Citation Nr: 21010394 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 18-52 847 DATE: February 24, 2021 ORDER Entitlement to service connection for hypertension, including as secondary to exposure to herbicide agents and/or service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT Hypertension did not initially manifest during or within one year of service and is not otherwise related to service, including the Veteran’s presumed exposure to herbicide agents, or his service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, including as secondary to exposure to herbicide agents and/or service-connected PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1962 to October 1966, including in the Republic of Vietnam during the Vietnam era. His claim comes before the Board of Veterans' Appeals (Board) on appeal of a January 2018 Department of Veterans Affairs (VA) rating decision. The Board remanded this claim to the Agency of Original Jurisdiction (AOJ) in November 2020. Entitlement to service connection for hypertension, including as secondary to exposure to herbicide agents and/or service-connected PTSD The Veteran seeks service connection for hypertension on either a direct basis as related to in-service exposure to herbicide agents, or secondary basis as related to or aggravated by his service-connected PTSD. During his hearing and VA examinations, he reported that he first had elevated blood pressure readings in 2017 (three months prior to November 2017), which correspond to the time period his PTSD symptoms began to worsen, supporting his assertion that the hypertension is attributable to his PTSD. The Veteran argues that, according to his VA doctor, although he had risk factors for developing hypertension, PTSD, which include symptoms of depression and anxiety, was the main factor in its development. The Veteran further argues that his exposure to Agent Orange increased his chances for developing hypertension. He contends that obesity, a risk factor for hypertension, also plays a role in the etiology of this disability. He argues that, although obesity is not eligible for service connection, it may be viewed as an intermediate step between a service-connected disability and another disability, allowing for secondary service connection for hypertension under 38 C.F.R. § 3.310(a) and VAOGCPREC 1-2017 (Jan. 6, 2017). The Veteran testified that, in November 2017, Dr. E. Miller submitted an opinion that PTSD made it difficult for him to manage his hypertension. He testified that his psychologist and psychiatric too told him a relationship exists between his PTSD and hypertension, but that because they were not medical doctors, they could not submit letters to this effect. When queried regarding the ways in which PTSD-related anxiety and depression worsen his hypertension, the Veteran responded that fireworks and feeling confined in a crowd made him nervous and caused his blood pressure to rise sky high. He testified that a nurse his son was dating was at his house on July 4th, when fireworks went off, and her testing revealed high blood pressure; he planned to ask her for a statement to this effect after the hearing ended. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted on a secondary basis, for disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. For cardiovascular-renal disease, which includes hypertension, service connection may be presumed when the condition is shown to a degree of 10 percent or more within one year of discharge from active duty. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In some circumstances, service connection may also be presumed for disability resulting from exposure to an herbicide agent. In such a case, a veteran must have had active military, naval, or air service in the Republic of Vietnam during the Vietnam era. He or she will be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence establishing otherwise. 38 C.F.R. § 1116(f). If a veteran was exposed to an herbicide agent, certain diseases listed at 38 C.F.R. § 3.309(e) shall be service connected, provided additional criteria are met, even though there is no record of such disease during service. 38 C.F.R. § 3.307(a)(6)(ii). Hypertension is not included in the list of diseases acknowledged to be presumptively related to exposure to herbicide agents; however, this fact does not preclude a veteran from presenting evidence that this disability resulted from such exposure. See Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994). Based on the Veteran’s active service in Vietnam, he is presumed to have been exposed to herbicide agents while there. He is currently service connected for PTSD. The questions for the Board are therefore whether the Veteran has hypertension that began during or within a year of service, and, if not, whether such disability is at least as likely as not related to an in-service injury, event, or disease, to include the herbicide agent exposure, or his service-connected PTSD. For the reasons that follow, the Board concludes that, while the Veteran currently has hypertension, the preponderance of the evidence weighs against finding that this disability initially manifested during or within a year of service or is otherwise related to service, including the herbicide agent exposure, or the service-connected PTSD. The Veteran was first diagnosed with hypertension in 2017, decades after his discharge from service. Multiple medical professionals have addressed the etiology of this disability. In November 2017, E. Miller, R.N., to whom the Veteran referred early on in this appeal (mistakenly as a doctor), submitted a letter for the purpose of documenting “the significant health conditions which impair activities” of the Veteran. She noted that she had been the Veteran’s primary VA care provider for the last year. She indicated that the Veteran had a history of PTSD, which made it difficult to manage his hypertension. Given the nature of PTSD, it might very well interfere with the Veteran’s ability to function in certain activities of daily living, including managing his medical conditions. However, as Ms. Miller did not elaborate on the effect of this interference or provide rationale for her statement, the Board accords this statement limited probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that factually accurate, fully articulated, sound reasoning for a conclusion contributes probative value to a medical opinion). In December 2017, based on a VA examination, an examiner found the Veteran’s hypertension less likely than not proximately due to or the result of his service-connected PTSD. The examiner based this opinion on the following facts: (1) The Veteran was diagnosed with hypertension in November 2017, three months prior to which he had elevated blood pressure (2) He recently experienced an increase in his PTSD symptoms; (3) Although he attributed his hypertension to the PTSD, he has multiple risk factors that may contribute to such a diagnosis, including degenerative arthritis/osteoarthritis with painful joints, obesity, anxiety, depression, adjustment disorder with depressed mood and chronic PTSD. He concluded that there was no evidence that the PTSD, alone, caused the hypertension. The Board accords this opinion limited probative value. The first question in this case is whether the hypertension is at least as likely as not (50 percent or greater probability) related to the Veteran’s service, including the exposure to herbicide agents, which this examiner did not address. The second question is whether the PTSD caused or aggravated the hypertension, not whether and to what extent it contributed to the PTSD, the matter on which the examiner focused. In light of the inadequacy of the previous two opinions, the Board remanded this claim to the AOJ in November 2020 for another opinion, which a different VA examiner provided in December 2020, considering all theories of entitlement. Considering the claim on a direct basis, she opined that the Veteran’s hypertension is not at least as likely as not related to in-service herbicide agent exposure and less likely than not proximately due to, the result of, or aggravated by, his PTSD. She based this on a finding that hypertension is not presumed to be associated with gent Orange, and available evidence does not support such an association. Considering the claim on a secondary basis, she opined that, although a mental health condition such as PTSD may play a role in elevated blood pressure, in the Veteran’s case, it does not outweigh the collective effect of his other risk factors for developing hypertension. She considered Ms. Miller’s statement but discounted it on the basis that it did not include rationale. She also considered treatment records showing that the Veteran had multiple risk factors for developing hypertension, including poor dietary and exercise habits (6 to 8 caffeinated beverages daily), high ethanol alcohol intake, chronically obese body habitus, and chronic low back pain, status post multiple corticosteroid injections. She also considered the Veteran’s assertions, explaining that, although a specific trigger like fireworks or a caffeinated beverage might cause a momentary elevation in blood pressure, it would not result in an overall worsening of chronic hypertension. As this opinion is based on a review of the record and the Veteran’s assertions and supported by rationale, the Board accords it great probative value. The Veteran has not submitted a medical opinion refuting it or otherwise addressing the etiology of his hypertension, and his assertions, not based on any medical training or expertise, may not be considered competent evidence of a nexus in this case. The facts are complex, involving the interaction between the Veteran’s cardiovascular system and mental health. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n.4 (Fed. Cir. 2007). The Board acknowledges the Veteran’s assertions that his hypertension diagnosis corresponded to the worsening of his PTSD; however, no medical professional has found this fact significant in terms of the etiology of the hypertension. Instead, the most competent evidence establishes that, in terms of etiology, the Veteran’s other risk factors for developing hypertension outweighed the risks of his PTSD and its symptoms. The Board also acknowledges the Veteran’s assertion that his Agent Orange exposure increased his chances for developing hypertension, but the December 2020 VA examiner did not agree. The Board provided the Veteran time to submit such an opinion on his own initiative, but no such opinion has been received. The Board is thus constrained to decide this claim based on the evidence now of record, which unfortunately includes an unfavorable nexus opinion. The Veteran also argues that he is entitled to service connection for hypertension based on his obesity being an intermediate step between a service-connected disability and a current disability under 38 C.F.R. § 3.310(a) and VAOGCPREC 1-2017. However, this argument fails. To prevail here based on this theory of entitlement, the evidence must show that the service-connected PTSD caused the Veteran to become obese. There is nothing of record indicating that this is the case, and, for the same reasons noted above, the Veteran is not competent to provide an opinion on the matter. In any event, his assertion to this effect conflicts with statements he made for purposes of treatment during the course of this appeal. When queried regarding his obesity, he specifically indicated that he was watching his diet but was unable to exercise due to his back issues. As the Veteran’s hypertension did not initially manifest during or within a year of service, and there is no competent evidence of record otherwise relating it to service or a service-connected disability, the criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L.N. 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.