Citation Nr: 21013155 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 14-17 483 DATE: March 8, 2021 ORDER Entitlement to service connection for hypertension is granted. FINDING OF FACT Resolving reasonable doubt in favor of the Veteran, his hypertension is related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from September 1981 to September 1984 and from March 1986 to March 2003. This matter comes to the Board of Veterans’ Appeals on appeal from a July 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in February 2018 and May 2019. In the February 2018 Board decision, this matter was remanded to the RO for further development. In the May 2019 Board decision, the Board denied service connection for hypertension. The Veteran appealed the Board’s May 2019 decision to the United States Court of Appeals for Veterans Claims (CAVC). In a June 2020 Memorandum Decision, CAVC vacated the May 2019 Board denial of service connection for hypertension and remanded for further proceedings consistent with the directives in the Memorandum Decision. Specifically, CAVC found that the Board’s reasons or bases for relying on an August 2018 VA medical opinion was inadequate in denying the Veteran service connection for hypertension. The February 2018 remand, and in the recitation of the facts in the decision on appeal, the Veteran’s service treatment records reflected “an elevated blood pressure reading of 140/100” in March 1995. However, the August 2018 VA examiner’s opinion found “no evidence of hypertension range blood pressure readings during active service.” Considering the VA’s definition of hypertension, the Board’s statement of reasons or bases is inadequate because it did not reconcile the evidence that it cited of an in-service diastolic blood pressure reading of 100 with the examiner’s finding, or explain why the examination report was responsive to the February 2018 remand and adequate to permit the Board to make an informed decision. Service Connection Service connection may be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a causal relationship between the two. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Consistent with this framework, 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). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease, such as hypertension, is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a), which include hypertension. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Blood pressure (BP) is measured in millimeters of mercury (mm Hg) and is written systolic over diastolic (for example 120/80 mm Hg). For VA purposes, “hypertension” means that diastolic blood pressure is predominately 90 mm Hg or greater or systolic blood pressure is predominately 160 or greater. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Entitlement to service connection for hypertension The Veteran contends he is entitled to service connection for hypertension due to his “Stage 1” hypertension reading of 140/100 during service, and his current treatment for hypertension. See Notice of Disagreement, December 2011. Hypertension is considered a chronic disease for VA purposes. 38 C.F.R. § 3.309(a), 4.104. The Board finds that service connection is warranted based on continuity of the Veteran’s symptoms (high blood pressure). 38 C.F.R. § 3.303(b). Service treatment records (STRs) reflect numerous in-service blood pressure readings. Notably, on a few occasions, the Veteran’s diastolic blood pressure was near or at 90 mm Hg. For instance, an STR dated December 1999 shows a blood pressure reading of 138/88 mm Hg and an undated STR shows a reading of 134/89 mm Hg. During an episode of acute gastroenteritis, an STR dated March 1995 shows a reading of 140/100 mm Hg, which meets the VA’s hypertension definition. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Although a single elevated blood pressure reading cannot be used to establish a hypertension diagnosis, it is sufficient to show a symptom, namely elevated blood pressure, possibly associated with hypertension. In other words, a hypertension symptom was “noted” during service for 38 C.F.R. § 3.303(b) purposes. See also 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Sixteen months post-service, in July 2004, the Veteran’s blood pressure was measured at 145/96 and he was diagnosed with elevated blood pressure. Upon seeking private treatment in October 2004, the provider described him as having hypertension. An August 2006 VA medical record shows the Veteran was diagnosed with hypertension in July 2004. Additional post-service records show the Veteran’s recorded blood pressure readings fluctuated, with diastolic pressure being recorded at 90 or above on numerous occasions. For example, August 2005 he had a sitting BP reading of 144/94 and a repeat reading of 141/102; January 2007 he had a BP reading of 132/94; February 2007 he had a BP reading of 135/93; September 2007 he had a BP reading of 160/98; March 2008 he had a BP reading of 112/90; September 2008 he had a BP reading of 134/96 and a manual re-check reading of 134/87; January 2009 he had a BP reading of 123/90; June 2009 he had a BP reading of 122/92; July 2009 he had a BP reading of 120/90; March 2010 he had a BP reading of 130/96; September 2012 he had a BP reading of 123/89; and December 2014 he had a BP reading of 130/87. In an August 2015 medical record, the Veteran presented with a chief complaint of high blood pressure. It was noted his blood pressure was controlled by 40mg tablets of Lisinopril daily and he was regularly monitored. His blood pressure was recorded as 135/86. During his August 2018 VA Compensation and Pension examination, his blood pressure was taken three times, with readings of 158/104, 154/104, and 154/102. More contemporaneous medical records show elevated readings, including a February 2020 reading of 146/93 and a November 2020 reading of 144/91. The above evidence shows that elevated blood pressure was noted both during service and shortly thereafter. The current medical evidence confirms a current hypertension diagnosis. The remaining issue is nexus. As explained below, the Board finds the evidence regarding a continuity of symptomatology nexus for hypertension to be evenly balanced. By resolving reasonable doubt in the Veteran’s favor, a nexus is shown and service connection for hypertension is granted. The Veteran asserts a continuity of symptomatology for hypertension. In his December 2011 Notice of Disagreement (NOD), he reported having an elevated reading during service and is currently receiving treatment through the VA. He is competent to report his medical history for hypertension. Contemporaneous VA treatment records confirm that hypertension was listed as a current problem for the Veteran. These reports are sufficient to show a symptom of a chronic disease in service and continuity of symptomatology for hypertension after service. 38 C.F.R. § 3.303(b), 3.309(a). The Board acknowledges the negative opinion provided by the August 2018 VA examiner, to include the medical opinion reflecting that the Veteran’s current hypertension is not related to service. However, CAVC found this opinion inadequate, as it was based on evidence that was contrary to the record. Additionally, the Veteran asserts that he had high and/or elevated blood pressure in service and has been treated for high blood pressure ever since service. As noted above, service connection may be shown by evidence of the existence of a chronic disease in service and present manifestations of the same chronic disease. 38 C.F.R. § 3.303(b). In this case, hypertension is an enumerated chronic disease under 38 C.F.R. § 3.309(a), and as explained above, the Veteran has competently and credibly reported continuity of high blood pressure treatment since service. See Walker, 708 F.3d at 1331; Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Thus, the Board assigns probative value to the Veteran’s lay statements that are confirmed by the medical evidence. Given the STRs showing elevated blood pressure in service, the Veteran’s competent and credible lay statements that his symptoms have continued since service, and his current diagnosis, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s hypertension had its onset in service. Thus, resolving all reasonable doubt in his favor, the Board finds that service connection for hypertension is warranted on the basis of continuity of symptomatology for a chronic disease. 38 U.S.C. § 5107. Accordingly, the claim is granted. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Krista Johnson, 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.