Citation Nr: 21009184 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 15-43 410 DATE: February 19, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for heart disease is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1984 to December 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This appeal has been advanced on docket pursuant to 38 C.F.R. § 20.900 (c); 38 U.S.C. § 7107 (a)(2). The Veteran’s claims were previously remanded by the Board in a July 2020 decision. The Board finds that the RO has substantially complied with the July 2020 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for hypertension is remanded. The Board previously remanded this case in a July 2020 decision for further development. Specifically, the Board directed that the RO obtain an addendum opinion. In its remand, the Board noted that a November 2009 VA examiner did not address a January 1993 VA examination that indicated the Veteran continued to have elevated blood pressure readings shortly after service. The Veteran was afforded a VA examination in November 2020. The examiner provided two inconsistent opinions. The first opinion indicated, “the Veteran’s claimed condition of hypertension was less likely than not (less than 50 percent probability) incurred in or caused by the hypertension during service as during service Veteran was not diagnosed with hypertension.” The second opinion indicated that it was less likely than not that “the Veteran’s condition incurred in or caused during active service, manifested within one year of discharge from active service, noted during service with continuity of the same symptomatology since active service, or is related to an in-service injury, event, or disease.” As such, it is unclear whether the examiner opined that the Veteran did, in fact, have hypertension during service. As such, the opinion is inadequate. The Board further notes that the VA examiner cited to the 2017 ACC/AHA High Blood Pressure Guidelines as rationale for his opinion. The VA examiner indicated that the Veteran’s in-service blood pressure readings were consistent with pre-hypertension. However, the 2017 ACC/AHA High Blood Pressure Guidelines no longer include pre-hypertension. Instead, the ACC/AHA High Blood Pressure Guidelines define Stage I hypertension as systolic between 130-139 or diastolic between 80-89 and Stage 2 hypertension as systolic at least 140 or diastolic at least 90 mm Hg. The Veteran’s September 1991 service treatment notes show a diagnosis of elevated blood pressure with readings of 130/98, 130/88, 144/98, and 136/92. As such, it appears that the Veteran’s elevated blood pressure readings were consistent with Stage 1 hypertension under the 2017 ACC/AHA High Blood Pressure Guidelines. The Board also notes that hypertension for VA purposes is defined as the “diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm.” 38 C.F.R. § 4.104. Additionally, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As such, the opinion is inadequate as it is internally inconsistent. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). An addendum opinion is required to resolve the above issues. 2. Entitlement to service connection for heart disease is remanded. Finally, because a decision on the remanded issue of service connection for hypertension could significantly impact a decision on the issue service connection for heart disease, the issues are inextricably intertwined. A remand of the claims for service connection for heart disease is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to the Veteran’s diagnosis of an elevated blood pressure during service. Further, provided is it at least as likely as not that the Veteran’s hypertension (1) began during active service, (2) manifested within 1 year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran’s description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of secondary service connection for heart disease. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. Taylor, 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.