Citation Nr: 21022898 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 13-25 091A DATE: April 19, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The preponderance of the evidence is against finding that hypertension began during active service or is otherwise related to the Veteran's military service or was caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Navy Reserves between April 1997 and April 2011, with active duty for training (ACDUTRA) in October 1997, from January 1999 to February 1999, in April 2000, from July to August 2000, in September 2000, from June 2001 to August 2001, in September 2001, in May 2002, in May 2003, from January 2004 to April 2004, from August 2004 to September 2004, in May 2005, in June 2005, active duty from August 2005 to May 2006, and active duty for training from January 2008 to March 2008. She also had periods of Inactive Duty for training (INACDUTRA). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). In August 2017, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board issued a remand in October 2020 instructing the RO to obtain outstanding treatment records and obtain an addendum opinion for whether the Veteran’s hypertension was secondary to her service-connected post-traumatic stress disorder (PTSD). A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The RO obtained outstanding VA treatment records and a January 2021 VA examination. The Board finds the RO substantially complied with the October 2020 remand directives. Entitlement to service connection for hypertension. The Veteran contends that her hypertension was caused by her military service or her service-connected PTSD. During the August 2017 Board hearing, the Veteran stated that she was diagnosed with hypertension in 1998 during service. She stated that she was provided medication for hypertension due to migraines that were so severe that she would vomit. At the time of the hearing, she reportedly continued to take medication for hypertension and depression. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may only be grated for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or for an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303, 3.304. ACDUTRA is defined, in part, as "full-time duty under sections 316, 502, 503, 504, or 505 of title 32 U.S. Code or the prior corresponding provisions of law." 38 U.S.C. § 101 (22) (2012); 38 C.F.R. § 3.6(c). The term inactive duty for training (INACDUTRA) is defined, in part, as duty, other than full-time duty, under sections 316, 502, 503, 504, or 505 of title 32 U.S. Code or the prior corresponding provisions of law. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Secondary service connection requires: (1) a service connected disability; (2) a nonservice connected disability; and (3) evidence that the nonservice connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability. See 38 C.F.R. § 3.310. The report of a service entrance examination dated in February 1997 notes that blood pressure was 107/79. She was found to be qualified for enlistment. On an evaluation of physical condition dated in November 1997, it was noted that her blood pressure was 140/100. It was recorded that she had noted increased blood pressure readings buy eval by her clinic so far yields normotensive readings. Service treatment records (STR) indicate the Veteran was subsequently seen for headaches and found to have mildly elevated blood pressure while in the reserves. See e.g., December 1997 STR. Her blood pressure readings at that time were 140/100 and 138/96. The Board notes that her service personnel records do not indicate any active service or ACDUTRA at these times. A service record dated in March 1998 reflects that her blood pressure was 140/100. She reportedly had been evaluated over the last month at a Daughters of Charity clinic and so far had normotensive readings. It was noted that she would continue to be evaluated and would report if treatment was needed. An annual service certificate of physical condition dated in May 1998 notes that blood pressure was 118/98. The Veteran denied being on medication in the past 12 months. There was no mention of hypertension. An annual certificate of physical condition dated in August 1998 notes that the Veteran denied being on medication in the past 12 months. There was no mention of hypertension. An annual certificate of condition dated in August 1999 notes that her blood pressure was 126/84. The only prescription medication which she reportedly had taken in the previous 12 months was Imarex (sic) Evals. The Board notes that this likely was a reference to Imitrex which is a treatment for headaches. The report of medical history provided by the Veteran in May 2000 notes that she checked a box indicating that she had a history of high or low blood pressure. The examiner at that time noted that it had been elevated blood pressure. She reportedly never had been seen by a physician and there were no documented problems in the last 8 months. Examination noted a blood pressure reading of 124/84. No diagnosis was noted. An annual certificate of physical condition dated in April 2001 shows blood pressure was 136/82, and the Veteran denied taking any medications for the past 12 months. A February 2002 annual certificate of physical condition reflects that blood pressure was 136/90. A record from the Louisiana State University Health services Center which does not have a legible date (but is apparently from April 2002 as discussed below) reflects that the Veteran reported that she had headaches that were worsening. Her blood pressure on exam was 140/90. The plan included trying Verapamil 180mg, Exedrin for migraines, and Maxalt for acute headaches. The Board notes that Verapamil is an anti-hypertension medication. A service medical record from April 2002 says that the Veteran had recently been diagnosed with hypertension and had been started on Verapamil on April 10, 2002. The Board notes that the Veteran was not on active duty or ACDUTRA at that time. A note from a doctor at the Louisiana State University Health Services Center dated in April 2003 states that the Veteran was seen by the clinic on June 13, 2002. At that time she was instructed to stop taking Verapamil, and her blood pressure was normal. A February 2003 annual certificate of physical condition reflects a blood pressure reading of 122/80. A January 2004 service record notes a there was a history of elevated blood pressure without hypertension. This was not considered disabling. A February 2004 annual certificate of physical condition notes a blood pressure reading of 132/91. A January 2005 service report of medical history notes that the Veteran had a history of hypertension and was placed on Verapamil in 2002, but was able to discontinue to medications. It was noted that she needed to be reevaluated for restarting the medications. He current BP was 148/98. The Board notes that the Veteran was not on active duty or ACDUTRA at that time. A medical, dental and educational suitability screening for service and family members dated August 26, 2005 notes that her blood pressure was elevated. She reportedly had been off her Verapamil but would restart it. An associated record reflects multiple elevated blood pressure readings taken the same day with the highest being 148/100. A pre-deployment examination also dated August 26, 2005 indicates that she need a blood pressure check after restarting Verapamil. The Board notes that the foregoing records are essentially entrance examination reports for the period of active duty which extended from August 2005 to May 2006. A service treatment record dated in December 2005 notes that the Veteran had previously been diagnosed with hypertension and took Verapamil 180mg qd. She reportedly had a history of hypertension in the past, had been taken off meds but restarted in August 2005. The diagnosis was hypertension (systemic). An April 2006 service report of medical assessment reflects that the Veteran had been taking Verapamil for 9 months. This history places the date of onset of use of the medication as being in July 2005 which is not a period of active duty or ACDUTRA. The Veteran underwent a VA examination in December 2006. During the examination, the Veteran gave a history of the disorder occurring during active service and reported that she was diagnosed in 1999. She said she was treated for her headaches and was told that she had elevated blood pressure which had become progressively worse. Her medication at that time was Verapamil 180mg daily. It was noted that no medical opinion was requested. A June 2007 service record notes that the Veteran was required to obtain a medical clearance for hypertension and pulmonary issues. Post-service treatment records reflect that she has a current disability. May 2008 Women’s Health Note. The Veteran was afforded another VA examination in September 2019. The examiner stated that Veteran had clear and unmistakable evidence of the preexisting hypertension. There is evidence to indicate the Veteran continued to sufferfrom the disorder during service, which is typical of the condition. However, the progression is not beyond normal progression for this disorder. Objective evidence in the c-file of a clinic note dated 1/23/2007 notes "HTN well controlled", 12/1/2009 noted "HTN well controlled on current medications, and 11/27/2017 noted "HTN controlled". There is objective evidence in the c-file of a Women's Health clinic note dated 7/2/2010 with noted "HTN fairly controlled. She ran out of meds". A note in the c-file states that in 10/2009 she was sent to the clinic from the behavioral health department because her BP was 188/123. However, it notes that the Veteran reported she did not take all of her blood pressure medications that day. No evidence of permanent aggravation beyond normal progression identified. In a January 2020 Appellant’s Brief, the Veteran’s representative asserted that the Veteran’s hypertension had been aggravated by her service-connected PTSD with major depressive disorder. In support of that assertion, the representative cited to a scholarly article that indicated, among other things, that heightened arousal from anxiety disorders was associated with an increased risk of hypertension and a pro-inflammatory state. In February 2020, the Board remanded the claim for an addendum opinion to determine whether it was at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension had been aggravated beyond its natural progression by her service-connected PTSD disorder with major depressive disorder. The Board asked for the examiner to comment on the medical article submitted by the Veteran “Anxiety disorders, hypertension, and cardiovascular risk: A Review.” The March 2020 addendum opinion stated that the Veteran’s hypertension existed prior to service, averages were under the projected natural history of the condition and did not represent aggravation. In addition, the examiner stated that the URL link provided to the article submitted by the Veteran was not valid; therefore, the examiner did not make comments about article. This opinion was inadequate because it did not discuss whether the Veteran’s hypertension was related to her service-connected PTSD with major depressive disorder. A new medical opinion was obtained in January 2021. The Veteran’s diagnosis of hypertension was confirmed. The Veteran stated that she was diagnosed with hypertension when she went in for a physical exam in the military. The examiner opined that the Veteran’s hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition. According to the Mayo Clinic, anxiety doesn't cause long-term high blood pressure (hypertension). But episodes of anxiety can cause dramatic, temporary spikes in your blood pressure. If those temporary spikes occur frequently, such as every day, they can cause damage to your blood vessels, heart and kidneys, as can chronic high blood pressure. The examiner concluded that the cause of hypertension is unknown. He then explained that secondary hypertension is sustained elevated blood pressure that is the direct result of another medical condition. According to the National Heart, Lung and Blood Institute, high blood pressure is a common disease that develops when blood flows through the arteries at higher-than-normal pressures. Blood pressure is made up of two numbers: systolic and diastolic. Many factors raise your risk of high blood pressure. Some risk factors, such as unhealthy lifestyle habits, can be changed. Other risk factors, such as age, family history and genetics, race and ethnicity, and sex, cannot be changed. A healthy lifestyle can lower your risk for developing high blood pressure. Blood pressure tends to increase with age. Our blood vessels naturally thicken and stiffen over time. These changes increase the risk for high blood pressure. After reviewing the medical literature, the examiner concluded that mental health conditions such as PTSD, anxiety and depression have not been shown to acceptable secondary causes of HTN. The examiner also acknowledged the article submitted into evidence by the Veteran. After reviewing the citied article of “Entitled anxiety disorders, hypertension, and cardiovascular risk: a review,” the examiner found that there was not enough significant evidence to establish correlation between anxiety disorders causing hypertension. The article stated that “multiple cross-sectional studies reveal a positive association between anxiety and hypertension. These associations are bidirectional, with those with hypertension being more likely to have anxiety and those with anxiety being more likely to have hypertension. However, a few studies have shown no association. Longitudinal studies point to an increased risk of development of hypertension in patients who suffer from anxiety. More convincing studies show links between anxiety symptoms and disorders, including panic disorder and PTSD, and cardiovascular outcomes. Drawing broad conclusions from these studies is challenging, however, given the multiplicity of scales used to measure anxiety disorders. Given this information, the examiner preferred the explanation given by the Mayo Clinic, anxiety doesn't cause long-term high blood pressure (hypertension). But episodes of anxiety can cause dramatic, temporary spikes in your blood pressure. If those temporary spikes occur frequently, such as every day, they can cause damage to your blood vessels, heart and kidneys, as can chronic high blood pressure. In reviewing the evidence that is of record, the Board notes that the onset of elevated blood pressure readings do not correspond with active duty or ACDUTRA. In addition, it is noted that she was first placed on an anti-hypertensive medication on a date that she was not on active duty or ACDUTRA. There is no basis to conclude that hypertension was aggravated by any subsequent period or service. In addition, the medical opinions weigh against a claim that the hypertension was caused or aggravated by a service-connected disability. The January 2021 examiner found that the available medical literature does not support a relationship between the two. The Veteran has submitted no objective medical opinion in support of her claim. The Board acknowledges the Veteran's assertion that her hypertension was related to her military service or service-connected PTSD. However, a lay person is not considered competent to medically attribute hypertension to another disability as doing so to requires medical knowledge and expertise the Veteran has not been shown to possess. See Kahana v. Shinkseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the competent medical evidence of record answered the question and did not support a causal relationship between the Veteran's hypertension, her military service and her service-connected PTSD. Accordingly, the criteria for entitlement to service connection for hypertension have not been established, either through medical or lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim of entitlement to service connection for hypertension, that doctrine is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harris, Attorney Advisor 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.