Citation Nr: 21014947 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 13-31 425 DATE: March 16, 2021 REMANDED Entitlement to service connection for hypertension (HTN), to include as secondary to acquired psychiatric disorder, posttraumatic stress disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1969 to September 1971, with combat service in the Republic of Vietnam (RVN), receiving the National Defense Service Medal, Vietnam Service and Campaign medals. See DD 214. This matter was last before the Board in December 2020, at which time the Board remanded the matter for a new examination to determine the nature and etiology of his hypertension, to include as due to in-service exposure to herbicide agents, whether the HTN manifested to a compensable degree within a year after discharge from service or was continuous since service, and whether the Veteran’s HTN was caused or aggravated beyond its natural progression by his service-connected PTSD, an acquired psychiatric disorder. See December 2020 Board remand. The examiner was asked to address the studies provided by the Veteran in the October 2019 Brief. In January 2021, the Veteran was afforded a new VA examination. The Veteran testified at a February 2016 Board hearing. A transcript of that hearing is part of the record. The Board finds that for the reasons listed below the Veteran’s claim needs to be remanded for an addendum opinion that adequately addresses the nature and etiology of his HTN, as well as claim for aggravation. In the January 2021, the Veteran was afforded a new examination regarding his HTN. The examiner was to address the competent textual evidence submitted by the Veteran that support a nexus to service. See December 2020 Board remand, pgs. 2-3. The Veteran submitted eight published medical journal articles that support a relation between PTSD and HTN, one of which was Elevated basal levels of cardiovascular responses in Vietnam veterans with PTSD: A health problem in the making? Journal of Anxiety Disorders, Volume 4, Issue 3 (1990) (finding Veterans with combat-related PTSD have consistently higher blood pressure). While the Board finds that the evidence is not controlling, it is probative of a claim that his HTN is secondary to his service-connected PTSD. See Wise v. Shinseki, 26 Vet. App. 517, 531-32 (2014) (citing Caluza v. Brown, 7 Vet. App. 498. 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996); 38 C.F.R. 159(a)(1) (“statements conveying sound medical principles found in medical treatises” is competent medical evidence that the Board is required to address.). However, it appears that this evidence was not addressed by the January 2021 examiner except to provide a list of online links to learned treatise online addresses. The examiner did not explain how these articles compare to the articles submitted by the Veteran. Second, the VA examiner was to opine whether the Veteran’s HTN was caused by herbicide exposure but did not provide a clear rationale regarding herbicide exposure aggravation. The examiner opined that HTN is multifactorial to age, sex, obesity, family history, underlying disease and drugs. The examiner stated that HTN can be caused by herbicide exposure but added yet it is difficult to conclude the Veteran’s HTN is due to herbicide exposure 41 years ago and not due to his long history of drug abuse. It is unclear how much weight the examiner gave to the herbicide exposure versus the other factors of smoking, drinking and drugs which can cause and aggravate pre-existing hypertension. Furthermore, the examiner noted that it is unclear when the Veteran’s hypertension began. See January 2021 VA examination opinion, pg.3 (indicating that the date of the initial HTN diagnosis is unknown). Whereas, the Veteran testified that he felt symptoms of elevated blood pressure while in service, and after service, such as headaches. See February 2016 Board hearing transcript. The examiner did not address that the Veteran’s hypertension may have predated any other risk factors he highlighted. Finally, regarding aggravation by a service-connected disability, the VA examiner provided a conclusory statement that the Veteran’s HTN was not caused by or aggravated beyond its natural progression (increased in service) by a service-connected disability to include his service-connected PTSD, an acquired psychiatric disorder. The conclusion does not address causation or aggravation of a service-connected disability. The examiner also indicated that studies also state that neither the prospective relationship of PTSD to incident hypertension risk, nor the effect of PTSD treatment on HTN risk has been established. This appears to address causation rather than addressing aggravation. See January 2021 VA Examiner Opinion, Section VI- Medical Opinion for Aggravation of a Nonservice Connected Condition by a Service Connected Condition, 6b. Provide Rationale. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the nature and etiology of the Veteran’s HTN. The examiner must opine on the following: a) Whether the Veteran’s HTN is at least as likely related to his period of service, to include in-service exposure to herbicide agents. b) Whether Veteran’s HTN was caused by or aggravated beyond its natural progression by a service-connected disability to include his service-connected PTSD, an acquired psychiatric disorder. All conclusions and opinions should be accompanied by adequate rationale. The examiner’s attention is drawn to the October 3, 2019 Brief which includes argument that hypertension is either related to in-service herbicide exposure or caused or aggravated by mental conditions and which references studies in support of both arguments. The examiner must address the studies provided by the Veteran. See Wise v. Shinseki, 26 Vet. App. 517, 531-32 (2014) (citing Caluza v. Brown, 7 Vet. App. 498. 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996); 38 C.F.R. 159(a)(1) (“statements conveying sound medical principles found in medical treatises” is competent medical evidence that the Board is required to address.). K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. McKenzie, 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.