Citation Nr: 21022004 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-56 262A DATE: April 14, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The Veteran’s hypertension did not manifest in service or within one year after separation from service, and is not otherwise etiologically related to service, to include as due to presumed exposure to herbicide agents, or a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Army from November 1965 to November 1968, including service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2016 rating decision issued by a Department of Veterans’ Affairs (VA) Regional Office (RO). The Board remanded this matter in June 2019, September 2020, and January 2021 for additional development. This matter has been advanced on the docket pursuant to 38 C.F.R. § 20.902. The Veteran is encouraged to file a claim for presumptive service connection for his diagnosed diabetes mellitus type II. The Veteran asserts that his hypertension either had its onset during active duty or is otherwise related to his active duty service, to include as being due to his presumed exposure to herbicides while serving in the Republic of Vietnam. The Veteran also asserts that his hypertension is proximately due to or aggravated by his service-connected psychiatric disorder or his diabetes mellitus type II. See May 2016 VA Form 21-526EZ, January 2020 Appellant’s Brief. Service connection will be granted if the evidence demonstrates that a 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 relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). 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). Service connection may also be granted if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 C.F.R. § 3.307 are met, even though there is no record of such disease during service. The enumerated diseases associated with exposure to herbicide agents do not include hypertension. 38 C.F.R. § 3.309(e). However, when a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during service, to include as based on exposure to herbicide agents. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic disabilities, including hypertension, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The option of establishing service connection through a demonstration of continuity of symptomatology is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Regarding element one, current disability, the Veteran was diagnosed with hypertension in December 2015 and the diagnosis was confirmed by a VA examiner in September 2019. See December 2015 VA treatment records, September 2019 VA examination report. Accordingly, element one of direct and secondary service connection is met. Regarding element two of service connection, the Veteran is presumed to have been exposed to herbicide agents during his service in the Republic of Vietnam and he is service connected for a psychiatric disorder (anxiety and depression). See Service Personnel Records. The Board notes that the Veteran is not currently service-connected for diabetes mellitus, but given his recent diagnosis of the same and conceded herbicide agent exposure the Board will consider this theory of entitlement. Thus, element two of both direct and secondary service connection are met. The crux of this matter is whether there exists a relationship, or nexus, between the Veteran’s active duty service or his service-connected psychiatric disorder or diabetes mellitus type II and his current diagnosis of hypertension. Initially the Board notes that at the time of his discharge from active duty, his blood pressure was recorded as 120/80. For VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. (millimeters of mercury) or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90mm. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Accordingly, the Veteran was not hypertensive at the time of his discharge. In October 2020, a VA examiner reviewed this finding, per the September 2020 Board remand, and opined that the Veteran’s blood pressure reading at the time of his discharge was not consistent with or diagnostic of hypertension. Critically, while the Veteran was noted to have “white coat hypertension” in June 2003, he was not diagnosed with hypertension until December 2015, more than four decades after his discharge from active duty and well past the one-year presumptive period for chronic disease. See June 2003, December 2015 VA treatment records; September 2019 VA examination report (Veteran reports he typically experiences elevated blood pressure in a clinic setting); DD Form 214. Accordingly, there is no possibility of establishing a continuity of symptomatology. See Walker, supra. There are no other reports or complaints in the Veteran’s service treatment records that are causative of hypertension. See September 2019 VA examination report. Regarding the Veteran’s presumed exposure to herbicide agents in Vietnam, the September 2019 VA examiner considered the Institute of Medicine of the National Academies, Veterans and Agent Orange: Update 2018. The examiner opined that while the National Academy of Sciences (NAS) 2018 update moved the diagnosis of hypertension from “limited or suggestive” to “sufficient” regarding a relationship to exposure to herbicide agents, that the study upon which this recommendation was predicated was based on a limited subset of veterans in the Army Chemical Corps who actually engaged in the spraying of Agent Orange. The examiner noted the study did not support a broader connection to soldiers not involved directly in the spraying of herbicide agents and concluded that as the Veteran had not asserted that he engaged in the spraying of herbicide agents, the conclusions of the study were inapplicable to him. The September 2019 VA examiner opined that it was less likely than not that the Veteran’s exposure to herbicide agents was the proximate cause of his hypertension and cited the Veteran’s advancing age, coffee use, and continued tobacco use as the relevant risk factors regarding his development of hypertension. See September 2019 VA examination report. In October 2020, the same VA examiner again confirmed that the Veteran’s risk factors for the development of hypertension were his advancing age, tobacco use, and the Veteran’s report of drinking up to 12 cups of coffee per day. The Board finds the September 2019/October 2020 VA examiner’s opinion to be well-reasoned, based upon a review of the Veteran’s entire medical history and a review of relevant medical literature, and thus is of great probative value. Accordingly, the Board finds that there is no nexus between the Veteran’s active duty service, to include his diastolic reading of 80 at the time of his discharge or his presumed exposure to herbicide agents, and the Veteran’s current hypertension diagnosis. After a review of the evidence of record, the Board also finds that there is no nexus between the Veteran’s diabetes mellitus type II or his psychiatric disorders and his hypertension. In this regard, the October 2020 VA examiner opined that as the Veteran’s hypertension pre-existed his history of diabetes and there was no diabetic nephropathy, that it was less likely than not that the Veteran’s service-connected diabetes either caused or aggravated the Veteran’s hypertension. The October 2020 VA examiner likewise opined that the Veteran’s psychiatric disorder did not proximately cause or aggravate the Veteran’s hypertension. In support of this opinion, the VA examiner reviewed the article entitled, “Are Symptoms of Anxiety and Depression Risk Factors for Hypertension?” that was submitted by the Veteran in January 2020. The VA examiner noted the authors of the article clearly stated that it was impossible to assess the independent effects of anxiety and depression on the development of hypertension and concluded that more research is needed to determine if there were any independent effects. The October 2020 VA examiner concluded that the medical consensus is that there was not an association between anxiety or depression and hypertension and it was therefore less likely than not that the Veteran’s hypertension was due to or aggravated by his psychiatric disorders. In January 2021, a different VA medical doctor reviewed the entire claims file, including the Veteran’s extensive VA medical center treatment and laboratory results. The January 2021 VA examiner noted that the Veteran’s renal function labs (blood urea nitrogen tests, creatinine tests) were normal. See August 2020 VA treatment records. The January 2021 VA examiner then reported that the mechanism by which hypertension is caused by or aggravated by diabetes mellitus type II is through significant kidney disease caused by diabetes mellitus type II. The examiner concluded that a review of the Veteran’s medical records did not demonstrate impaired kidney function and accordingly, it was medically impossible that diabetes mellitus type II could have been the proximate cause of hypertension. Upon a review of the Veteran’s blood pressure readings from 2009 through 2020 and an August 2020 VA treatment record indicating the Veteran was not taking any anti-hypertensive medication, the VA examiner opined that it was less likely than not that the Veteran’s diabetes mellitus was aggravating the Veteran’s hypertension. Regarding whether the Veteran’s psychiatric disorders were the proximate cause of or aggravating hypertension, the January 2021 VA examiner noted the Veteran’s diagnosis was that of primary hypertension and was most likely the result of the age, habitus (increased BMI), and lifestyle factors including physical inactivity. In reviewing the article submitted by the Veteran in January 2020, entitled “Are Symptoms of Anxiety and Depression Risk Factors for Hypertension,” the VA examiner noted the study did not find an association between generalized anxiety and hypertension. The examiner conceded that the study did find an association between clinically significant symptoms of depression and hypertension in elderly adults, but also an association with being overweight and obesity across the two study groups. The January 2021 VA examiner noted limitations in this study, specifically that the positive association between depression and hypertension conflicts with data from other population-based studies. In this regard, the VA examiner cited to two separate studies that indicated a relationship between high symptom levels of anxiety and depression, particularly when the patient is taking tricyclic anti-depressants (TCAs), and hypertension. The VA examiner noted that the Veteran is not taking TCAs. The January 2021 VA examiner concluded that when considering the overall medical literature, that the evidence consistently supports that the risk factors of age, habitus (increased BMI), lifestyle factors, genetic factors, and tobacco (for elevated BP) are the contributory factors that led to the Veteran's hypertension and not the service-connected psychiatric disorders. The Board finds the October 2020 and January 2021 VA examiner’s opinions to be well-reasoned, based on a complete review of the Veteran’s claims file (including medical records and scholarly articles), and of great probative value. Indeed, there is no evidence to the contrary. Thus, element three of secondary service connection, or nexus, is not met and the claim must be denied on this basis. Accordingly, the preponderance of the evidence is against the claim of entitlement to service connection for hypertension on a direct, secondary, or presumptive basis. As such, the benefit of the doubt doctrine is not for application, and service connection must be denied. 38 U.S.C. § 5107(b). S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Rouse, 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.