Citation Nr: 21030315 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 11-08 331 DATE: May 18, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1976 to August 1980. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In December 2013, the Veteran had a hearing before the undersigned judge via Video Conference and a transcript of that hearing is of record. In July 2014, April 2017, and November 2018, this claim was remanded for additional development. Entitlement to service connection for hypertension is remanded. The Veteran and representative assert that his hypertension is related, as in caused or aggravated by, his service-connected disabilities. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. A September 2020 VA examination resulted in a diagnosis of hypertension. Therefore, the Board finds that the evidence as to whether the Veteran has a current disability for this claim meets the initial threshold criterion for entitlement to service connection. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). The Board notes that the September 2020 VA examiner opined that his hypertension is less likely than not caused by his service-connected disabilities. The examiner explained that the Veteran's service-connected right wrist ganglion cyst, duodenitis, gastritis, and dysthymic disorder are not medically related to a diagnosis of hypertension and are not likely to cause or aggravate the Veteran's disability. The examiner added that a thorough review of medical literature failed to demonstrate a causal relationship between these disabilities and a diagnosis of hypertension. Regarding a potential link between the Veteran's service-connected hepatitis C and his hypertension, the examiner explained that hypertension has numerous risk factors, including "unhealthy diet, harmful use of alcohol, smoking, lack of physical activity, overweight/obesity and longstanding stress," and nonmodifiable risks include "age, gender, and ethnicity." The examiner added, that based on research, hepatitis C and cardiovascular alterations are common conditions observed in a large proportion of the general population and it is difficult to establish whether a simple association exists between the two conditions, or whether other pathogenic mechanisms directly or indirectly link chronic hepatitis C infection to cardiovascular disorders. The examiner added that with a variety of risk factors and comorbidities present in this Veteran that can lead to hypertension it would be mere speculation to definitively state one specific etiology was the origin of this disease in the presence of multiple risk factors and comorbidities. The examiner also explained that the Veteran's hypertension was diagnosed as essential hypertension as it has no known secondary cause. The examiner concluded that, based on a thorough review of medical literature, while there may be comorbidities with these disabilities, a causal relationship with these disabilities have not been demonstrated and there is no objective evidence that hepatitis C leads to hypertension. In January 2021, another VA examiner provided an addendum that explained why the Veteran's hypertension was not related to his active duty service. The examiner based this opinion on the fact that the Veteran's hypertension originated years after his active duty service, with a diagnosis in 2006. The examiner also provided a likely cause for the Veteran's hypertension, noting that the Veteran's nonservice-connected HIV led to his nonservice-connected renal disease and likely caused the Veteran's hypertension. Subsequently, the Veteran and his representative submitted a Brief supporting the Veteran's claim in May 2021. In this Brief, they challenged the credentials of the VA examiners' opinions, and notably, they provided some medical literature from the Centers for Disease Control and other sources noting a link between sleep impairment and number of chronic diseases and conditions, including cardiovascular disease. In this regard, the Board notes that the Veteran's psychiatric disorder includes symptoms of a sleep disorder. Based on this, the Board finds that this medical literature, raises the possibility of a link between the Veteran's service-connected dysthymic disorder and his hypertension. Accordingly, another remand is needed so that a VA examiner can adequately address the noted medical literature and whether the Veteran's symptoms associated with his service-connected psychiatric disorder impact his hypertension. The matter is REMANDED for the following action: Afford the Veteran a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's hypertension. Any and all tests, studies, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, and medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: a. Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's hypertension was caused or aggravated by the Veteran's service-connected disabilities, primarily his dysthymic disorder. b. The examiner is also asked to specifically address the noted medical literature linking the impact of noted sleep impairments with cardiovascular disease, including hypertension. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. R. Montalvo, 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.