Citation Nr: 21030937 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 16-28 191 DATE: May 20, 2021 REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for heart disease is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1985 to October 1985 and from August 1986 to December 1991. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran presented testimony at a Board hearing in March 2019. A transcript of the hearing is associated with the Veteran's claims folder. This case was previously before the Board in June 2019 and January 2021, on which occasions the claims were remanded. 1. Entitlement to service connection for hypertension is remanded. Upon review of the claims file, the Board has determined that further development is necessary before the claim can be adjudicated. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In the Board's January 2021 decision, the Veteran's claim of service connection for hypertension was remanded for an addendum opinion regarding whether the Veteran's current hypertension is related to in-service elevated blood pressure readings, and whether hypertension is at least as likely as not due to or aggravated beyond its natural progression by his service-connected migraine syndrome. In remanding the claim, the Board specifically directed the examiner to address medical articles submitted by the Veteran. In January 2021 the requested addendum opinion was proffered by a VA examiner. The examiner concluded that the Veteran's hypertension was less likely than not related to in-service elevated blood pressure readings. In rendering an opinion, the examiner indicated that the aforementioned elevated blood pressure readings were "transient elevations" followed by normal readings. The examiner noted that the Veteran was not diagnosed or treated for hypertension during service, and was not diagnosed with hypertension until "several years after" his period of active duty service. (1/24/2021, C&P Exam, p. 3). Regarding whether the Veteran's hypertension is at least as likely as not due to or aggravated beyond its natural progression by his service-connected migraine syndrome, the examiner concluded that there is no causative relationship between the disorders. In rendering an opinion, the examiner review the medical articles submitted by the Veteran, but indicated that the articles do not "show evidence of a direct etiological or causational link between migraine headaches and development of . . . hypertension." (1/24/2021, C&P Exam, p. 2-3). The Board finds that the January 2021 VA addendum opinion is inadequate for evaluation purposes. The Board finds that the examiner erred in concluding that the articles do not show evidence of a causational link between migraines and hypertension. In the article "Migraines: Fast Facts on Headaches Pain and Frequency," the author notes that "[r]egular use of [acetylsalicylic acid], ibuprofen and acetaminophen can elevate blood pressure in men . . .." (3/24/2011, Web Documents, p. 4). The Board notes that the Veteran has a long-standing prescription of acetylsalicylic acid and acetaminophen. (3/26/2021, CAPRI, p. 110, 1039). As the January 2021 examiner did not acknowledge or address the Veteran's use of acetylsalicylic acid and acetaminophen, and the possible causative relationship between the regular use of these medications and hypertension, the Board finds that the January 2021 addendum opinion is inadequate. As such, the claim must be remanded for further medical development. 2. Entitlement to service connection for heart disease is remanded. Upon review of the claims file, the Board has determined that further development is necessary before the claim can be adjudicated. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. In the Board's January 2021 decision, the Veteran's claim of service connection for heart disease was remanded for an addendum opinion regarding whether the Veteran's current heart disorders are related to an in-service diagnosis of cardiomegaly, and whether the Veteran's heart disease is at least as likely as not due to or aggravated beyond its natural progression by his service-connected migraine syndrome. In remanding the claim, the Board specifically directed the examiner to address medical articles submitted by the Veteran. In January 2021 the requested addendum opinion was proffered by a VA examiner. Regarding whether the Veteran's current heart disorders are related to an in-service diagnosis of cardiomegaly the examiner concluded that it was not. In rendering an opinion, the examiner acknowledged a March 1989 abdominal Xray report wherein a "mild degree of cardiomegaly" was noted. However, the examiner concluded that a "[d]iagnosis of cardiomegaly can not be established based on the abdominal Xray report." The examiner goes on to conclude that "[s]ervice medical records are silent for diagnosis of cardiomegaly or heart disease." Regarding whether the Veteran's heart disease is at least as likely as not due to or aggravated beyond its natural progression by his service-connected migraine syndrome, the examiner concluded that the disorders are not causally related. In rendering this opinion, the examiner reviewed the medical articles submitted by the Veteran, but indicated that the articles provide an "observational association without established causation or accepted pathophysiological explanation . . .." (1/24/2021, C&P Exam, p. 4-5). The Board finds that the January 2021 VA addendum opinion is inadequate for evaluation purposes. Regarding the examiner's conclusion that a diagnosis of cardiomegaly could not be established based on the Veteran's in-service abdominal Xray report, it is unclear on what grounds the examiner reached this conclusion. The absence of supporting rationale frustrates the Board's review of this claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions."). As such, the Board finds that the opinion is inadequate, and therefore, the claim must be remanded for further medical development. Additionally, the Board finds that the examiner erred in concluding that the Veteran's medical articles provided an "observational association" without evidence of causation. The Board notes that the article "Comorbidities of Migraine" from Frontiers in Neurology, suggests a causative relationship between migraines and heart disease. Specifically, the article indicates that "the proinflammatory or vasoactive peptide released during migraine attacks may damage the vascular endothelium and result in stroke or other vascular events." (3/24/2011, Web Documents, p. 12). As the January 2021 examiner did not acknowledge or address the articles theory of a causative relationship between migraines and heart disease, the Board finds that the January 2021 addendum opinion is inadequate. The claim must therefore be remanded for further medical development. Upon remand, a VA examiner must specifically address the aforementioned article, and in doing so, the examiner must bear in mind the reasonable doubt doctrine. See Quirin v. Shinseki, 22 Vet. App. 390, 395 (2009). In keeping with the benefit of the doubt standard of proof, a medical principle need not reach scientific consensus to adequately support a grant of VA benefits. Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran's disabilities from February 2021 to the present. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's hypertension. The examiner must opine on whether hypertension is at least as likely as not: (a.) related to in-service elevated blood pressure readings, (12/19/1991, STR, p. 68, 71, 77, 100, 119); (b.) proximately due to service-connected migraine syndrome; (c.) aggravated beyond its natural progression by service-connected migraine syndrome; and (d.) related to the Veteran's use of acetylsalicylic acid and acetaminophen. (3/26/2021, CAPRI, p. 110, 1039). The examiner must provide a full explanation for all opinions provided. A full explanation must include discussion of the medical articles submitted by the Veteran and Dr. D's 2015 opinion, and whether the VA physician agrees or disagrees and the reasons why. (3/24/2011, Web Documents, p. 1); (3/2/2018, Medical Treatment Record, p. 1). 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's heart disease. The examiner must opine on whether heart disease is at least as likely as not: (a.) related to an in-service diagnosis of cardiomegaly, (12/19/1991, STR, p. 54); (b.) proximately due to service-connected migraine syndrome; and (c.) aggravated beyond its natural progression by service-connected migraine syndrome. The examiner must provide a full explanation for all opinions provided. A full explanation must include discussion of the medical articles submitted by the Veteran and Dr. D's 2015 opinion, and whether the VA physician agrees or disagrees and the reasons why. (3/24/2011, Web Documents, p. 1); (3/2/2018, Medical Treatment Record, p. 1). The examiner must specifically address the article "Comorbidities of Migraine" and the author's suggestion that "the proinflammatory or vasoactive peptide released during migraine attacks may damage the vascular endothelium and result in stroke or other vascular events." In rendering an opinion, the examiner is reminded that a medical principle need not reach scientific consensus to adequately support a grant of VA benefits. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Glenn, 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.