Citation Nr: 21021970 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-24 031 DATE: April 14, 2021 REMANDED Service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1970 to April 1972. This matter is on appeal from an August 2013 rating decision and was previously remanded by the Board in April 2020. Unfortunately, the Veteran’s service connection claim for hypertension is remanded again for additional development. It is the Veteran’s contention that he is entitled to service connection for hypertension due to his service-connected major depressive disorder, panic disorder, and agoraphobia. Based on a July 2013 VA examination for his hypertension, the examiner noted that the Veteran’s hypertension was first diagnosed in 2003 and he was prescribed antihypertensives as treatment. The examiner indicated that mental health and medical conditions overlay in interactions that are variable, not fixed. Due to the changing stressors and nonspecific reactions, she can only speculate as to the relationship between the Veteran’s medical and mental health conditions. In support of his claim, the Veteran submitted two medical articles to illustrate the possible nexus between his current hypertension and his service-connected psychiatric conditions. The first article titled, ‘Anxiety and Depression in Patients with Pulmonary Hypertension,’ found that anxiety and depression are frequent in patients with pulmonary hypertension and increase as the severity of the disease progresses. The second article titled, ‘Generalized Anxiety and Major Depressive Disorders, Their Comorbidity and Hypertension in Middle-Aged Men,’ found that separate regression models adjusting for age, place of service, ethnicity, marital status, alcohol consumption, smoking, body mass index, household income, education grade, showed that both generalized anxiety disorder (GAD) and major depressive disorder (MDD) were positively related to hypertension. In age-adjusted and fully adjusted models comparing comorbid GAD/MDD, GAD alone, MDD alone, and neither condition, comorbidity showed the strongest relationship with hypertension. When the matter came to the Board in April 2020, it found that the June 2013 VA medical opinion was inadequate and remanded the matter to obtain a new medical opinion. The addendum was to address the nexus between the Veteran’s hypertension and his service-connected psychiatric conditions. In doing so, the examiner was to determine the significance of the two medical articles submitted by the Veteran. A new medical opinion addendum was obtained in May 2020, but it failed to address the Veteran’s articles. The examiner indicated that he could not find the medical articles submitted by the Veteran. Nevertheless, he concluded that the Veteran’s hypertension is less likely due to the Veteran’s service-connected psychiatric conditions. In his rationale, the examiner indicated that the Veteran had hypertension since 2003, which had been controlled with medication. It is noted that since his 2013 examination, the Veteran has steadily gained weight, approximately 35 pounds in 6 years. Weight gain, diet, and sedentary lifestyle is more likely than not going to aggravate hypertension. The Veteran has a diagnosis of essential or primary hypertension. According to ‘Up to Date: Risk Factors for Primary Hypertension,’ the predominate risk factors for primary hypertension are obesity, family history, high sodium diet, and physical inactivity. The Veteran’s depression or mental health disorder did not cause his hypertension, nor is it considered a risk factor. Based on the review of the records, the examiner opined the Veteran’s psychiatric conditions did not aggravate his hypertension in the long term. Since the medical articles submitted by the Veteran were not addressed, the AOJ requested a new medical opinion addendum. An August 2020 addendum indicated that the medical article cited by the Veteran only pertained to pulmonary hypertension, which is distinct from the Veteran’s diagnosis of primary hypertension. However, the examiner did not address the second article. The examiner added that after reviewing the files, it is his opinion that the Veteran’s hypertension is less likely as not related to or aggravated by his major depressive disorder, panic disorder, or agoraphobia. Since these are separate and distinct medical conditions, one does not cause or have an effect on the other. Furthermore, based on the current medical literature, there is no direct correlation between hypertension and mental health condition. Again, as the August 2020 VA examiner only briefly addressed the first article submitted by the Veteran, the AOJ requested a new medical opinion addendum to adequately opine on the second article. Instead, a new addendum that same month, went on to include other internet sources in its opinion. The examiner stated that based on Harrison’s Principles of Internal Medicine, in the United States, approximately 30 percent of adults have hypertension. The likelihood of hypertension increases with age. Individuals of approximately age 60 have a prevalence of hypertension of 65.4 percent. Both environmental and genetic factors may contribute to regional and racial variations in hypertension prevalence. There are multiple known causes of hypertension in which the cause of primary hypertension tends to be familial. Obesity and the metabolic syndrome are also known causes of hypertension. Cross sectional studies indicated that there is a direct linear correlation between body weight and blood pressure. Renal parenchymal diseases are the most common causes of secondary hypertension. Hypertension can also be due to an occlusive lesion of a renal artery or renovascular hypertension. Primary aldosteronism secondary to excess aldosterone is also a cause of hypertension. Cushing syndrome and pheochromocytoma are also causes of hypertension. Coarctation of the aorta is the most common congenital cardiovascular cause of hypertension. Furthermore, Uptodate.com reported risk factors for primary essential hypertension include age, obesity, family history, race, reduced nephron number, excessive alcohol consumption, and physical inactivity. It also reports secondary or contributory causes of hypertension include medication or supplements, drug use, primary renal disease, primary aldosteronism, renovascular hypertension, pheochromocytoma, Cushing’s syndrome, endocrine disorders and coarctation of the aorta. The Board finds that while the October 2020 VA examiner has provided additional information on the risk of hypertension in general, he did not offer an adequate opinion on the Veteran’s medical articles and how they specifically apply to this Veteran. The Board acknowledges that the Veteran is not currently diagnosed with pulmonary hypertension and therefore the first article titled, ‘Anxiety and Depression in Patients with Pulmonary Hypertension,’ does not apply in the Veteran’s specific case. However, the Veteran’s second article strongly suggests a relationship between hypertension and psychiatric conditions such as depression and generalized anxiety disorder. The new medical opinion obtained should address the article’s significance, if any, to the Veteran’s specific case. In addition, while the VA examiner provided a litany of risk factors, the examiner failed to indicate which, if any, of these risk factors apply to the Veteran. Accordingly, the Board finds that an addendum VA medical opinion is necessary to fully comply with the Board’s April 2020 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Obtain updated VA and non-VA treatment records. 2. Obtain a new medical opinion from an examiner other than the examiners who provided the May 2020, August 2020, and October 2020 opinions on the etiology of the Veteran’s hypertension. A copy of the claims file and this remand should be provided to the examiner. In doing so, the VA examiner must provide an opinion as to the following: a. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is related to or caused by his service-connected psychiatric disorders? Why or why not? b. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s hypertension is aggravated (made worse) by his service-connected psychiatric disorders? Why or why not? The examiner must consider the articles submitted by the Veteran on June 7, 2019, and specifically address the article titled, ‘Generalized Anxiety and Major Depressive Disorders, Their Comorbidity and Hypertension in Middle-Aged Men.’ The examiner should determine whether this article supports the Veteran’s argument that his hypertension is related to his service-connected psychiatric disorders. (Continued on the next page)   A complete medical rationale for all opinions expressed must be provided. If an opinion cannot be provided without resorting to speculation, the examiner should provide complete explanations of why this is so. In so doing, the examiner is requested to explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or the limits of current medical knowledge have been exhausted in providing an answer to that particular question. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Yeh, 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.