Citation Nr: 21026954 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 11-28 368 DATE: May 4, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to herbicide agent exposure and as secondary to service-connected ischemic heart disease, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from April 1969 to October 1970, to include service in the Republic of Vietnam. In November 2016, December 2017, May 2019, and January 2021, the Board remanded the appeal for additional development. Although further delay is regrettable, the Board finds that another remand for additional development is required to ensure compliance with the most recent remand directives. The Veteran contends that his hypertension is due to exposure to herbicide agents during service. Pursuant to the Board's remand, an opinion was sought as to whether the Veteran's hypertension is at least as likely as not related to in-service exposure to herbicide agents. The examiner was asked to consider the National Academy of Science's (NAS) Agent Orange: Update 11 (2018). The examiner opined that exposure to herbicide agents is not an acceptable cause for hypertension because most diagnosis of hypertension are idiopathic, and association does not mean causal. In addressing the NAS update, she stated there is no current evidence to suggest that. It is unclear what "that" is referring to and no further rationale was provided for her opinions. Furthermore, the Veteran submitted a handwritten correspondence asking that his letter from his private physician from July 2020 be considered, stating his echocardiogram is significant for normal systolic heart function and there is increased stiffness of the heart muscle consistent with age and high blood pressure. As the Veteran is service connected for ischemic heart disease, a secondary opinion is warranted. The matters are REMANDED for the following action: Forward the Veteran's claims file to a VA examiner to determine the nature and etiology of his hypertension. The examiner is requested to review all pertinent records associated with the claims file. After considering the Veteran's pertinent medical history and lay statements regarding his reported symptoms, the examiner should opine as to: a) Whether the Veteran's hypertension is at least as likely as not related to in-service exposure to herbicide agents. In making this determination, the examiner must address the National Academy of Science's Agent Orange: Update 11 (2018), which upgrades hypertension from the category of "limited or suggestive" evidence of an association with herbicide exposure to the category of "sufficient" evidence and Veteran's lay statements from his March 2021 correspondence. The examiner is further advised that service connection for a disease can be established on a direct basis as related to herbicide agents and is not precluded solely because the disease is not listed as a presumptive condition associated with herbicide exposure. b) Whether the Veteran's hypertension is at least as likely as not proximately due to the Veteran's service-connected ischemic heart disease. c) Whether the Veteran's hypertension is at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the Veteran's service-connected ischemic heart disease. Aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. The examiner is advised that a finding that the Veteran's hypertension was aggravated beyond the normal progression due to a service-connected disability does not require evidence of permanent worsening and may encompass any additional impairment in earning capacity resulting from an already service-connected condition. The examiner must address the June 2020 letter from the Veteran's physicians as well as the Veteran's lay statements from his March 2021 correspondence. (Continued on the next page) A complete rationale should be provided for the opinion. The clinician is encouraged to cite to medical/scientific information to support the opinion as appropriate. B. G. LeMoine Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Townsend, 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.