Citation Nr: 22003147 Decision Date: 01/21/22 Archive Date: 01/21/22 DOCKET NO. 17-09 108 DATE: January 21, 2022 ORDER Entitlement to service connection for hypertension, to include as due to herbicide exposure, or as secondary to service-connected ischemic heart disease, is denied. FINDING OF FACT The Veteran's hypertension is not secondary to his service-connected ischemic heart disease, and is not otherwise related to an in-service injury, event or disease, to include exposure to herbicide agents. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, to include as due to herbicide exposure, or as secondary to service-connected ischemic heart disease have are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1963 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. The Board remanded the issue on appeal in January 2020 and November 2020 for further development. There has been substantial compliance with remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). This appeal has been advanced on the Board's docket. 38 C.F.R. § 20.902 (c). SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Pursuant to 38 C.F.R. § 3.309(e), veterans who have been exposed to an herbicide agent during active service are entitled to presumptive service connection for certain listed diseases and must have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(ii). Certain chronic diseases such as hypertension, will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service, that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Entitlement to service connection for hypertension, to include as due to herbicide exposure, or as secondary to service-connected ischemic heart disease is denied. The Veteran asserts in a February 2017 statement that his hypertension is related to Agent Orange exposure, specifically tetrachlorodibenzodioxin (TCDD). Alternatively, he asserts that his hypertension is secondary to his service-connected ischemic heart disease. The Veteran's service treatment records (STRs) reflect service on the landmass of Vietnam and the RO has conceded exposure to herbicide agents. Thus, the question for the Board is whether the Veteran has a current hypertension disability that began during service or is at least as likely as not related to an in-service injury, event, or disease; or is proximately due to or aggravated by his service-connected heart disease. The Board concludes that, while the Veteran has a current diagnosis of hypertension, and he is presumed to have had exposure to herbicide agents during service, the competent and probative medical evidence weighs against finding his hypertension began during service, is otherwise related to an in-service injury, event, or disease; or, is secondary to his service-connected heart disease. Turning to the evidence of record, STRs show the Veteran's blood pressure reading on enlistment as 116/80; at separation it was 98/68. Service treatment records do not reflect a diagnosis of hypertension. Private treatment records show the Veteran was not diagnosed with hypertension until 1995, nearly 30 years after his separation from service. The Veteran submitted two disability benefits questionnaires (DBQ) from Dr. Baum, a private clinician. In June 2014, Dr. Baum reported an August 2009 diagnosis of hypertension along with additional diagnoses including, coronary artery disease (CAD). Dr. Baum indicated that the Veteran's treatment plan included taking continuous medication and that in May 2014 his blood pressure reading was 120/62. A year later, in the May 2015 DBQ, Dr. Baum reported the Veteran's diagnosis of hypertension as 1995 and noted the CAD diagnosis. Dr. Baum did not provide a medical opinion in either DBQ; thus, they are not probative on the question of in-service onset or causal nexus. The Veteran was provided VA examinations in November 2014 and in June 2016. In November 2014, the VA examiner reported the year of diagnosis for hypertension as 2004 and listed the Veteran's two prescribed medications. A direct opinion was not provided; however, the examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of his service-connected heart disease. The examiner's rationale was that the Veteran "stated that he has been treated for [hypertension] for at least the past 10 years." The June 2016 VA examiner reported the Veteran's diagnosis of hypertension as occurring in the 1990s. The Veteran's continuous use of medication for hypertension was noted. This examiner also did not provide a direct opinion. The examiner opined that the Veteran's hypertension was not caused by or aggravated beyond its natural progression by his CAD because the diagnosis of hypertension "predated his diagnosis of CAD and CAD does not cause or aggravate [hypertension]." In February 2017, the Veteran submitted an article authored by a VA physician which concluded that "Occupational herbicide exposure history and Vietnam service status were significantly associated with hypertension risk." This association was based on the presence of TCDD, a component of Agent Orange. Also, the National Academy of Sciences Institute of Medicine (NAS) recently upgraded hypertension to the "sufficient" category from the previously "limited or suggestive" category, indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide agent exposure. See November 15, 2018, press release from NAS. In January 2020, the Board determined that both examination reports were not adequate for adjudication purposes as neither examiner provided an opinion regarding direct service connection. Further, both reports contained inadequate rationale for the secondary service connection opinions. Additionally, consideration of the NAS recent findings was needed. Thus, the issue was remanded for an addendum opinion. Pursuant to the Board's remand, the Veteran was afforded a new VA examination in February 2020. The examiner reported that the Veteran was diagnosed with hypertension in the 1990s and noted his two prescribed medications for hypertension treatment. The VA examiner opined that the Veteran's hypertension was not directly due to active military service and reasoned that he was discharged from service in 1967. The examiner also reasoned that the Veteran was not diagnosed with hypertension until the 1990s and therefore was not diagnosed within a year of his discharge from military service. The examiner opined that it was less likely than not that the Veteran's hypertension was either caused by or aggravated beyond its normal progression by his exposure to herbicides such as Agent Orange. The examiner explained that although current medical literature "may show a positive association between Agent Orange exposure and hypertension, there is no generally accepted cause-and-effect relationship... to show that hypertension is either caused by or aggravated by exposure to herbicides." Lastly, the examiner stated that "coronary artery disease/ischemic heart disease does not cause or aggravate hypertension; therefore, the Veteran's hypertension was not caused by or aggravated beyond normal progression by his [service-connected heart disease]." In a November 2020 remand, the Board explained that although VA provided the Veteran with a new examination in February 2020, the examiner's rationale remained insufficient for adjudication purposes. Regarding secondary service connection, the February 2020 VA examiner provided the same rationale from his June 2016 report, which the Board previously rejected as insufficient. The examiner reported "coronary artery disease/ischemic heart disease does not cause or aggravate hypertension. Therefore, this Veteran's hypertension was not caused by or aggravated beyond normal progression." The Board determined that this rationale did not provide the necessary information to render a fully informed decision and assess the probative value of this opinion because a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Thus, another addendum opinion was requested. In December 2020, a new VA examiner provided an addendum opinion. Upon reviewing the evidence as requested along with the Board's remand directives, the VA examiner determined that there was insufficient evidence to confirm a causal relationship between hypertension and herbicide agent exposure. The examiner explained that the key words, in the NAS report were "positive association," acknowledging "it was found that a proportionally large number of Vietnam War veterans exposed to Agent Orange also had hypertension." In assessing whether there was a cause/effect relationship, the examiner stated that the study, "did not prove that relationship, and several scientists in the medical community have reported concerns with the NASEM report." The examiner identified two anticipated studies that would "help in answering this question" of a cause/effect relationship between hypertension and herbicide agent exposure and indicated that until such time, it was less likely than not that the Veteran's hypertension was related to his presumed exposure to herbicide agents. Regarding the Veteran's claim of service connection as secondary to his service-connected heart disease, the examiner explained that the Veteran's onset of hypertension "preceded his CAD by 15 plus years, and his diabetes by 13 plus years." Therefore, it was less likely than not that his hypertension was proximately due to or caused by his service-connected ischemic heart disease (CAD) or by his service-connected diabetes. The examiner also explained that the Veteran's VA treatment records did not show aggravation of hypertension and noted that the Veteran's blood pressure readings "have remained relatively stable and he continues on a two-drug regimen, the same as when he was diagnosed with CAD and diabetes mellitus (DM)." Taken together, the February 2020 and November 2020 VA opinions establish that the Veteran's hypertension is not at least as likely as not related to an in-service injury, event, or disease, including his presumed exposure to herbicide agents. Moreover, his hypertension is not proximately due to or aggravated by his service-connected heart disease. The combined rationale explain that hypertension did not onset in service but rather decades after his discharge from military service. Though the NAS report in question has noted a positive association between hypertension and herbicide agent exposure, the report itself has not proven such relationship and scientist in the medical community have expressed concerns with the report. While the November 2020 examiner indicated that two anticipated studies (expected to be released in mid-2021) would assist in answering the question regarding cause and effect between herbicide agent exposure and hypertension, it does not appear that these studies are complete or updated per online research. The Veteran's diagnosis of hypertension precedes his diagnosis of ischemic heart disease and over the course of this claim, his VA treatment records have shown "relatively stable" blood pressure readings and his continued use of a two-drug regimen for treatment of hypertension. The Board finds the examiners' combined opinions probative because they are 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). Indeed, the Veteran believes his hypertension is related to an in-service injury, event, or disease. However, in this case, the Veteran is not competent to provide a nexus opinion regarding this issue because it is medically complex; it requires knowledge and interpretation of complicated diagnostic medical testing. 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 January 2020 and November 2020 VA examiners' opinion. The Board has considered whether presumptive service connection for hypertension is warranted as it is a chronic disease. However, as previously discussed, the Veteran's hypertension did not manifest to a compensable degree within one year of his discharge from military service it was diagnosed in the 1990s; the Veteran did not have high blood pressure or a diagnosis of hypertension in service; and there is no evidence of continuity of symptomatology since service. As such, service connection is not warranted. See 38 C.F.R. § 3.309. The appeal of entitlement to service connection for hypertension, to include as due to herbicide exposure, or as secondary to service-connected ischemic heart disease, is denied. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, 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.