Citation Nr: 21032636 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 11-08 883A DATE: May 27, 2021 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents, or as secondary to service-connected coronary artery disease (CAD) with ischemic heart disease (IHD), posttraumatic stress disorder (PTSD), and/or diabetes mellitus, type II, with proteinuria, (DM) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1964 to April 1968, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In August 2014, the case was remanded in order to afford the Veteran his requested Board hearing. In September 2015, he testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In November 2017, January 2019, and September 2020, the case was remanded for additional development and it now returns for further appellate review. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents, or as secondary to service-connected CAD with IHD, PTSD, and/or DM. In the September 2020 Remand, the Board remanded the claim in order to obtain an opinion addressing whether the Veteran's hypertension is related to his acknowledged in-service exposure to herbicide agents. In this regard, the Board directed that, in offering his or her opinion, the VA should examiner consider the National Academy (NAS) Institute of Medicine's (IOM's) Veterans and Agent Orange: Update 11 (2018) that upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association with exposure to Agent Orange to the category of "sufficient" evidence of an association; the Veteran's argument that he was 33 at the time of his hypertension diagnosis and did not have an elevated body mass index (BMI); and the medical treatise cited by the Veteran's representative in the August 2020 Written Brief Presentation for the proposition that hypertension can exist for years without detection. In a September 2020, a VA examiner reviewed the record, to specifically include the August 2020 Written Brief Presentation and the arguments and medical treatise cited therein, and opined that the Veteran's hypertension was less likely than not related to his acknowledged herbicide exposure. In support thereof, he noted that the article cited by the Veteran's representative was correct in that hypertension can be quiescent of symptoms for years, but such also listed other risk factors for hypertension, to include tobacco use and an elevated BMI. The examiner further observed that the Veteran was diagnosed with hypertension seven years after his separation from service and last exposure to herbicide agents. He also noted that nicotine in smoke is a clear and undebatable vasoconstrictor that can have sustained lifelong detrimental effects, to include hypertension, even when it has been ceased and the exposure was in the past. Thus, the examiner found that, while the Veteran had been smoke-free for more than 20 years, he had a significant history of smoking prior to quitting. Consequently, he determined that, even if the Veteran did not recall having an elevated BMI at age 33, he met the threshold for significant smoking/nicotine, which could not be ignored as a major risk factor for hypertension. The examiner further stated that, if his exposure to herbicide agents, i.e., Agent Orange, in service caused his hypertension, his February 1968 separation examination would reflect such disorder; however, at such time, his blood pressure was 122/64. Thus, he found that the Veteran was not diagnosed with hypertension during service or within 12 months afterwards, and did not develop such disorder proximally after his exposure to herbicide agents. The examiner also reiterated that, even if the Veteran's BMI was not elevated at the time of his diagnosis of hypertension, he had other major risk factors to account for such disorder. Consequently, he found that, even in consideration of the NAS IOM's recent in 2018, it was unlikely that his exposure to herbicide agents caused the Veteran's hypertension. However, while the September 2020 VA examiner properly discounted the Veteran's alleged elevated BMI in offering his opinion, the Board finds that it is unclear whether he properly considered the length of time that he smoked prior to his diagnosis of hypertension. In this regard, the examiner indicated that the Veteran had a significant history of smoking prior to quitting 20 years previously, which is true as he had a 57 year history of smoking as began at age 16 (see July 2017 VA treatment records), he only had a 17 year history of smoking by age 33, at which time he was diagnosed with hypertension. Furthermore, in determining that the Veteran's hypertension is unrelated to his in-service exposure to herbicide agents, the examiner relies on the fact that his blood pressure was normal at the time of his February 1968 separation examination. However, in his May 2021 Written Brief Presentation, the Veteran's representative asserts that, "[t]he Agent Orange: Update 11, like preceding reports, is based on long term studies of the health effects, often latent and slow to become manifest, of herbicide exposure." Additionally, the examiner noted that "hypertension can be quiescent of symptoms for years." Thus, it appears that he relied upon an improper premise in reaching his opinion. Consequently, a remand is necessary in order to obtain another addendum opinion to address such matters. The matter is REMANDED for the following action: Forward the record, to include a copy of this Remand, to an appropriate VA clinician other than the examiner who provided the October 2019 and September 2020 opinions, if possible, to obtain an addendum opinion regarding the etiology of the Veteran's hypertension. Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e. a probability of 50 percent or greater) that the Veteran's hypertension is related to his acknowledged in-service exposure to herbicide agents. In offering such opinion, the examiner should consider NAS IOM's Veterans and Agent Orange: Update 11 (2018) that upgraded hypertension from its previous classification in the category of "limited or suggestive" evidence of an association with exposure to Agent Orange to the category of "sufficient" evidence of an association; the Veteran's argument that he was 33 at the time of his hypertension diagnosis and did not have an elevated BMI; had a smoking history of approximately 17 years before diagnosis; and the medical treatise cited by the Veteran's representative in the August 2020 Written Brief Presentation for the proposition that hypertension can exist for years without detection. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.