Citation Nr: 21041437 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 17-19 798 DATE: July 9, 2021 ORDER Service connection for hypertension, to include as secondary to in-service exposure to herbicide agents and/or as secondary to the service-connected coronary artery disease (CAD) and the service-connected posttraumatic stress disorder (PTSD), is denied. FINDING OF FACT The Veteran's hypertension was not manifested in service or for many years thereafter and is not related to service or any aspect thereof, including in service exposure to herbicide agents and service-connected CAD or service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as due to in service exposure to herbicide agents or as secondary to service-connected CAD or service-connected PTSD are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from December 1967 to September 1971. In September 2019, he testified at a Board of Veterans' Appeals (Board) hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Board remanded this matter for further development in February 2020 and March 2021. As that development has since been completed, the Board will proceed with adjudication. Service Connection for Hypertension Service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection requires evidence of a current disability, an in-service incurrence, disease or injury and a causal relationship between the current disability and the in-service incurrence, disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and a disease, to include hypertension, became manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303 (b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). If a veteran was exposed to herbicide agents during active service, presumptive service connection is warranted for certain specified diseases. 38 C.F.R. §§ 3.307, 3.309. A veteran who served in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975 will be presumed to have been exposed to an herbicide agent during such service unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307. The National Academy of Sciences (NAS) opined at 75 Fed. Reg. 81,332 (December 27, 2010) that there is limited, or suggestive, evidence of an association between exposure to Agent Orange/herbicide agents and hypertension. Notwithstanding the foregoing presumption, a veteran is not precluded from establishing service connection with proof of direct causation. 38 U.S.C. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Service connection may also be granted where a disability is proximately due to, or the result of, an already service-connected disability. 38 C.F.R. § 3.310. Secondary service connection for a disability requires: (1) a current disability (for which secondary service connection is sought); (2) an service-connected disability; and (3) evidence that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service-connected disability. 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Here, the Veteran contends that he is entitled to service connection for his hypertension because he was exposed to herbicide agents while serving in Vietnam. Alternatively, he contends that his hypertension is secondary to his service-connected CAD or his service-connected PTSD. In a September 2013 administrative decision, VA conceded his exposure to herbicide agents in service. The Veteran's service treatment records are silent for complaints of, treatment for, or a diagnosis of, hypertension. His August 1971 separation physical examination report shows a normal blood pressure reading of 118/72. His vascular system was also noted as normal upon separation. However, VA treatment records reflect a current diagnosis of hypertension. See, for e.g., VA Treatment Records, September 11, 2019. In February 2020, a VA examiner opined that the Veteran's hypertension was not secondary to a service-connected disability, to include CAD and PTSD. As rationale, the examiner explained that, according to the general knowledge of the American Family Physician (AFP) peer-reviewed medical journal, 80 percent of hypertension cases are "essential" in nature, with inherently unknown etiology. The examiner further explained that CAD is not a precipitant to hypertension, but rather a vascular disease secondary to atherosclerosis, which is cholesterol plaques within the arteries. The examiner noted that hypertension's relationship to CAD is secondary to the overall cardiovascular physiology, in that, the arteries transport blood pumped from the heart, and, inherently, if the arteries are restricted, some increase in pressure could be noted, but the causality and worsening are not related because CAD is often noted in the presence of normalized blood pressure. The examiner stated that PTSD and other mental illnesses have no bearing on hypertension other than potentially transient increases when systemic output could be increased, secondary to stress-related tachycardia, which is generally short-term, and which has a normal physiologic process. The examiner concluded that, given the known physiologies, no aggravation or sequela is reasonable between CAD, PTSD, and hypertension. Another VA medical opinion was obtained in March 2021. This examiner opined that the Veteran's hypertension is not related to his service, to include exposure to herbicide agents, and that it is not secondary to CAD or PTSD. The examiner thoroughly explained his responses and cited to various medical journals. Specifically, the examiner noted that the Veteran's records show that the Veteran developed hypertension in 1976, approximately five years after leaving service. The examiner explained that the pathogenesis of primary hypertension is poorly understood but is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function. The examiner noted that the most-widely accepted risk factors for hypertension are age, obesity, family history, race, reduced nephron (kidney) mass, high sodium diet, excessive alcohol consumption, physical inactivity, diabetes mellitus, depression, and personality traits such as aggression. He further noted that, per a review of medical literature, PTSD and Agent Orange are not known risk factors for the development of either primary or secondary hypertension at this time. The examiner explained that one is often asked for the "cause" of a medical condition when, medically, no specific cause can be identified plausibly. He further explained that hypertension is a common medical condition affecting millions of Americans yearly, without a specific cause but rather due to complex factors including a strong genetic component, and is termed primary or "essential" in 80 percent of cases because a specific cause, outside of the listed medical conditions under "secondary" hypertension, cannot be identified. He, therefore, concluded that he agrees with the February 2020 examiner's opinion that Agent Orange is not causative of the Veteran's hypertension. Regarding the relationship between hypertension and CAD in particular, the examiner noted that, in medical literature, it is well-known that uncontrolled hypertension can be a risk factor for CAD or atherosclerotic disease of the coronary arteries due to increased sheering stresses and pressure on the vessels walls, but that does not mean the inverse is true as the medical literature does not support the notion that CAD can worsen hypertension. He explained that the Veteran's hypertension has advanced over the years, with more medications required to control the condition, which is a common clinical occurrence. The examiner referred to the Veteran's medical records showing that, when the Veteran was first evaluated at a VA Medical Center for primary care evaluation in January 2010, the Veteran was obese, with a body mass index (BMI) of 32.62, and his blood pressure was controlled by two medications. The examiner noted that, at present, the Veteran is prescribed four medications for control of his blood pressure, with a BMI of 36.86, recorded in November 2019, and has no signs of active CAD, with a normal cardiac stress test in September 2019. He concluded that the Veteran's hypertension has likely worsened due to the effects of aging, obesity, and worsening renal function (GFR 63.26 noted in January 2021) and not due to stable, asymptomatic CAD, as noted on a recent cardiac stress test. Regarding the relationship between hypertension and PTSD in particular, the examiner noted that the Veteran developed PTSD due to his experiences on active duty and that the Veteran developed hypertension in 1976, according to the Veteran's own reports. The examiner further noted that there is no evidence in the medical records or medical literature to show that the Veteran's hypertension is worse than its baseline due to the condition of PTSD, when other more common and medically accepted factors such as age, increasing weight, and decreasing renal function are present. The examiner explained that PTSD does not directly change cardiovascular or renal physiology, resulting in a permanent change in blood pressure, and therefore is not one of the widely accepted causes of secondary hypertension, nor as an aggravating factor for essential hypertension. Based on the above, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for hypertension, to include as due to in-service herbicide exposure or as secondary to service-connected CAD or service-connected PTSD. While the Board finds that the Veteran does have a current diagnosis of hypertension and therefore meets the first requirement of presumptive, direct, and secondary service connection, the nexus and in-service elements are not present. With regard to presumptive service connection, as the Veteran's hypertension was first diagnosed years after service, he is not entitled to a grant of service connection pursuant to the presumptive provisions of 38 C.F.R. §§ 3.307, 3.309(a) for a chronic disease present to a compensable degree within the first post-service year. Therefore, as there is no credible evidence of continuity of related symptomatology after service, presumptive service connection is not warranted. The Board acknowledges that, while presumptive service connection is not warranted, that does not preclude the Veteran from establishing direct service connection either to his active service or his conceded exposure to herbicides. In this regard, the Board notes that the March 2021 VA examiner opined that it was less likely than not that the Veteran's hypertension was related to his herbicide exposure. The examiner cited to studies and medical literature, concluding that there is inadequate or insufficient evidence to determine the association between hypertension and herbicide exposure. The examiner also noted that the Veteran otherwise had several risk factors for hypertension. In addressing the probative evidence of record, the Board finds that the negative opinions of the February 2020 and the March 2021 VA examiners, provided after reviewing the entirety of the claims file, are highly probative as they reflect consideration of all relevant facts. The examiners provided detailed rationales for the conclusions reached and the opinions are supported by the medical evidence of record and the relevant medical literature. See Nieves-Rodriguez, 22 Vet. App. at 302-04. Significantly, there is no probative medical opinion of record to the contrary. Accordingly, the claim for service connection for hypertension, to include as due to in service herbicide exposure, is denied. Concerning secondary service connection, both the February 2020 and March 2021 examiners gave very detailed rationales as to why there is no causal relationship between the Veteran's hypertension and CAD, or hypertension and PTSD. The March 2021 examiner further explained that the Veteran's hypertension was not aggravated, or made worse, by CAD or PTSD. Notably, the March 2021 examiner concluded that there is no evidence in the medical records or medical literature to show the Veteran's hypertension is worse than its baseline due to the condition of PTSD, when other more common and medically accepted factors such as age, increasing weight, and decreasing renal function are present. The examiner further explained that the Veteran's hypertension has likely worsened due to the effects of aging, obesity, and worsening renal function, and not due to CAD. As such, secondary service connection is not warranted. In sum, the Board finds that service connection for hypertension is not warranted. To the extent the Veteran contends that a connection exists between his herbicide exposure and hypertension, his hypertension and CAD, or his hypertension and PTSD, the Board notes that the Veteran has not been shown to have the requisite medical training and expertise to be competent to render probative (i.e., persuasive) opinions on such complex medical matters. See Jandreau, 492 F.3d at 1376-77; Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Hence, his lay assertions in this regard have no probative value. In reaching the above conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. Hence, the claim for service connection for hypertension is denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55-56. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Trowers, 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.