Citation Nr: 21013375 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 15-36 711 DATE: March 9, 2021 REMANDED 1. Entitlement to service connection for a cardiovascular disability, including biatrial enlargement, LVH, and hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. 2. Entitlement to service connection for a gastrointestinal disability, including gastroesophageal reflux disease (GERD), to include as secondary to service-connected PTSD, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1983 to March 1985. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in which the RO, inter alia, denied service connection for cardiovascular and gastrointestinal disabilities. The Veteran disagreed with those denials and perfected an appeal to the Board, The instant matters were then previously before the Board in January 2020 at which time they were remanded for further development. Upon completion of the requested development, the agency of original jurisdiction (AOJ) issued a November 2020 supplemental statement of the case (SSOC) in which it continued to deny service connection for cardiovascular and gastrointestinal disabilities. The Board’s remand instructions were not substantially complied with and therefore must be remanded to complete the necessary development. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the examiner’s failed to address the lay statements that the Veteran’s medication to treat PTSD and its attendant symptomatology caused the Veteran’s obesity which is identified in every examination as a primary risk factor for her cardiovascular and gastrointestinal disabilities. In the instant case, the Veteran has asserted that she has cardiovascular and gastrointestinal disabilities that are etiologically related to service or to her service-connected PTSD. She has stated that her cardiovascular and gastrointestinal symptoms in service and has asserted her belief that her disabilities were caused or worsened by her service-connected PTSD, to include medication taken therefore. Specifically, with regard to her PTSD medication, the Veteran has asserted a belief that medications prescribed to treat her PTSD contributed to her weight gain and obesity that, in turn, contributed to her cardiovascular and gastrointestinal disabilities. A review of the record shows that the Veteran was afforded a VA examination in May 2019, the report of which was found to be inadequate by the Board in its January 2020 remand action. The Veteran was then afforded VA heart and esophageal examinations in March and September 2020, the reports of which reveal diagnoses of hypertension, biatrial enlargement, LVH, and GERD. The examining clinician opined that the Veteran’s cardiovascular disease is less likely than not proximately due to or the result of her service-connected PTSD. The clinician also opined that it is less likely than not that the Veteran’s GERD is secondary to her PTSD. In April 2020, another VA clinician reviewed the claims file an opined that it is less likely than not the Veteran’s GERD was caused by or worsened by her service-connected PTSD. In September 2020, yet another VA clinician offered an opinion in connection with the Veteran’s claims, opining that the Veteran’s cardiovascular disease is less likely than not proximately due to or the result of her service-connected PTSD. The clinician stated that “psychological conditions including PTSD are note documents to have any permanent effects on [the physiological determinants of blood pressure] and so would not cause or aggravate high blood pressure.” In November 2020, the clinician offered another opinion, reiterating the previous opinion, but stressing aggravation. Upon review of these examination and opinion reports, the Board finds that they are inadequate to rely upon. Notably, the examiners identify obesity as the primary risk factor for the Veteran’s cardiovascular disability. See 2020 VA Examination (identifying Veteran’s obesity as one of the primary risk factors for the Veteran’s hypertension); March 2020 VA Examination (reciting the Veteran’s “primary risk factor is obesity” and that the “Veteran’s heart disease is directly related to essential hypertension”); May 2019 VA Examination (Risk factors for essential hypertension include obesity, sedentary lifestyle). Similarly, for GERD, the March 2020 VA examiner found that it is commonly seen with obesity, and some medications. However, none of the examiners opined on whether there is a link between the medications used to treat the Veteran’s service-connected PTSD and the Veteran’s obesity, which all of the reports attribute as a primary risk factor for each claimed disability. In this regard, the Board notes that VA’s Office of General Counsel has issued a precedential opinion addressing questions regarding whether obesity may be considered a “disease” for the purposes of service connection under U.S.C. §§ 1110 and 1131. In general, VAOPGCPREC 1-2017 concludes that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct basis. Similarly, obesity is not a “disability” for the purposes of secondary service connection under 38 C.F.R. § 3.310. However, VAOPGCPREC 1-2017 recognizes that obesity may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). When considering obesity as an intermediate step for secondary service connection, “side effects of medication where the medication is prescribed for a service-connected disability” and “lay statements by a veteran attributing weight gain or obesity to the service-connected disability” are two of the factors to be considered. See Garner v. Tran, No. 18-5865 (Vet. App., Jan. 26, 2021). In the instant case, the Veteran’s medical records do list the Veteran as being obese. Accordingly, given the Veteran’s argument raised as part of the current appeal, the Board finds that the matters must be remanded for development and consideration of this theory of entitlement. The Board notes also that medical literature suggests a potential association between PTSD and hypertension. See e.g., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141329/ (providing that “[p]ersons with PTSD have also been reported to be more likely to have hypertension”). Indeed, several studies referenced on VA’s website suggest some association between PTSD and the development of cardiovascular disease. Although this research may not “show a clear cause-and-effect relationship,” it is indicated that “‘[o]verall, the evidence to date seems to point in the direction of a causal relationship.’” https://www.research.va.gov/currents/spring2015/spring2015-8.cfm; see https://www.ptsd.va.gov/professional/newsletters/research-quarterly/V28N1.pdf; https://www.research.va.gov/currents/spring2014/spring2014-1.cfm. This undercuts the VA clinician’s opinion that PTSD does not cause or aggravate hypertension. Accordingly, in light of the arguments raised during the pendency of the appeal and in consideration of evidence of record, the Board finds that on remand, the agency of original jurisdiction (AOJ) should arrange to obtain medical opinions regarding the likelihood that the Veteran’s service-connected PTSD caused or aggravated the her GERD and/or hypertension, to include consideration of the theory that medication taken for the Veteran’s service-connected PTSD caused or contributed to her obesity which in turn caused or aggravated his GERD and/or hypertension. With regard to any opinion obtained concerning the likelihood that the Veteran’s PTSD caused or aggravated her hypertension, the clinician must include consideration and discussion on the evidence outlined above that is published on VA’s own website. The matters are REMANDED for the following action: 1. Arrange for review of the Veteran’s claims file by an appropriate clinician. Upon review of the claims file, the designated clinician should render an opinion as to whether it is at least as likely as not (a 50 percent or greater possibility) that: A. the Veteran’s GERD was caused OR is or has been aggravated (worsened beyond natural progression) by the Veteran’s PTSD; and B. the Veteran’s hypertension, or other diagnosed cardiovascular disease (to include biatrial enlargement) was caused OR is or has been aggravated (worsened beyond natural progression) by the Veteran’s PTSD. The clinician should offer separate opinions for the Veteran’s diagnosed gastrointestinal and cardiovascular disabilities. Also for each claimed disability the physician must address both causation and aggravation. Complete, clearly-stated rationale for the conclusions reached must be provided. The clinician is reminded that merely stating that it is his or her opinion that a condition was not caused or aggravated by a service-connected disability is not sufficient. An explanation is required that takes into account the record and pertinent medical principles and the clinician’s rationale should include citation to pertinent evidence and/or medical principles relied upon to form the opinion. The clinician must also specifically consider and discuss the published literature identified above that suggests, at a minimum, that persons with PTSD are at an increased risk for the development of heart disease than those without PTSD. The clinician must also render an opinion regarding the likelihood that the Veteran’s PTSD, to include any medication prescribed for the treatment thereof, caused or contributed to the Veteran’s obesity. If such a link is determined, the physician should then render an opinion as to whether it is at least as likely as not that the Veteran’s obesity caused or aggravated his and/or hypertension, or any other diagnosed cardiovascular or gastrointestinal disability. 2. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the claims on appeal, considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority. KRISTIN E. NEILSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Boushehri, Darjush M. 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.