Citation Nr: 22040197 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 19-39 174 DATE: July 13, 2022 ORDER Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to service connection for gastroesophageal reflex disease (GERD), to include as secondary to service-connected PTSD, is remanded. FINDING OF FACT The Veteran's hypertension is aggravated by service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for hypertension, as secondary to service-connected PTSD, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from January 1965 to January 1969, including service in the Republic of Vietnam from March 1966 to November 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), the agency of original jurisdiction (AOJ). 1. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD Service Connection To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, for secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service connected disease or injury, or that service-connected disease or injury has aggravated the nonservice-connected disability for which service connection is sought. 38 C.F.R. § 3.310. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153 (a); 38 C.F.R. § 3.303 (a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, some medical issues fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well reasoned rationale and a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999). In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). Where 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; 38 C.F.R. § 3.102. Analysis The Veteran contends that currently diagnosed hypertension is either caused by active service, or is secondary to service-connected PTSD. The Veteran has been diagnosed with hypertension. The Veteran was afforded a VA examination in January 2018. The Veteran reported that he believed his PTSD caused his blood pressure to become elevated. He stated that he uses a home blood pressure monitor. During the examination, the examiner noted that when the Veteran discussed his medical history, his heart rate was 100 and his blood pressure was 200/90. The Veteran then laid down on the examination table, relaxed his breathing, and closed his eyes for five minutes. His heart rate dropped to 80 and his blood pressure was 160/80. He reported that he took his blood pressure medications the night before the examination. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by service. The rationale was that the Veteran's medical history indicates he did not develop hypertension during service or proximal to service. He developed hypertension in his 50s. Medical literature documents increasing incidence of hypertension with advancing age. The examiner cited medical articles entitled "Overview of Hypertension in Adults" and "The Prevalence and Control of Hypertension in Adults." The examiner stated that, although the Veteran's anxiety causes his heart rate and blood pressure to go up, as seen in the office visit, after a few minutes of control of his anxiety, his heart rate and blood pressure went down. The examiner concluded this is a "normal physiologic response to stress." The Board finds that the VA examiner's notation that the Veteran's anxiety causes his heart rate and blood pressure to go up supports a finding that the Veteran's PTSD aggravates his hypertension. The medical evidence at the examination documents that the Veteran's blood pressure increased to 200/90 due to stress. In Ward v. Wilkie, 31 Vet. App. 233 (2019), the Court of Appeals for Veterans Claims (Court) held that, in the context of secondary service connection based on aggravation, the aggravation at issue need not be permanent in nature. Therefore, the examiner's statement that the Veteran's increase in blood pressure was temporary and alleviated with rest does not sustain a finding that his hypertension is not aggravated by the service-connected PTSD. In fact, it supports the Veteran's assertion that PTSD causes his blood pressure to rise, and aggravates his hypertension. The examiner's opinion that a blood pressure reading of 200/90 is a "normal physiologic response to stress" is not accompanied by any medical reasoning. As to the cited medical literature, the Board notes that the examiner did not offer any explanation as to how the medical literature supported his opinion. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). However, treatise evidence must "not simply provide speculative generic statements not relevant to the [claimant]'s claim." Wallin v. West, 11 Vet. App. 509, 514 (1998). Following the issuance of the February 2018 rating decision, the Veteran filed a Notice of Disagreement and elected de novo review. The decision review officer noted the January 2018 VA examiner's documented observation that the Veteran's anxiety causes his heart rate and blood pressure to go up, but after a few minutes of controlling his anxiety, his heart rate and blood pressure went down. The Board finds that VA has acknowledged an aggravating relationship between the Veteran's PTSD symptoms and his hypertensive symptoms. At an office visit in July 2018, a private doctor noted that the Veteran reported that his blood pressure is usually good at home, but elevated when he leaves the house; the Veteran stated that he has PTSD and becomes anxious whenever his leaves his home. In September 2018, the Veteran submitted a statement that he tracks his blood pressure at home, and it is usually normal at that time; however, the blood pressure becomes high when he leaves home for any reason due to the PTSD symptoms. In November 2018, an independent medical opinion was submitted. The evaluating physician indicated that the Veteran has mild hypertension with abnormal blood pressure readings since December 2014. The physician stated that the Veteran is currently being maintained on second line antihypertension drugs, plus first line drugs, for the Veteran to reach normal blood pressure readings. The physician noted that the Veteran's most recent untreated blood pressure was 162/92, which is clearly abnormal. The physician opined that it is as likely as not that the Veteran's hypertension is related to his service-connected PTSD. He cited an article from a medical journal that discusses studies noting "growing evidence that exposure to psychologically traumatic events is related to increased medical morbidity, including the onset of different diseases and premature mortality." He stated that the evidence for cardiovascular disease is particularly strong and comes from a wide range of studies spanning different populations with traumatic exposures. He also cited an article entitled "Angiotensin Type I Receptor Inhibition Enhances the Extension of Fear Memory." He stated that there is a clear causal link between fear memory, increased cortisol levels, and the renin angiotensin system, which controls blood pressure, and that such is the case for the Veteran. The Board notes that the physician related the medical literature cited to the Veteran's specific facts and claim. 38 C.F.R. § 3.159(a)(1); Wallin v. West, 11 Vet. App. 509, 514 (1998). The Board finds that this opinion is entitled to high probative value. Bloom v. West, 12 Vet. App. 185, 187 (1999). Reviewing the VA examination and medical opinion, the independent medical opinion, the medical records, and the Veteran's statements, the Board finds that the evidence is at least in approximate equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Providing the benefit of the doubt to the Veteran, the Board finds that the Veteran's hypertension is aggravated by the service-connected PTSD. Therefore, service connection for hypertension, as secondary to service-connected PTSD, is warranted. REASONS FOR REMAND 2. Entitlement to service connection for GERD, to include as secondary to service-connected PTSD, is remanded. The Veteran's disability has been diagnosed as GERD. He has contended that his GERD is secondary to his service-connected PTSD. The Veteran was afforded a VA examination in January 2018. The Veteran reported developing frequent heartburn in 2000. The examiner noted that the Veteran had an upper gastrointestinal series (UGI) in February 2015 showing moderate tertiary contractions with esophageal dysmotility and moderate size hiatal hernia without evidence of reflux. He was advised to continue the proton pump inhibitors (PPI). He was taking over the counter Prilosec 10 mg, 2 tabs daily. He reported that he switched to over the counter medication because it was less expensive. If he forgets to take his medication, he will have reflux acid and midsternal burning. When he refluxes at night it causes him to cough. The Veteran reported that he believes the reflux is due to his PTSD. The examiner opined that the Veteran's GERD is less likely than not incurred in or caused by service. The rationale was that the Veteran's past medical history indicates he did not develop GERD during service or proximal to service. It appears that he developed GERD while in his 50's. The examiner stated that medical literature documents that the development of GERD as multifactorial, related primarily to obesity, age, diet, stress, and medications. Presently the medical literature has not been able to isolate emotional stress as a primary risk factor of GI disease or a single risk factor for disease. The examiner cited: "NIH The Effect of Emotional Stress and Depression on the Prevalence of Digestive Diseases," and "Pathophysiology of reflux esophagitis." The Board finds the VA examiner's opinion is inadequate, as the examiner failed to provide an adequate rationale for the opinion that it is less likely than not that the Veteran's GERD is aggravated by his service-connected PTSD. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Noting multifactorial causes including obesity, age, diet, stress, and medications, the examiner addressed alternative causes of GERD, but the examiner did not explain how each of these factors is more likely than not a cause of the Veteran's GERD. The examiner's opinion that the medical literature has not isolated "emotional stress" as a primary risk factor of GI disease is not dispositive of the Veteran's claim that his PTSD aggravated his GERD. PTSD is not "emotional stress." The examiner also noted medications as a possible cause for GERD, but did not address whether any medications prescribed to the Veteran for his service-connected PTSD may aggravate his GERD. For these reasons, the opinion is inadequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that in May 2022, the Veteran's counsel submitted an article entitled "Causes of Gastro-Esophageal Reflux Disease (GERD)" that discusses different risk factors, including medication and stress. In May 2022, the Veteran's counsel also submitted argument, including a study entitled, "PTSD, Depression, and Gastrointestinal Symptoms in Veterans of the Afghanistan and Iraq conflicts: What's the Relation," published in The American Journal of Gastroenterology, which found that veterans with a positive PTSD screen may be more likely to have GI symptoms. The Board finds that a remand is required for an addendum opinion addressing whether the Veteran's GERD is aggravated by his service-connected PTSD. This matter is REMANDED for the following action: Obtain an addendum opinion addressing whether it is approximately as likely as not that the Veteran's GERD was caused or aggravated by the service-connected PTSD, including medications prescribed therefore. In rendering the opinion, the VA examiner should address the medical articles submitted by the Veteran's representative, discussed above. E. BLOWERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debra B. McLoughlin, 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.