Citation Nr: 21022566 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 16-24 667A DATE: April 16, 2021 ORDER Entitlement to service connection for hypertension, including as due to herbicide exposure, and including as secondary to service-connected disabilities is denied. FINDING OF FACT The Veteran’s current hypertension is not related to his active service or to herbicide agent exposure, nor is it secondary to his service-connected disabilities. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the United States Navy from August 1971 to August 1975 and from January 1977 to January 1993. For his meritorious service, the Veteran was awarded (among other decorations) the Vietnam Service Medal with one Bronze Star and Navy Achievement Medal. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The matter was previously before the Board in October 2018 and remanded for further development. The Board finds substantial compliance with the remand directives. Service Connection Entitlement to service connection for hypertension, including as due to herbicide exposure, and including secondary to service-connected disabilities is denied. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for certain chronic diseases listed at 38 C.F.R. § 3.309 (a), such as hypertension, if manifested to a compensable degree within one year from the date of separation from service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307 (a), 3.309(a). Additionally, 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 §3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of §3.307(d) are also satisfied. 38 U.S.C. § 1116; 38 C.F.R. § 3.309 (e). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran contends his hypertension is related to his active service, including exposure to herbicide agents or secondary to his service-connected disabilities. The Board acknowledges that hypertension is not currently listed among the disabilities listed in 38 C.F.R. § 3.309(e) for which presumptive service connection is warranted. Nonetheless, medical literature published in November 2018 suggests a potential relationship between exposure to herbicide agents and hypertension. The National Academy of Sciences (NAS), in its most recent Agent Orange update, concluded there was “sufficient evidence of an association between exposure to the chemicals of interest and the following outcomes,” of which hypertension is listed. See National Academy of Sciences Report, Veterans, and Agent Orange: Update 11 (2018). Direct service connection may still be established if competent evidence indicates the Veteran’s disease is related to that herbicide agent exposure. The Veteran’s VA treatment records reflect a diagnosis of hypertension. The first criterion in establishing service connection for hypertension is met. Exposure to herbicide agents has been conceded based on the Veteran’s assignment on the USS Schenectady during operations off the coast of the Republic of Vietnam. The second requirement for service connection is met. The Veteran’s claim fails, however, as there is no competent evidence linking his current disability to his active service or to his in-service herbicide agent exposure. The Veteran’s service treatment records reflect at the time of his separation examination, his blood pressure was 108/78. At re-enlistment in 1977, the Veteran’s blood pressure 100/70. The Veteran had multiple periodic reports of medical history examinations during service, his blood pressure readings were noted to be 130/86 in May 1976, 124/84 in January 1977, 110/70 in October 1985, and 110/70 in October 1990. His retirement examination in November 1992 reflected a reading of 128/78. The Veteran’s VA treatment records reflect the Veteran was diagnosed with hypertension and underwent treatment for the disability. The Veteran’s VA treatment records from June 1998 reflect the impression at the time to be hypertension and the Veteran was not on medication. The VA treatment records document the Veteran did not start medication at the time and wished to try other measures. The VA treatment records reflect the Veteran was seen in the emergency room in November 1997 but noted the Veteran was currently asymptomatic as of June 1998. The Veteran’s VA treatment records continue to reflect a positive history of hypertension and document his hypertension as stable. The Veteran takes medication for control of the hypertension. The Veteran underwent a VA examination in November 2019 and the VA obtained addendum opinions in May 2020, June 2020, and July 2020. The November 2019 VA examination and May 2020 VA addendum medical opinion are inadequate. Both the November 2019 VA examination and May 2020 VA addendum opinion provided insufficient rationale, did not discuss secondary service connection, and did not comply with the Board’s remand directives. As such, they were inadequate and not utilized in the evaluation of the Veteran’s claim. The June 2020 VA opinion was performed as an independent medical opinion. This opinion sufficiently complied with the Board’s remand directives. The VA examiner noted the Veteran contends his hypertension is the result of his worrying about his service-connected disabilities. The VA examiner referenced the Veteran was diagnosed and treated for hypertension approximately 20 years ago and notes the Veteran’s service treatment records do not reflect abnormally elevated blood pressure readings. The VA examiner stated the October 2018 Board decision characterized in-service blood pressure readings as elevated, but the VA examiner concluded there were no readings that would be sufficiently or consistently elevated to confirm a diagnosis of hypertension in-service. The VA examiner concluded the Veteran’s hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted the Veteran was exposed to herbicide agents while in-service. The VA examiner additionally reported the Veteran has a documented history of hypertension and treatment with medication since 1998. The VA examiner referenced medical literature that supports an association between anxiety and worry with hypertension, although a causal relationship is not proven. Also noted was an increased risk of hypertension of patients with chronic anxiety versus those without anxiety. The VA examiner concluded that in the medical literature the effect of anxiety on blood pressure is a transient phenomenon and it is generally stated that chronic anxiety less likely than not causes sustained hypertension. The VA examiner cited to recent evidence in medical literature of an increased risk of hypertension in Veterans exposed to herbicide agents and those who served in the Republic of Vietnam in the absence of herbicide agent exposure. The VA examiner concluded that while exposure to herbicide agents is associated with an increased risk of developing hypertension, a causal nexus is not proven. The VA examiner reported there are more potent factors that increase the risk of hypertension, including lack of physical activity, overweight, excess salt intake, and a family history of hypertension. In support of his conclusion, the VA examiner referenced excerpts from medical articles and resources. The VA examiner referenced information from the Mayo Clinic regarding whether anxiety causes blood pressure and the physician response stated that anxiety does not cause long-term hypertension. The information stated that anxiety can cause dramatic, temporary spikes in blood pressure. The VA examiner that provided the June 2020 opinion also provided the July 2020 opinion. In the July 2020 opinion, the VA examiner provided further analysis as to his conclusion that the Veteran’s hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner further discussed the findings by the Committee to Review Health Effects in Vietnam Veterans of Exposure to Herbicides 2010 report “Veterans and Agent Orange: Update 2010.” The VA examiner discussed in the June and July 2020 opinion that there is more recent evidence from 2016 discussing the association between hypertension and herbicide exposure. The VA examiner found the 2016 paper, published in the Journal of Occupational and Environmental Medicine, discussed an increased risk of hypertension in Veterans of the Army Chemical Corp. The study reflected that for Army Chemical Corp. Veterans, there was an increased risk of both Veterans who were exposed to herbicides and those who were not. The VA examiner reported the Veterans with the Army Chemical Corp. were exposed to much higher levels of herbicides than the average Vietnam Veteran but concluded despite an increased risk in association with herbicide exposure, causality was not documented. Additionally, the VA examiner cited the 2010 study suggests an association between exposure to herbicides and the outcome of hypertension, but the examiner concluded that a firm conclusion is limited due to chance, bias, and confounding could not be ruled out. The VA examiner felt the 2010 studying findings were relevant but an association between exposure to herbicide agents and hypertension was not convincingly demonstrated. The VA examiner noted additional data has been found but concluded the strength of the study is not robust and hypertension is a condition with multiple contributory causes. The VA examiner concluded that association is not proof of causation. The VA examiner referenced the NAS 2018 and its most recent Agent Orange update that concluded there was “sufficient evidence of an association between exposure to the chemicals of interest and the following outcomes,” of which hypertension is listed. The VA examiner cited to the information that stated there are “significant gaps in knowledge remain” and it was noted that no definitive causal links between hypertension and herbicide agents was provided as there are other risk factors for hypertension, as the VA examiner cited in his opinion. The VA examiner concluded there are other more potent risk factors for the development of hypertension in the Veteran, including obesity and a family history of hypertension. The VA examiner concluded that given these considerations, it is less likely than not the Veteran’s hypertension was incurred in or caused by the claimed in-service event, injury, or illness. The Veteran’s contended his hypertension was due to his worry over his service-connected disabilities. As discussed above, a VA medical opinion was provided in July 2020 to address secondary service connection. The VA examiner concluded the Veteran’s claimed condition is less likely than not proximately due to or the result of the Veteran’s service-connected disabilities, including residuals of prostate cancer, tinnitus, erectile dysfunction, and malignant melanoma. Regarding residuals or prostate cancer, the VA examiner noted the Veteran’s medical records do not provide a causal nexus between the residuals of prostate cancer and hypertension. The VA examiner also noted the Veteran’s erectile dysfunction is a residual of his prostate cancer. The VA examiner noted the residuals of prostate cancer and erectile dysfunction are documented in 2015, seventeen years after the diagnosis of hypertension. The VA examiner reported the service-connected tinnitus is due to acoustic trauma in-service and concluded the medical records do not support a causal nexus between tinnitus and hypertension. Additionally, the VA examiner also considered the service-connected disability of malignant melanoma. The Veteran was diagnosed with melanoma in 2002, four years after he was diagnosed with hypertension. The VA examiner noted there is no plausible medical or pathophysiologic causal relationship between tinnitus and hypertension, melanoma and hypertension, or the scar from melanoma and hypertension. The VA examiner concluded the Veteran’s hypertension was not caused or worsened beyond its normal progression by any of the Veteran’s service-connected disabilities. The VA examiner again reiterated there is no plausible medical or pathophysiologic causal relationship between the residuals of the Veteran’s prostate cancer, tinnitus, erectile dysfunction, malignant melanoma, or the scar from malignant melanoma. The VA examiner also referenced the Veteran’s contention his hypertension is elevated due to stress associated with worry and anxiety over his service-connected disabilities. The VA examiner concluded the stress, worry, and anxiety is a transient phenomenon and does not lead to sustained hypertension or worsening beyond its normal progression. The VA examiner concluded the Veteran’s hypertension was less likely than not proximately due to or the result of the Veteran’s service-connected disabilities and his hypertension was also not caused or worsened beyond its normal progression by any of the service-connected disabilities. The June and July 2020 VA opinions are probative as to the question of etiology. It is based on the facts of the case with specific citations to the record and medical literature, it is well-reasoned and addressed the Veteran’s lay statements, and it is supported by an adequate rationale. There is no other competent evidence regarding a link between the Veteran’s hypertension and his active service, herbicide exposure, or secondary to his service-connected disabilities. To the extent that the Veteran contends that such a relationship exists, his opinion is not considered competent to offer such an opinion, as determining the etiology of hypertension is complex, requiring specialized medical knowledge or training. See Jandreau, 492 F.3d at 1377. In sum, the Board acknowledges the Veteran’s current disability and his in-service exposure to herbicide agents. That said, the competent evidence of record does not establish that his hypertension is related to his active service, his exposure to herbicide agents, or secondary to his service-connected disabilities. As to presumptive service connection, the VA examiner also notated there is no evidence of hypertension within one year following the Veteran’s separation from service. The record reflects diagnosis of hypertension around 1997, more than one year after his separation. For these reasons, the Board finds that the preponderance of the competent and credible evidence establishes that the Veteran’s hypertension was not incurred in service, was not related to his active service, was not related to herbicide exposure, was not secondary to his service-connected disabilities, and was not diagnosed to a compensable degree within a year of his separation. There is no doubt to be resolved; service connection for hypertension is not warranted. J. NICHOLS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Mouzakis, 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.