Citation Nr: 21040203 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-60 259 DATE: July 2, 2021 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), and to include as due to exposure to herbicide agents, is denied. FINDING OF FACT The Veteran's hypertension did not manifest in service, or within one year after separation, and is not shown to be causally or etiologically related to an in-service event, injury or disease; or to be related to exposure to herbicide agents; or as secondary to service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from November 1967 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in December 2018, the Board remanded the issue on appeal for further evidentiary development. That development having been completed the issue is once again before the Board for appellate consideration. The Board observes that additional VA treatment records were received following the last adjudication by the RO in the June 2020 supplemental statement of the case. The Board has reviewed these records and observes that they are duplicative, cumulative, and/or not pertinent to the issue on appeal addressed in the decision below. Service Connection Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). Certain diseases, to include hypertension may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. Service connection may also be established based on herbicide agent exposure. 38 C.F.R. § 3.307(a)(6). For VA purposes, an "herbicide agent" includes the chemicals 2, 4-D; 2, 4, 5-T and its contaminant TCCD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i). For the purposes of determining herbicide agent exposure, a veteran who served in qualifying locations is presumed to have been exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). If the veteran is presumed to have been exposed to herbicide agents, the veteran is entitled to a presumption of service connection for certain disorders. See 38 C.F.R. § 3.309(e). Here, the Veteran's military personnel records confirm that the Veteran was in Vietnam and was awarded the Purple Heart for wounds received in connection with military operations against a hostile force. See June 2019 Military Personnel Record. As such, exposure to herbicide agents is conceded. See February 2020 VA Memo. However, hypertension is not on the list of presumed disease based on exposure to herbicide agents. Accordingly, the Veteran is unable to avail himself under the theory of presumptive service connection based on exposure to herbicide agents. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, and to include as due to exposure to herbicide agents In this case, the Veteran argued that he is entitled to service connection for his hypertension as his hypertension has been a chronic issue since his first work physical after returning from Vietnam. See December 2016 Form 9. The Veteran contends that his hypertension manifested due to his service-connected PTSD, or in the alternative, due to his exposure to herbicide agents. Id. At the outset, the Board notes that in a February 2021 VA treatment record the Veteran was diagnosed with hypertension. See March 2021 CAPRI. As such, the first element of service connection is met. The Board also notes that the Veteran is service connected for PTSD. Concerning the second element, the service treatment records are silent for any complaints, symptoms, or diagnoses of hypertension during his service. However, the Board notes that the Veteran's blood pressure was elevated with a reading of 128/68 in the July 1967 induction examination, 140/80 in a June 1969 examination, and 134/72 in the October 1969 separation examination. That being said, in the October 1969 separation report of medical history, the Veteran denied having high blood pressure. The Veteran was not diagnosed with hypertension or borderline hypertension in service. In fact, based on the records, the earliest diagnosis of hypertension was in 2005, more than 30 years after service. See March 2016 Medical Treatment Record Non-Government Facility. Moreover, even the Veteran conceded that his hypertension manifested after service. See December 2016 Form 9. However, as the Veteran was stationed in Vietnam the Board finds that the Veteran was exposed to herbicide agents and as such the second element of service connection has been met. As the Veteran alleged that his hypertension manifested as secondary to his service-connected PTSD and as a result of his exposure to herbicide agents, the Board will address both concurrently. Turning to the medical evidence, the Board notes that VA medical opinions were obtained in May 2017, September 2019, and December 2019. The May 2017 VA examiner opined that the Veteran's hypertension is less likely than not proximately due to or the result of his service-connected PTSD. The examiner explained that PTSD has been implicated in temporarily raising blood pressure but does not have a proven association with sustained elevation of blood pressure. Based on peer-reviewed medical literature, PTSD has not been confirmed as a cause of or risk factor for chronic hypertension. Some studies have suggested a relationship may exist between PTSD, hypertension, and heart disease but scientific evidence to date has not definitively linked these conditions. The examiner also opined that the Veteran's hypertension is less likely than not was permanently worsened or aggravated beyond its natural progression by his service-connected PTSD. The examiner explained that from a review of objective clinical records, there is no evidence that the Veteran has ever complained of PTSD symptoms since he was diagnosed with hypertension. The examiner further noted that since 2005 the Veteran's hypertension was well managed and controlled with medication. Additionally, the examiner opined that the Veteran's hypertension is less likely than not due to his presumed exposure to herbicide agents during his service in Vietnam. The examiner explained that credible peer-reviewed medical literature indicates that there are numerous risk factors for development of hypertension, such as age, obesity, dyslipidemia, obstructive sleep apnea, and family history of hypertension. Of note, environmental exposure to herbicides of any type are not reported as a risk factor for developing hypertension. While a National Academy of Science (NAS) report indicated that there was 'limited or suggestive evidence of an association between herbicide exposure and hypertension,' it does not report that hypertension is caused by herbicide exposure, including exposure to Agent Orange. The examiner further referenced several studies that found that there were no compelling scientific studies demonstrating a causal relationship between herbicide agents and disease development. As such, the examiner determined that it is less likely than not that the Veteran's hypertension was caused by or due to his conceded exposure to herbicide agents. In December 2018, the Board remanded the issue on appeal as there was a change of association between hypertension and exposure to herbicide agents. Since the May 2017 VA examination, as noted in Veterans and Agent Orange: Update 11 (2018), the NAS found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War. Hypertension has been upgraded from its previous classification in the category of "limited or suggestive" evidence of an association to the category of "sufficient" evidence of an association. According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. Based on the foregoing, the Board remanded the issue as the examiner should consider the NAS 2018 conclusion that hypertension has been upgraded from its previous classification in the category of "limited or suggestive" evidence of an association to the category of "sufficient" evidence of an association. In the September 2019 VA addendum opinion, a psychologist reviewed the medical articles referenced in the representative's brief and although the article indicated that a relationship between PTSD and hypertension may exist, no definitive finding was cited. A correlation between two disorders does not mean that one caused or contributed to the other. In the December 2019 VA addendum opinion, the same examiner from the May 2017 opined that it is less likely than not that hypertension was caused by, or is otherwise etiologically related to, the Veteran's presumed exposure to herbicide agents. The examiner explained that there is no confirmed evidence that herbicide agents cause hypertension. The examiner stated that IOM agent orange report openly acknowledged that it is reporting on 'associations' between presumed herbicide exposure and a medical condition. A finding of 'association' requires less evidence and does not the meet the stricter criteria to establish causality. Although the NAS found sufficient evidence of an association for hypertension and exposure to Agent Orange and other herbicides used during the Vietnam War, sufficient evidence needs to be established with corresponding epidemiologic data and may be strengthened by experimental data supporting biologic plausibility. Based on the numerous cited literature the examiner opined that it is less likely than not that the Veteran's hypertension was caused by, or is otherwise etiologically related to, the Veteran's presumed herbicide exposure. The examiner also opined that it is less likely than not that the Veteran's hypertension was caused by the Veteran's service-connected PTSD. The examiner explained that credible references do not confirm that PTSD causes hypertension. Although PTSD may temporarily increase blood pressure, it does not cause sustained hypertension. The examiner also addressed the medical literature submitted by the Veteran's representative. The examiner explained that the article used verbiage such as 'may contribute to' and 'may partly account for' which does not meet the VA criteria for being at least 50 percent likely. Further, one pertinent cited article even noted that there was limitation in their studies. The examiner stated that the cited articles were published in 2011 whereas more recent references (i.e., 2018) provides conflicting evidence. Based on the entirety of the record, the examiner opined that it is less likely than not that the Veteran's hypertension was caused by the Veteran's service-connected PTSD. Additionally, the examiner opined that it is less likely than not that the Veteran's hypertension was permanently aggravated or worsened by the Veteran's service-connected PTSD. The examiner explained that there is no evidence that the Veteran's hypertension worsened over time. The examiner noted that since 2005 the Veteran's hypertension was well controlled with medication. As his blood pressure is well controlled and he remains on the same number of medications, there is no evidence to indicate that his hypertension worsened due to PTSD. In support of his claim, the Veteran submitted a medical article from the Open Cardiovascular Medicine Journal that stated that persons with PTSD may have an increased risk of coronary artery disease and that reported links between PTSD and hypertension and other cardiovascular risk factors may partly account for reported associations between PTSD and heart disease. The Veteran conceded that his hypertension manifested after service. Although the Veteran claims that his hypertension manifested as a result of his PTSD and/or exposure to herbicide agents, he failed to submit any medical evidence that shows that his hypertension has been caused, or aggravated by, his PTSD or that his hypertension is etiologically related to his exposure to herbicide agents. The Board affords low probative value to the medical article referenced in the December 2017 appellant's brief as the article used terms such as "may" and "may partly" which implies that PTSD may or may not cause hypertension. Thus, it is too speculative on whether PTSD causes or aggravates a claimant's hypertension. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (physician's comment couched in terms of "may or may not" was held to be speculative); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the Veteran "may" have had pertinent symptoms also implied "may or may not," and was deemed speculative). The Board also notes that the medical article referenced in the December 2017 appellant's brief doesn't discuss the circumstances specific to this Veteran. Based upon the foregoing, the Board finds that competent evidence of a nexus between the Veteran's hypertension and his PTSD is not of record. The Board affords great probative value to the 2017 VA examiner's medical opinion that the Veteran's hypertension was not proximately caused by or aggravated by his service-connected PTSD. The examiner explained that from a review of objective clinical records, there is no evidence that the Veteran has ever complained of PTSD symptoms since he was diagnosed with hypertension. The examiner further noted that since 2005 the Veteran's hypertension was well managed and controlled with medication. The Board also finds probative the opinion of the 2019 VA psychologist that reviewed the medical articles referenced in the representative's brief and opined that a correlation between two disorders does not mean that one caused or contributed to the other. The Board notes that the examiner opined that the Veteran's PTSD did not permanently aggravate the Veteran's hypertension. Although a finding of aggravation does not require a finding of permanent aggravation, the Board finds that a remand is not necessary as the examiner explained that since 2005 the Veteran's hypertension is well controlled with medication with the same number of medications indicating that the hypertension was not worsened due to PTSD. As such, the Board finds that the weight of the competent evidence of record weighs against a finding that the Veteran's service-connected PTSD caused, or aggravated, his hypertension. The Board also affords great probative value to the December 2019 VA examiner's assessment that it is less likely than not that hypertension was caused by, or is otherwise etiologically related to, the Veteran's presumed exposure to herbicide agents as it is uncontradicted and based on the examiners' medical knowledge, training, and experience. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The December 2019 examiner stated that current medical literature does not support a cause and effect relationship between PTSD and/or exposure to herbicide agents and hypertension. As such, the Board finds that the weight of the competent evidence of record weighs against a finding that the Veteran's hypertension is directly due to any event or injury incurred during his period of active service, to include his exposure to herbicide agents. The Board has considered the Veteran's statements and belief that his hypertension is related to service. Although lay persons are competent to provide opinions on some medical issues, etiology of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Accordingly, the Board gives no probative value to the Veteran's statement as to the etiology of his hypertension. As for presumptive service connection based on chronic disease, the Board finds the preponderance of the evidence does not support a finding that the Veteran's hypertension manifested to a compensable level in the first post-service year. 38 C.F.R. § 3.309(a). Based on the records, the Veteran's high blood pressure was first documented in 2005, more than 30 years after his service. See March 2016 Medical Treatment Record Non-Government Facility. As there is no evidence of manifestation within the first post-service year, service connection for hypertension based on the presumption in favor of chronic disease is not warranted in this case. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. (Continued on the next page) In sum, the criteria for service connection for hypertension have not been met. The evidence does not show that hypertension is directly related to his military service, to include exposure to herbicide agents. Further, there is insufficient evidence to support the Veteran's allegation that his hypertension was proximately caused or aggravated by his service-connected PTSD. 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309, 3.310. Accordingly, service connection for hypertension must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Patrick M. Johnson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.