App. 296, 301 (1999). Thus, the Veteran’s opinion regarding the etiology of his hypertension is not competent medical evidence. The Board finds the opinions of the VA examiners to be significantly more probative than the Veteran’s lay assertions. In sum, the preponderance of competent and probative evidence is against finding that the Veteran’s hypertension began during active service, has been continuous since active service, or is related to service or a service-connected disability or pain or stress associated with those conditions, and the claim is denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of evidence is against the Veteran’s claim, the doctrine does not apply. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. C. Birder 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.