Citation Nr: 21023847 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 14-22 938 DATE: April 21, 2021 ORDER Service connection for hypertension, to include as secondary to ischemic heart disease, is granted. REMANDED Entitlement to service connection for limited use of the left hand, claimed as secondary to hypertension, is remanded. FINDING OF FACT Resolving all doubt in favor of the Veteran, the probative medical evidence of record has shown that his current hypertension is proximately due to his service-connected ischemic heart disease. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for hypertension are met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1967 to September 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In March 2019, the Veteran testified at videoconference hearings at the RO before the undersigned Veterans Law Judge sitting in Washington, DC. Transcripts of the testimony are associated with the claims file. This claim was previously before the Board in June 2020, at which time it was remanded for further development SERVICE CONNECTION Service connection may be established for a disability resulting from personal injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen’s disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term “chronic disease” refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a chronic disease under 3.309(a) is “shown as such in service” (“meaning clearly diagnosed beyond legitimate question,” Walker, 708 F.3d at 1339) or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is “shown as such in service,” the Veteran is “relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought.” Walker, 708 F.3d at 1336. Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, “there is no ‘nexus’ requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease.” Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not “shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,” i.e., “when the fact of chronicity in service is not adequately supported,” then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and service, and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed.” Walker, 703 F.3d at 1336; 38 C.F.R. § 3.303(b). Entitlement to service connection for hypertension, to include as secondary to ischemic heart disease The Veteran seeks entitlement to service connection for hypertension, which is defined as high arterial blood pressure. Dorland’s Illustrated Medical Dictionary 801 (28th ed. 1994). Various criteria for its threshold have been suggested, ranging from 140 systolic and 90 diastolic to as high as 200 systolic and 110 diastolic. Id. For purposes of rating the disease, VA defines the term as meaning “that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm.” See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). At the March 2020 Board hearing, the Veteran testified that he was told that he had high blood pressure during service but never received medication for his condition. The Veteran’s representative then indicated that, while the blood pressure may have been at the high end of normal, the Veteran’s heart disease might be a very likely contributing factor. Pursuant to the June 2020 Board remand, the Veteran received a VA examination in August 2020 and the examiner noted a diagnosis of hypertension. The condition started in 1999 when the Veteran was feeling dizzy and went to the doctor. He was told to go home and relax but had a stroke later that evening. Based on the results of the examination, the examiner concluded that the condition was less likely than not caused or aggravated by the service-connected ischemic heart disease. The examiner found that ischemic heart disease did not cause a diagnosis of hypertension in the vast majority of patients. Review of the Veteran’s file showed no objective evidence supporting the premise that his hypertension was caused or aggravated by his ischemic heart disease. At the outset, the Board finds the August 2020 VA examination to be of diminished probative value, as the examiner used the wrong standard to evaluate whether there was a relationship between the Veteran’s hypertension and his service-connected ischemic heart disease. While the examiner used the “less likely than not” standard, his rationale that ischemic heart disease did not cause a diagnosis of hypertension in the vast majority of patients appears to require a more definitive relationship between the two conditions. However, reading the evidence in the light most favorable to the Veteran, the examiner concedes that ischemic heart disease causes hypertension in some patients. Furthermore, he does not offer any evidence to conclude that ischemic heart disease would not cause hypertension in this veteran. According, giving the Veteran the benefit of the doubt, the Board concludes that the evidence supports a finding that the Veteran’s hypertension is related to the service-connected ischemic heart disease and that service connection for this disability is warranted. REASONS FOR REMAND Entitlement to service connection for limited use of the left hand, claimed as secondary to hypertension The Veteran submitted correspondence in August 2011 that he started to have problems with hypertension in 1997 and then he suffered a stroke. Following the stroke, the Veteran’s use of his left hand was limited. Pursuant to the June 2020 Board remand, the Veteran received a VA Hand and Finger Conditions examination in August 2020 and the examiner found that he did not have a current diagnosis associated with his left hand. The Veteran also received a VA Central Nervous Systems examination in August 2020 and the examiner noted a diagnosis of thrombosis, transient ischemic attack (TIA), or cerebral infarction. The Veteran had a stroke in 1999 that left him with residual left side weakness after rehabilitation. He had intermittent left-hand weakness and coordination. The Veteran was a drummer and music teacher with partial loss of use of the left hand particularly after increased use. The examiner’s findings included weakness of the muscles in the left hand. In light of this current Board decision to grant service connection for hypertension, and the Veteran’s contentions regarding a possible connection between his hypertension and limited use of his left hand, the Board finds that a new examination is warranted. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of his limited use of the left hand. The claims file must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner is asked to opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s limited use of the left hand was caused or aggravated by his service-connected hypertension and/or ischemic heart disease. Aggravation is defined for these purposes as a worsening of the underlying condition versus a temporary flare-up of symptoms. If the examiner finds that the Veteran’s limited use of the left hand has been permanently aggravated/worsened by his service-connected conditions, the degree of worsening should be identified. The examiner should also offer an opinion with regards to what muscle group and/or nerve is involved in the Veteran’s limited use of the left hand, as the August 2020 examiner found intermittent left-hand muscular weakness and incoordination. The examiner should consider all evidence, including lay statements (such as the credible statements that his hypertension caused the stroke that caused the limited use of the left hand), medical records, and other medical opinions of record. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Daniels, 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.