Citation Nr: 21012681 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-41 067 DATE: March 4, 2021 ORDER Service connection for hypertensive vascular disease or hypertension, to include as secondary to type II diabetes mellitus or coronary artery disease, is denied. VETERAN’S CONTENTIONS The Veteran contends that he developed hypertensive vascular disease (or hypertension) secondary to his service-connected type II diabetes mellitus or coronary artery disease. Alternately, the Veteran contends that he developed hypertensive vascular disease (or hypertension) as a result of in-service exposure to herbicide agents including Agent Orange. FINDING OF FACT Neither hypertension nor hypertensive vascular disease were shown in service or for many years thereafter and are not otherwise related to service, to include exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for hypertensive vascular disease (and hypertension) are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to April 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Jurisdiction is currently with the RO in Philadelphia, Pennsylvania. This claim was previously before the Board at which times it was remanded for further development. Entitlement to service connection for hypertensive vascular disease (and hypertension), to include as secondary to type II diabetes mellitus or coronary artery disease Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may also be granted through the application of statutory presumptions for chronic conditions. See 38 U.S.C. §§ 1101 (3), 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303 (b), 3.307(a)(3), 3.309(a). Cardiovascular-renal disease is classified as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) also applies. 38 C.F.R. § 3.307; Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Presumptive service connection for "chronic diseases" must be considered on three bases: chronicity during service, continuity of symptomatology since service, and manifestations within one year of the claimant's separation from service. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1336-38. The application of these presumptions operates to satisfy the "in-service incurrence or aggravation" element and establish a nexus between service and a current disability, which must be found before entitlement to service connection can be granted. Further, service connection may be established on a secondary basis for a disability which was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). Here, in addressing the criterion of a current disability, a November 2020 VA examination confirmed a current diagnosis of hypertension. See November 2020 Hypertension Examination Report. In addressing in-service incurrence, as noted above, the Veteran has alleged that he has hypertensive vascular disease as a result of in-service exposures to herbicides, including Agent Orange. In a July 2019 Board decision, the Board found that the Veteran’s duties while stationed in Thailand brought him near the base perimeter of Nakhon Phanom Royal Thai Air Force Base on a regular basis and, therefore, he was presumed to have been exposed to herbicides. Thus, element two is met as to in-service herbicide exposure. The Veteran's service treatment records (STRs), however, are void of diagnosis of or treatment for any heart disease, including hypertension. In addressing nexus, to the extent that the Veteran has stated that he has hypertensive vascular disease or hypertension attributable to service, the Board finds that he is competent to report on his symptoms and that of which he has personal knowledge, but he is not competent to provide an opinion as to the etiology of his disability because such a question is not answerable by the application of knowledge within the realm of a lay person. See Layno, 6 Vet. App. at 469-70; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, because the etiology of hypertensive vascular disease may be multifactorial, and he lacks the requisite expertise, he is not competent to offer an opinion as to a relationship to service. The evidence of record otherwise includes an August 2019 VA opinion that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran reported that he was not diagnosed with hypertension until the mid to late 1980s and he denied knowledge of sustained blood pressure problems during service, suggesting that the condition was not related to service. The examiner further reasoned that the Veteran's STRs documented a mildly elevated blood pressure reading of 138/78 on February 10, 1970, however, this reading was insufficient to diagnose hypertension at that time or to establish nexus for currently claimed hypertension. The examiner also opined that the claimed condition was less likely than not approximately due to or the result of the Veteran's service-connected diabetes mellitus and coronary artery disease. The examiner reasoned that although the Veteran was a poor historian, it is clear from his medical records and personal history that his hypertension predated his diabetes by several years. As such, it would be inaccurate to state that his diabetes condition could have led to or contributed to the onset of his hypertension. In addressing aggravation, the examiner opined that it was less likely than not that the Veteran's hypertension was aggravated beyond normal progression by the onset of his diabetes mellitus. The examiner reasoned that there was no clear evidence of a sustained increase in the Veteran's blood pressure following his diabetes diagnosis in September 2005, with multiple clinical notes from Dr. Lawrence to reference and compare in that time period. Blood pressure fluctuations during that time period were generally modest and could be explained by his evolving antihypertensive regimen and PCI or stenting procedures. The examiner acknowledged that there was a possible tertiary relationship of the Veteran's hypertension being worsened by his stage three chronic kidney disease that was being exacerbated by his service-connected diabetes mellitus. However, the examiner indicated that this explanation would have to be subject to extensive speculation as this chronology is not established and the Veteran's hypertension is diagnosed as primary and not renovascular in etiology. Again, the record would not support the claim that the Veteran’s blood pressure was clearly elevated by aggravation. The examiner additionally opined that it was less likely than not that the Veteran's hypertension was related to his coronary artery disease. The examiner reasoned that as with his diabetes, there was no clear evidence of significant or sustained blood pressure elevations following the diagnosis of coronary artery disease in 2002. In fact, the cardiovascular interventions and more intensive care may have aided in stabilizing his cardiovascular status following cardiac revascularizations and ablation for atrial fibrillation. Furthermore, any influence of diabetes, coronary artery disease, or kidney disease could conceivably be masked by the presence of the Veteran's evolving antihypertensive regimen, such that to opine on the impact of each discrete condition would be largely if not entirely speculative. In February 2020 the Board remanded the Veteran's claim for an addendum opinion addressing direct service connection, including exposure to herbicides, and an April 2020 VA examiner opined that it was less likely than not that the Veteran's currently claimed hypertensive disease/hypertension was caused by his active service or his exposure to herbicide agents. The examiner reasoned that during the original encounter with the Veteran in August 2019, he reported that he was not formally diagnosed with hypertension until the mid-1980s and denied knowledge of any sustained or chronically elevated blood pressures during active service. Regarding the 2018 statement by the National Academy of Science, the relationship between hypertension and herbicide exposure, and the general consensus is that there is "sufficient evidence" to suggest an association. However, there does not appear to be a mechanism of action or degree of causality that is explicitly included and so the examiner indicated that his opinion would not deviate from the list of diseases linked to Agent Orange exposure as approved by the VA. In September 2020 the Board remanded the Veteran’s claim for an addendum opinion addressing herbicide exposure and aggravation by coronary artery disease and a November 2020 VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that hypertension is well-known to be idiopathic in 95% of cases. This indicates that the cause of hypertension is unknown and unable to be determined in 95% of cases. In other cases of secondary hypertension, there is a well-known etiology such as renal disease, renal artery stenosis, hormonal problems etc. There is no indication in medical records that the Veteran has a secondary cause of hypertension therefore he has primary hypertension. He is only on two medications for hypertension control and his hypertension is well controlled with just these two medications. Therefore, the Veteran’s hypertension is primary in nature, and its clinical onset occurred well beyond service years. The examiner also opined that the claimed condition was less likely than not aggravated beyond its natural progression by service-connected coronary artery disease. The examiner reasoned that aggravation does not appear to have occurred because the Veteran’s blood pressure today is well controlled on only two blood pressure medications. Many people with aggravated blood pressure may require four or more medications, and even with those medications their blood pressure may still be high. This is not the case for this Veteran. Therefore, his hypertension likely has not been aggravated beyond its natural progression. In a January 2021 addendum opinion requested by the RO, an examiner opined that the Veteran’s hypertension was less likely than not related to Agent Orange exposure during service. The examiner reasoned that there was no clear evidence in the Veteran’s records that hypertension was caused by Agent Orange. There was no clear evidence in current medical knowledge that Agent Orange predisposed the Veteran to hypertension more than many other well-known factors do. It has been common medical knowledge for many years that factors such as poor diet, increased sodium chloride intake, lack of physical exercise, physical or psychological stress, obesity, tobacco use, inadequate sleep, normal aging, and many other factors predispose individuals to hypertension. Therefore, it is far more likely that any combination of these factors is more likely than not to have contributed to the Veteran’s development of hypertension and it is less likely than not that the Veteran’s hypertension is related to Agent Orange exposure. The Board finds the August 2019, April 2020, November 2020, and January 2021 VA examiner opinions to be highly probative. The opinions were based on a review of the claims file, relevant facts, and peer reviewed medical literature, and the examiners provided a detailed rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no competent evidence to the contrary. In sum, without any competent evidence that the Veteran has hypertensive vascular disease related to service, direct service connection is not warranted. Additionally, there is no indication that the condition manifested within one year of service. The Board finds that the Veteran's hypertensive vascular disease did not have its clinical onset in service, or within one year of his discharge from active service and is not otherwise related to a period of active service; therefore, service connection is not warranted. There is no doubt to be resolved in this case. 38 U.S.C. § 5107. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith-Jennings, 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.