Citation Nr: 21041719 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-15 509A DATE: July 10, 2021 ORDER Entitlement to service connection for hypertension, to include secondary to service connected post-traumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The Veteran's hypertension is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. 2. The Veteran's hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established. CONCLUSION OF LAW The criteria for service connection for hypertension due to service or service-connected PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served in the New York Army National Guard from May 1984 to March 1990 with active duty service from July 29 to September 18, 1985. This matter comes to the Board of Veterans' Appeals (Board) from an October 2014 rating decision issued by the Agency of Original Jurisdiction (AOJ). In April 2020, the Board remanded the appeal for further development. This case was returned to the Board for appellate review, after the AOJ substantially complied the Board's remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for hypertension, to include secondary to PTSD, The Veteran contends that symptoms associated with her service connected PTSD, to include depression, caused or aggravated her hypertension. See April 2016 VA Form 9. The question for the Board is whether there is sufficient evidence to find that the Veteran's hypertension is secondary to her service-connected PTSD or otherwise related to her period of service, from July 29 to September 18, 1985. For the reasons discussed below, the Board concludes that the evidence does not support a grant of service connection on a direct or secondary basis. In order to qualify for VA compensation benefits, the claimant must demonstrate he or she is a "Veteran." A "Veteran" for VA compensation benefits purposes is "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." 38 U.S.C. § 101(2); 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes "active duty, which is full-time duty in the Army, Navy, Marine Corps, Air Force, or Coast Guard, other than "active duty for training." Active service may also include periods of active duty for training (ACDUTRA) and, in specific cases, inactive duty for training (INACDUTRA). 38 U.S.C. § 101(24); 38 C.F.R. § 3.6 (a). When a claim for benefits is based on a period of ACDUTRA, there must be evidence that the claimant became disabled because of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA. 38 U.S.C. §§ 101(2), (22), (24); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). In the absence of such evidence, the period of ACDUTRA would not qualify as "active military, naval, or air service," and the claimant would not qualify as a "Veteran" for VA compensation purposes. 38 U.S.C. § 101(24); 38 U.S.C. §§ 101(2), 1110; Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Presumptive service connection does not apply to claims predicated on ACDUTRA and INACDUTRA service, but only for active duty. Biggins v. Derwinski, 1 Vet. App. 474 (1991); Smith v. Shinseki, 24 Vet. App. 40 (2010). Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Service connection may also be established for certain chronic diseases by satisfying the test for disability compensation for chronic diseases set forth in 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331, 1334 (2013) One method is to show the Veteran has (1) a current chronic disease listed under 3.309(a) and (2) that disease must have been "shown in service." Id. at 1335. As to (1), hypertension is identified as a "chronic disease" under 38 C.F.R. § 3.309(a). As to (2), 38 C.F.R. § 3.303(b) equates "shown in service" with a reliable diagnosis of the chronic disease while in service. Walker, 708 F.3d at 1335. Another method is to show continuity of symptomatology. Continuity of symptomatology may be demonstrated if a claimant can show (1) a condition was "noted" during service; (2) postservice evidence of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). Section 3.303(b) does not require medical evidence of an etiological link between service and a current disability. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the "benefit of the doubt" when the evidence is approximately balanced. Id. at 53. Evidence on an issue is in "approximate balance" when the evidence for and against a finding on that issue is "almost exactly or nearly equal" or "too close to call." Ortiz v. Principi, 274 F.3d 1361, 1364-65 (Fed. Cir. 2001). Beginning with the Veteran's service, her service personnel records show she entered the New York Army National Guard on May 4, 1984, and worked as a personnel administrative specialist through May 1, 1990, with active duty service from July 29 to September 18, 1985 for training. See Report of Separation and Record of Service; DD214. The Board notes the Veteran has reported she did not attend many of her scheduled drills while in the Guard and did not deploy with her assigned unit. See August 25, 2020, VA Disability Benefits Questionnaire (DBQ) PTSD at 6. The Board also notes the traumatic event for which she was granted service-connection for PTSD occurred between 1984 and 1985. Id. at 9. The available service treatment records (STRs) include a May 1985 entrance examination that did not note signs or symptoms of hypertension. Blood measurements taken as part of that examination were 102 systolic and 66 diastolic. See May 4, 1985, Report of Medical Examination. A physical examination was not taken during the period of active service (July 29 to September 18, 1985) but a record notes a September 4, 1985, visit to a medical clinic showing blood pressure measurements reading of 106 systolic and 76 diastolic. A physical examination following her active service period was conducted in December 1988. That examination did not note signs or symptoms of hypertension. Blood measurements taken as part of that examination were 98 systolic and 70 diastolic. See December 3, 1988, Report of Medical Examination. The record also consists of private medical records noting high blood pressure and hypertension. Generally, they are noted in progress notes or in the Veteran's complaint history. One of the earliest records is a September 2007 medical letter by R.H.S., MD, that notes the Veteran's blood pressure is "out of control." Dr. R.H.S. wrote another letter in February 2009, that states, in its entirety "[The Veteran] has severe hypertension, which has damaged her kidneys. Her hypertension was aggravated by her depression." In February 2020, a Board hearing was conducted for the Veteran's entitlement claim. She testified she was diagnosed with hypertension in 2009. She also testified that her doctor had attributed her hypertension to depression. She added that her depression is associated with her (now) service-connected PTSD. She indicated that she experienced a lot of stress and managed it by holding it in. She added that, eventually, the stress damaged her heart. See Transcript at 18, 19. Following a Board remand, the Veteran underwent a VA disability examination in October 2020 to evaluate her hypertension. She could not recall when she first observed symptoms of hypertension but observed it has progressed over time. Currently, her disorder is manifested by intermittent headaches. See VA DBQ at 2. On examination, the examiner noted the Veteran has a history of diastolic blood pressure elevation predominantly 100. The examiner diagnosed hypertension and noted it does not impact the Veteran's ability to work. Id. at 1, 3. The October 2020 examiner opined that the Veteran's diagnosed hypertension was not caused or aggravated by her service connected PTSD. The examiner noted the Veteran's blood pressure measurement taken on May 4, 1985, and December 3, 1988, reflected normal blood pressure. The examiner acknowledged the February 2009 letter from Dr. R.H.S. but indicated she researched a connection and found that medical literature does not yet support a strong enough connection between the conditions to conclude PTSD and/or depression caused her hypertension. She concluded the same for aggravation; that is, medical literature does not yet support concluding the Veteran's hypertension was aggravated by PTSD and/or depression. See October 2020 VA Medical Opinion at 3, 4. In June 2021, the VA received an appellate brief that included three articles proposing a link between PTSD and heart disease, to include hypertension. Beginning with the first article, PTSD Increases Risk of Hypertension in Injured Soldiers, it reported on a medical study that explored the effect of stress on blood pressure in military members. The report noted that among the over 3,000 participants studied, 42 percent were diagnosed with PTSD and a small percentage of those were diagnosed with high blood pressure. Also, analysis showed soldiers with PTSD were 77 to 85 percent more likely to develop high blood pressure than those without the disorder. The authors of the study noted further research was needed to confirm the associations. CardioSmart.org, PTSD Increases Risk of Hypertension in Injured Soldiers, https://www.cardiosmart.org/news/2018/4/ptsd-increases-risk-of-hypertension-in-injured-soldiers (last visited June 18, 2021). The second article, Trauma, PTSD, and Physical Health surveys several studies on the effect trauma has on a person's mortality and morbidity. The author surveyed research around the world on the impact trauma has had on a person's health. He noted his own research shows psychological and behavioral factors, like smoking, contribute to poor health outcomes in persons who experience trauma. The author concluded that the literature on trauma shows it is related to poor health outcomes. There was one mention of coronary artery disease found among civilians exposed to civil war, but there was no specific discussion of a direct link between hypertension and PTSD. https://www.ptsd.va.gov/publications/rq_docs/V7N3.pdf (last visited June 18, 2021). The third article, Hypertension in relation to posttraumatic stress disorder in the US National Comorbidity Survey, was an abstract that asserts cardiovascular disease and cardiovascular risk factors are common among individuals with PTSD. The authors designed a test to determine if the association was greater in individuals who also have a history of depression. The authors conclude there is a greater prevalence of hypertension among individuals with no history of depression. https://pubmed.ncbi.nlm.nih.gov/19064371/ (last visited June 18, 2021). A. Entitlement to service connection on a secondary basis. Turning to the Veteran's claim for disability compensation, the Board will first address her claim for entitlement to service connection under 38 C.F.R. § 3.310(a) and (b). That is, on a secondary basis. To answer that question, the first issue is whether the Veteran has a current disability. The record reflects several diagnoses of hypertension, to include the October 2020 VA DBQ. Thus, the Veteran has a diagnosed hypertensive disorder. The record also reflects she has one service-connected disability, which is PTSD. The next issue is whether the Veteran's hypertension was aggravated by her service-connected PTSD. Although the February 2009 letter from Dr. R.H.S. is favorable evidence, it was of little to no probative value. His opinion on the issue consisted of a conclusory sentence, which linked the Veteran's hypertension through a symptom of her service-connected PTSD. Even though the Board liberally construed it as an opinion linking hypertension to her service-connected PTSD anyhow, its probative value was diminished by the lack of any rationale for his conclusion. Due to the deficiency, the Board was unable to evaluate whether the data he relied on connects to his conclusion. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). So, it was of little to no probative value towards evaluating the issue. In contrast, the VA examiner who prepared the October 2020 medical opinion provided a reasoned explanation for concluding the Veteran's hypertension was not aggravated by her service-connected PTSD. The examiner acknowledged the evidence of record, February 2009 letter from Dr. R.H.S., and the Veteran's observations. So, the Board finds the examiner was aware of the relevant details of the Veteran's past medical history. Id. The examiner indicated that, based on her medical understanding and research on the issue, she could not endorse the opinion of Dr. R.H.S. The examiner indicated she researched literature that addressed the issue of aggravation and found there was not strong enough evidence to conclude the Veteran's hypertension was aggravated by her service-connected PTSD. The Board recognizes the examiner noted the literature was not definitive on the issue; however, when reviewing her opinion as a whole, it is apparent to the Board she applied the "less likely than not" standard. First, she did not dismiss the favorable evidence on the basis that it did not rise to a higher standard than VA requires. It appears she weighed it against the medical literature on the subject when coming to her conclusion and determined the state of medical knowledge weighed against finding aggravation. Considering the examiner is qualified to review medical literature and apply it to the particulars of the Veteran's case, the Board was able to connect the data she relied on to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Thus, her opinion was assigned significant weight against a finding of aggravation. The medical literature provided by the Veteran supports the examiner's opinion. All of the articles associate poor health outcomes with PTSD, but qualify their findings with the caveat that more research needs to be conducted on the matter. This indicates to the Board that, as the October 2020 medical opinion asserts, the state of medical knowledge with regards to causation and/or aggravation remains undecided. As to the probative value of those articles, considering none of them directly addressed the particulars of this Veteran's claim they were of little probative value. The article, PTSD Increases Risk of Hypertension in Injured Soldiers, did not speak to the particulars of the Veteran's claim at all; rather, the findings were based on statistical analysis that was too far removed from this claim to help decide the issue. The article, Trauma, PTSD, and Physical Health, spoke about poor health outcomes in persons diagnosed with PTSD; however, the behavioral factors associated with poor health outcomes were discussed generally. So, it was also far removed from this Veteran's claim. Finally, the article, Hypertension in relation to PTSD in the US National Comorbidity Survey, did related depression to hypertension. But, a general association is not sufficient to decide this claim. As to the issue of aggravation, the Board finds the evidence is not approximately balanced. The favorable February 2009 letter from Dr. R.H.S. was of little probative value. Even when combined with the probative weight assigned to the journal articles, it was outweighed by the more probative October 2020 VA medical opinion. So, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. As a result, she is not entitled to service connection under 38 C.F.R. § 3.310(b). The next issue is whether the Veteran's hypertension was proximately caused by her service-connected PTSD. The February 2009 opinion from Dr. R.H.S. does not address whether the Veteran's hypertension was caused by her service connected PTSD; therefore, it was not probative evidence towards evaluating the issue. The October 2020 VA medical opinion weighed against a finding of causation. Similar to the examiner's opinion as to aggravation, she acknowledged the favorable evidence but concluded her review of medical literature showed there is enough evidence to conclude the Veteran's hypertension was more likely than not caused by PTSD. Considering the examiner is qualified to review medical literature and apply it to the particulars of the Veteran's case, the Board was able to connect the data she relied on to her conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. Thus, her opinion was assigned significant weight against finding of causation. The Board recognizes the Veteran has asserted her hypertension was caused by symptoms associated with her service-connected PTSD. But she has not alleged to possess the qualifications to render an etiological link between a psychiatric disorder and a heart disorder. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). So, her lay observations were not probative towards evaluating the issue. As to the issue of causation, the Board finds the evidence is not approximately balanced. Although the medical articles associated PTSD with hypertension, they did not speak to the particulars of the Veteran's claims. Also, they were outweighed by the more probative October 2020 VA medical opinion that concluded her hypertension was not caused by PTSD. So, doubt cannot be resolved in her favor. Gilbert, 1 Vet. App. at 54. As a result, she is not entitled to service connection under 38 C.F.R. § 3.310(a). B. Entitlement to service connection on a direct basis. Now that the Board has addressed the Veteran's claim of entitlement to service connection on a secondary basis, the Board will explain why it concluded entitlement to service connection under 38 C.F.R. § 3.303 is not warranted either. Considering the Board has acknowledged the Veteran has a current disability, the first issue is whether the Veteran has an in-service incurrence of a disease or injury. Because the Board is not clear on the precise date between 1984 and 1985 that the Veteran experienced her in-service trauma while serving in the New York Army National Guard, the relevant period of service for this inquiry is from 1984 to the end of September 18, 1985, which also encompasses the Veteran's active service period. The Veteran's lay assertions weigh strongly against finding an in-service incurrence. The Veteran is competent to report whether she was told of a diagnosis of hypertension during service and/or saw blood pressure readings suggestive of that disorder. Layno v. Brown, 6 Vet. App. 465, 467-70 (1994). Here, she has expressly stated she had not been told she had hypertension by a military doctor. See April 2016 VA Form 9 at 1. Neither has she reported discussions with a medical provider about high blood pressure during the relevant period of service or within a year after that period. Considering notification of a medical diagnosis of disease or disorder is a significant event a Veteran is likely to remember, the Board finds her statement highly credible and assigned it significant weight against an in-service incurrence. The available STRs support the Veteran's statement. None of them reference hypertension. The STRs for the relevant period include blood pressure measurements at entrance (102 systolic, 66 diastolic) and during active service (106 systolic, 76 diastolic), which do not suggest the presence of high blood pressure or hypertension. See September 4, 1985, STR. Hypertension is defined as high arterial blood pressure, with various criteria for its threshold, ranging from 140 systolic and 90 diastolic to as high as 200 systolic and 110 diastolic. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 885 (33rd ed. 2020). Also, the examination following the relevant period of service does not mention hypertension. See December 3, 1988, Report of Medical Examination at 2. Considering the Veteran has not provided lay observations that conflict with the findings in her STRs, the Board finds them credible. So, they were assigned significant weight against finding an in-service incurrence. If there are doubts about the Board's reading of her blood pressure measurements, the VA examiner who prepared the October 2020 medical opinion indicated the May 4, 1985, and December 3, 1988, measurements were normal. See VA DBQ at 3. The Board recognizes the Veteran has provided evidence of hypertension following service; however, none of those items of evidence indicate her diagnosed hypertension began during service. See February 2009 Medical Opinion by R.H.S., MD. In this case, the evidence weighs against finding an in-service incurrence. The Veteran has not alleged she observed symptoms of high blood pressure or hypertension during service or within a year of leaving service. Also, her STRs do not show a diagnosis of hypertension at any time during the relevant period of service or within a year following that period of service. The next issue is whether there is a nexus between the Veteran's diagnosed hypertension and the relevant period of service. Although the VA examiner who prepared the October 2020 medical opinion did not discuss whether the Veteran's hypertension developed during service, her finding of normal blood pressure during service is medical evidence that weighs strongly in favor of finding the Veteran did not have hypertension during service. Even though the Veteran is not competent to render an opinion on an etiological link between hypertension and service, her lay statements provide sufficient evidence for the Board to decide there was no need to obtain one. Jandreau, 492 F.3d at 1377. An examination is warranted when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Considering the record reflects medical evidence showing the Veteran did not have hypertension during service and she has not suggested there is a causal link between hypertension and service, the Board finds obtaining a medical opinion on that matter is not warranted. As noted above the Veteran has not alleged she observed symptoms during service nor is there evidence suggestive of an in-service incurrence. Also, there is no indication her diagnosed hypertension is associated with service as an administrative specialist or any other event during the relevant period. In this case, weight of the evidence is against finding a nexus. The Veteran has not alleged her hypertension is related to service; rather, she has consistently asserted it is secondary to service. Also, the evidence of record does not suggest there is an etiological link between the Veteran's hypertension and service. Combined with medical evidence showing she did not have hypertension during service or within the year following service, the Board finds there is sufficient evidence weighing against a nexus to decide the issue. C. Entitlement to service connection based on chronicity or continuity of symptomatology. The Board recognizes the Veteran's hypertension is also considered a chronic disease under 38 C.F.R. § 3.309(a). But, as noted above, the Veteran has not shown a clear diagnosis of hypertension during the relevant period of service or within a year following that period of service. Considering she has not alleged she observed signs or symptoms of hypertension since the relevant period of service, consideration of service connection based on continuity of symptomatology is not warranted either. 38 C.F.R. § 3.303. In sum, the Veteran has not established service connection due to her service-connected PTSD. Although she has not alleged she observed symptoms of hypertension during service or a year from leaving service, the Board evaluated entitlement to service connection under 38 C.F.R. § 3.303 and finds entitlement to service connection under that code is not warranted. Also, the Veteran has not raised any other issues nor have any other issues been reasonably raised by the record. Robinson v. Peake, 21 Vet. App. 545, 552-54 (2008) (holding the Board is not required to address issues unless specifically raised by the claimant or reasonably raised by the record). The Board regrets a more favorable decision could not be reached in the Veteran's case. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dean, Michael S. 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.