Citation Nr: 21040161 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-58 637 DATE: July 2, 2021 ORDER Service connection for hypertension, including as due to or aggravated by service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The Veteran's hypertension is not shown to be causally or etiologically related to his military service or caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1131, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1974 to September 1976. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2017 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this case in January 2019 and again in June 2020 for further development, to include a VA examination. As the requested examination occurred in July 2020, no other action to ensure compliance with the remand directives is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although the Veteran's attorney attempted to withdrawal representation in a February 2021 letter, this notification was received after the recertification of the appeal to the Board in December 2020, a copy of which was mailed to the Veteran's attorney. In addition, the Veteran's attorney provided no good cause for the withdrawal of representation. Therefore, the attorney remains the Veteran's representative. Service connection for hypertension. The Veteran and his representative argue that the evidence of record shows that the Veteran began to experience chest and increased blood pressure while in service, noting he was seen in service with reports of chronic pain in the left side of his chest. Alternatively, the Veteran contends that his hypertension was caused or aggravated by his service-connected PTSD. Service connection will be granted for a current disability that resulted from an injury, disease, or aggravation while in active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection requires (1) a present disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the present disability and the in-service incurrence or aggravation of a disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may alternatively be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or worsened beyond its natural progression (aggravated) by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc); 38 C.F.R. § 3.310. The Veteran is competent to report symptoms and experiences he can observe. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102. The Veteran submitted two articles in support of his claim for secondary service connection: "Risk for Incident Hypertension Associated with PTSD in Military Veterans and The Effect of PTSD Treatment," which concluded the study observed a 24 to 46 percent greater risk for incident hypertension associated with untreated PTSD, and "Anxiety Disorder, Hypertension, and Cardiovascular Risk: A Review," which found a positive association between anxiety and hypertension. Service treatment records demonstrate the Veteran's blood pressure (BP) was high during the December 1973 entrance examination at 136/84 but was typically within normal limits while in service with a BP of 120/90 on February 15, 1976, a BP of 110/70 on February 16, 1976, and a BP of 120/80 during the August 1976 separation examination. In February 1975, the Veteran was seen for complaints of chest pain in the left side of his chest radiating to the left shoulder, notably not "chronic pain," as the Veteran's representative reported. The February 1975 physician determined the Veteran had chest congestion. In February 1976, the Veteran was treated for complaints of chest pain for three days, worse when inhaling; the physician's impression was chest congestion. Upon further examination the following day, the physician observed unusual calcifications of the left rib and determined possible costochondritis. The July 2020 VA examiner opined the Veteran's current hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness as service treatment records do not show any signs, symptoms, diagnosis, or treatment of hypertension while on active duty or within one year of separation. The examiner considered the Veteran's contention regarding service treatment records showing chest pain and elevated BP during service were manifestations of his hypertension. However, the examiner explained a diagnosis of hypertension requires persistently elevated BP over weeks. Isolated and transient elevations are common and physiologic/normal. The July 2020 VA examiner also opined that the Veteran's current hypertension was less likely than not proximately due to, the result of, or aggravated by the Veteran's service-connected PTSD because a review of current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health condition, including PTSD, and a physiologic condition of hypertension. While anxiety states can cause a temporary elevation in blood pressure, they do not cause or permanently aggravate primary or secondary hypertension. The July 2020 VA examiner's opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board concludes that, while the Veteran has a current diagnosis of hypertension, and evidence shows that he experienced chest pain in-service, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of hypertension began during service or is otherwise related to an in-service injury, event, or disease as the evidence does not show the chest pain experienced in service was related to hypertension. The preponderance of the evidence is also against finding that the Veteran's hypertension is proximately due to or the result of or aggravated beyond its natural progression by his service-connected PTSD. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). VA treatment records show the Veteran was not diagnosed with hypertension until 2000, 24 years after his separation from service. While the Veteran is competent to report having experienced symptoms of chest pain in service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of hypertension. The Veteran also believes his hypertension is proximately due to, the result of, or aggravated beyond its natural progression by his service-connected PTSD. While the Veteran provided articles finding a correlation between untreated PTSD and anxiety and hypertension, the articles did not prove causation. The Veteran and his representative, in this case, are not competent to provide a nexus opinion regarding this issue. These issues are medically complex, as they require knowledge of the interaction between multiple organ systems in the body and complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his representative in this case because the record does not show that they have the skills or medical training to make determinations regarding whether chest pain attributed to congestion and costochondritis in service was indicative of hypertension or whether medical articles illustrating a correlation between untreated PTSD and anxiety and hypertension is demonstrative of the Veteran's PTSD causing or aggravating his hypertension. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the July 2020 VA examiner's opinions. In deciding to deny the claim, the applicability of the benefit of the doubt doctrine was considered; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56; 38 C.F.R. § 3.102. The claim of service connection for hypertension is denied. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Costa, 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.