Citation Nr: 21030570 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 15-35 424 DATE: May 19, 2021 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a heart condition, including non-ischemic cardiomyopathy and aortic root dilation, is denied. FINDINGS OF FACT 1. The Veteran's pre-existing hypertension was documented on entrance, and was not aggravated by his active service. 2. The preponderance of the evidence is against finding that a heart condition, including non-ischemic cardiomyopathy and aortic roto dilation, began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1111, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for service connection for a heart condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1997 to October 1997 and from May 2004 to June 2004. He also served in the New Jersey National Guard from March 1997 to November 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Board remanded the claims for additional development. In March 2019, the Veteran testified at a hearing before a Board Veterans Law Judge (VLJ). In a March 2021 letter, the Board notified the Veteran that the VLJ who conducted his hearing is no longer employed by the Board, and that he could have a new hearing. The Veteran did not respond; therefore, another hearing will not be scheduled. Service Connection 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a heart condition, including valvular HD and endocarditis. The Veteran seeks service connection for hypertension and a heart condition. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 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). Generally, a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304 (b). A pre-existing injury or disease will be considered to have been aggravated during service where there is an increase in disability during service unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. However, aggravation of a pre-existing injury or disease will not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Service treatment records reflect a diagnosis of hypertension at entrance. At entrance examination in December 1996, blood pressure was noted as 183/99. The examination did not note any heart abnormalities. Blood pressure checks were noted at 154/90 and 165/92. The summary of defects and diagnosis indicated an assessment of hypertension. During service, the Veteran's treatment records indicate persistent elevated blood pressure. At a March 2001 examination, providers noted blood pressure of 140/108. Interval history showed that Veteran had hypertension and had been on medications since 1997. In June 2004, the Veteran presented to the emergency room with complaints of chest pain. He reported substernal chest pain, headache, and dizziness. Providers noted a prior medical history of difficult to control hypertension and mitral valve prolapse. Physical examination showed a blood pressure of 176/102. Providers found that it was possible that all the symptoms were related to markedly elevated blood pressure, but the possibility of acute coronary syndrome could not be excluded. A June 2004 exercise electrocardiogram was unassociated with anginal symptoms. However, an EKG revealed sinus tachycardia and left ventricular hypertrophy. An August 2004 letter from the Veteran's treatment provider indicated a longstanding diagnosis of hypertension and left ventricular hypertrophy. The Veteran's blood pressure was noted to be over 200/110 during an overseas deployment physical in June 2004. The treatment provider opined that the Veteran's blood pressure was strongly influenced by his mood state, specifically anxiety and depression, which had worsened when the Veteran became extremely anxious over the possibility of deployment to Iraq. Upon the Veteran's return, his blood pressure had improved significantly upon returning to civilian life. The treatment provider concluded that the diagnosis of left ventricular hypertrophy and aortic insufficiency make it imperative that his blood pressure be controlled adequately. Thus, he concluded the Veteran was unable to serve in the National Guard and was nondeployable due to severe anxiety interfering with his blood pressure control. The Veteran's report of separation indicate that he was medically discharged in November 2004. Private treatment records reflect ongoing cardiology treatment for hypertension, hyperlipidemia, and nonischemic cardiomyopathy. The Veteran underwent a cardiac catherization in December 2011. Blood pressure was noted as 160/80, and reveal mild left ventricular dysfunction. A March 2019 cardiology note showed no complaints of chest discomfort, shortness of breath, dizziness, palpitations, presyncope, or swelling. Prior medical history showed mild left ventricular systolic dysfunction, which treatment providers concluded was likely hypertensive in nature since the Veteran's blood pressure at the time was elevated and his overall ejection fraction had improved since he was on blood pressure medications. The Veteran was afforded a VA examination for hypertension in October 2020. Medical history showed a hypertension diagnosis in December 1996 at the Veteran's entrance examination. The Veteran's hypertension was noted as poorly controlled despite attempts with multiple medications and diagnostic testing to identify any other causes. A history of left ventricular ejection fraction was noted, and believed to be due to hypertension. The examiner opined that the Veteran's hypertension pre-existed service and was not specifically exacerbated by service. The examiner stated that the Veteran's hypertension was poorly controlled throughout his service periods. He explained that this was typical of hypertension. However, the examined indicated that the progression was not beyond normal progression for this disorder. Further, there was no evidence of permanent aggravation beyond normal progression identified. The examiner elsewhere remarked that the Veteran's hypertension was likely genetic, given that he had two brothers who have the same condition. The Veteran was afforded a VA examination for heart conditions in October 2020. In addition to hypertension, the examiner noted a history of non-ischemic cardiomyopathy and dilated aortic root. The examiner explained that chronically uncontrolled hypertension may have caused the systolic dysfunction; however, this had improved and recovered with treatment. The examiner also explained that the Veteran's dilated aortic root was likely genetic, since he had two brothers with the same condition. The examiner opined that the Veteran's systolic dysfunction and aortic dilation were not related to service. The examiner explained that, although the Veteran's hypertension remained poorly controlled during service, he developed non-ischemic cardiomyopathy after discharge. There was insufficient evidence to support that this was caused by or exacerbated by time in service. The examiner noted the Veteran also had mildly dilated aortic dilation, but explained that so do his brothers, making it far more likely to be genetic in origin and not caused by his hypertension. The examiner noted that recent research does not support any causal relationship between hypertension and aortic root dilation. Thus, the examiner concluded the Veteran's heart conditions were not related to service. Upon review, the Board finds that service connection is not warranted. Initially, the Board finds the presumption of soundness does not apply to the Veteran's hypertension. The December 1996 entrance examination indicates three elevated blood pressure checks, and a specific diagnosis of hypertension by the provider. As such, the presumption of sound condition at entrance does not apply to this condition. 38 C.F.R. § 3.304(b). As a pre-existing disability was noted on entrance, the remaining question is whether the Veteran's hypertension was aggravated by his service. On this question, the Board finds the October 2020 VA examination competent and probative evidence. The VA examines has the appropriate training, expertise, and knowledge to evaluate the claimed disability. He provided a thorough and cogent rationale for his findings and opinions, which included consideration of the Veteran's reported symptoms both during and after service, and the in-service and post-service clinical history. There is no competent medical opinion to the contrary. In the absence of a competent, favorable nexus opinion, the preponderance of the evidence is against the claim. Accordingly, service connection for hypertension is denied. As to the Veteran's other heart conditions to include non-ischemic cardiomyopathy and dilated aortic root, the Board finds the October 2020 VA opinion is competent and probative evidence against the claim. As noted, the examiner is competent to opine on the matter. The examiner also supported his negative opinion with a well-reasoned rationale. This included consideration of the Veteran's extensive service and post-service medical history. Ultimately, the VA examiner could not establish a nexus between the symptoms and diagnoses in service and the post-service diagnoses. Instead, the examiner noted that the Veteran's non-ischemic cardiomyopathy was indicative of uncontrolled hypertension. In addition, the examiner determined that the Veteran's symptoms resolved without sequela after his underlying hypertension was treated. With respect to aortic root dilation, the examiner explained this was likely genetic since the Veteran had two brothers with the same condition. The examiner also determined that the Veteran's non-ischemic cardiomyopathy condition was not diagnosed until many years after separation from service. Ultimately, as the weight of the competent and probative evidence is against the Veteran's claim. The Board has considered the applicability of the benefit of the doubt doctrine; however, that doctrine is not applicable. Service connection is not warranted. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Lauritzen, 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.