Citation Nr: 21029369 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 15-24 270 DATE: May 13, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents and secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from May 1966 to February 1968, to include service in the Republic of Vietnam. He is the recipient of the Purple Heart award. This matter is before the Board of Veteran's Appeals (Board) on appeal from a February 2014 rating decision of a Department of Veteran Affairs (VA) Regional Office (RO) in New York, New York. This matter was previously remanded by the Board for additional development in August 2018 and October 2019. Although the Board regrets the additional delay, another remand is necessary in order to afford the Veteran an adequate VA examination with opinion that addresses all theories of entitlement. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents and secondary to service-connected disabilities, is remanded. The Veteran is seeking service connection for hypertension. In its most recent remand, the Board found that although the April 2019 VA examiner determined that the Veteran's obesity was not caused by medications taken for his service-connected disabilities, the VA opinion was inadequate as the examiner did not address whether the Veteran's service-connected PTSD contributed to his hypertension as indicated in a March 2014 private opinion. There were also inconsistencies in the report concerning when the Veteran started taking medication for his erectile dysfunction. As such, the Board remanded this matter again for another VA examination with opinion to address these matters. The January 2020 VA examiner found that it is less likely than not that the Veteran's hypertension is related to PTSD, anxiety, and depression. The cause of primary (essential) hypertension is poorly understood and is most likely the result of numerous genetic and environmental factors that have compounding effects on cardiovascular and renal structure and function. Mental health conditions, although can cause acute elevations in blood pressure in acute stress, are not a common cause of secondary hypertension. The examiner also found that it is less likely than not that Veteran's hypertension is proximately due to medications that the Veteran used to treat his service-connected erectile dysfunction. The Veteran was diagnosed with hypertension many years prior to using medication for his service-connected erectile dysfunction. In an October 2020 addendum opinion, the examiner noted that the March 2014 private opinion was reviewed and again stated that while not the causation of hypertension, mental health conditions can cause acute elevation. Likewise, the examiner noted that the Veteran used Viagra, which did not cause hypertension. The examiner stated that one of the potential side effects of Viagra is a dangerous drop in blood pressure. However, the examiner did not offer a detailed rationale for finding that PTSD was not the cause of the Veteran's hypertension, but rather simply stated that there are numerous factors that cause hypertension without explicitly discussing the Veteran's risk factors. Moreover, there has been no medical opinion as to whether the Veteran's service-connected disabilities aggravated his hypertension. Importantly, the VA examiner indicated that anxiety could cause acute elevation in blood pressure. Significantly the United States Court of Appeals for Veterans Claims (Court) has held that any incremental increase in nonservice-connected disability by service-connected conditions warrants secondary service connection regardless of permanence. See Ward v. Wilkie, No. 16-2157, 17-1204 (Vet. App. June 14, 2019). Thus, an opinion is needed as to whether the Veteran's service-connected disabilities cause or aggravate his hypertension, to include any incremental increase, even transient, regardless of permanence. Moreover, importantly, when considering a claim for service connection, the Board is required to consider all theories of entitlement to service connection. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). Here, the Veteran's February 1968 discharge examination showed blood pressure of 120/70. Thus, the systolic reading was slightly elevated. Further, the Veteran served in the Republic of Vietnam during the Vietnam era and, thus, is presumed to have been exposed to herbicide agents. Although VA has not conceded a relationship between hypertension and herbicides, it is significant to note that the National Academy of Sciences (NAS) has indicated that there is 'sufficient' evidence of an association between hypertension and herbicide agent exposure. See National Academy of Sciences Report, Veterans and Agent Orange: Update 11 (2018); see also 38 C.F.R. § 3.309(e). However, there has been no opinion as to whether the Veteran's hypertension is presumed to be due to service, or directly related to service, to include exposure to herbicide agents. In light of the above, the Board finds that another addendum opinion is necessary to address the etiology of the Veteran's hypertension. Lastly, in light of the need to remand, additional VA clinical records should be obtained. The matters are REMANDED for the following action: 1. Obtain VA treatment records from August 2020 to the present. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hypertension. The need for another examination is left to the discretion of the clinician. After reviewing the record, the examiner must address the following: (a) The examiner must opine whether it is at least as likely as not that the Veteran's hypertension (1) began during active service, (2) manifested within one year after discharge from service, (3) was noted during service with continuity of the same symptomatology since service, or (4) related to an in-service injury, event, or disease, to include presumed exposure to herbicide agents. The examiner must offer a detailed rationale for the opinions. In rendering the above opinions, the examiner must specifically consider and discuss all relevant evidence of record, including the slightly elevated systolic blood pressure reading upon discharge and the 2018 NAS update which changed hypertension to the category of "sufficient" evidence of an association to herbicide exposure from its previous classification in the "limited or suggestive" category. A negative nexus opinion based on the fact that hypertension is not a chronic disease listed at 38 C.F.R. § 3.309 (e) is insufficient. (b) If hypertension is not found to be directly related to service, the examiner must opine whether it is at least as likely as not proximately due to service-connected PTSD and erectile dysfunction; or aggravated by service-connected PTSD and erectile dysfunction. The examiner must offer a detailed rationale for the opinions. In proffering this opinion, the examiner must determine whether the Veteran's service-connected disabilities cause any incremental increase, even transient, in his hypertension regardless of permanence. The examiner must specifically address the prior findings that anxiety can cause acute elevation in blood pressure. L.M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.N. Moats 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.