HYPERTENSION

Summary

The veteran, who served with multiple periods of active duty between July 1998 and August 2008, including service in Iraq, appeals the denial of service connection for hypertension. The veteran claimed hypertension was related to environmental hazards encountered in Southwest Asia during the Persian Gulf War, or secondary to his service-connected PTSD, radiculopathy, cervical strain, TBI with migraines, degenerative joint disease of the lumbar spine, and erectile dysfunction. The Board reviewed service treatment records, VA examinations, and the veteran's testimony. Service records from 1998, 2002, 2004, and 2008 indicated normal blood pressure readings, though some noted elevated cholesterol and systolic readings during dental treatment. A May 2010 VA examination noted elevated blood pressure readings, but the examiner diagnosed the veteran as negative for hypertension, though acknowledging a history of elevated blood pressure. An addendum noted symptoms consistent with hypertensive heart disease. Later VA outpatient records (2012-2014) indicated hypertension as an active problem. A November 2017 VA examination noted elevated blood pressure and symptoms, but the examiner concluded the veteran did not meet VA criteria for hypertension on that day, though acknowledging sufficient evidence of elevated blood pressure over time. A March 2018 private examination opined hypertension was more likely than not due to service-connected PTSD, but the Board found this opinion unsupported by medical literature and the examiner unqualified. The veteran testified at a hearing, asserting hypertension was due to environmental hazards in Iraq and secondary to PTSD, but also stated it was not secondary to PTSD. A September 2020 VA opinion found hypertension less likely than not related to service or any service-connected conditions, citing medical literature that hypertension is due to peripheral vascular resistance and not related to PTSD, TBI, cervical strain, radiculopathy, erectile dysfunction, or degenerative joint disease. The Board found no evidence of hypertension in service records and denied the claim, concluding the preponderance of the evidence was against the claim and the benefit of the doubt doctrine was inapplicable.

Rationale

No in-service complaints, diagnosis, or treatment for hypertension in STRs.; September 2020 VA opinion found less likely than not related to service or service-connected conditions.; Medical literature does not support nexus between hypertension and PTSD, TBI, cervical strain, radiculopathy, ED, or DJD.

Full Decision Text

Citation Nr: 21047437
Decision Date: 08/03/21	Archive Date: 08/03/21

DOCKET NO. 17-28 133
DATE: August 3, 2021

ORDER

Entitlement to service connection for hypertension as due to an undiagnosed illness resulting from service in Southwest Asia during the Persian Guld War, to include as secondary to his service connected disorders is denied.

FINDING OF FACT

Hypertension was not demonstrated during service, within 1 year following separation from service, is not shown to be due to Gulf War service, nor is the Veteran's hypertension proximately related to or aggravated by his service connected disorders.

CONCLUSION OF LAW

 The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310, 3.317.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had periods of active service from July 1998 to November 1998, from February 2005 to May 2005, and from February 2007 to August 2008.This included service in Iraq. He testified in an October 2019 hearing before the undersigned. A transcript is of record.

This matter was most recently remanded by the Board in January 2020.  Development has been accomplished and the above issues are now before the Board

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, 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" the so-called "nexus requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information lay and medical evidence of record in a case and when 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 (2012); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, a preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996).

For Veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including hypertension, may be presumed to have been incurred in service if they manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 

Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995).

For Persian Gulf War veterans, service connection for chronic, undiagnosed illnesses (or a medically unexplained chronic multi-symptom illness such as fibromyalgia, chronic fatigue syndrome, or functional gastrointestinal disorders) arising from service in Southwest Asia during the Persian Gulf War may be established under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317.

Under those provisions, service connection may be established for objective indications of a chronic disability resulting from an undiagnosed illness or illnesses, provided that such disability
ation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995).

For Persian Gulf War veterans, service connection for chronic, undiagnosed illnesses (or a medically unexplained chronic multi-symptom illness such as fibromyalgia, chronic fatigue syndrome, or functional gastrointestinal disorders) arising from service in Southwest Asia during the Persian Gulf War may be established under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317.

Under those provisions, service connection may be established for objective indications of a chronic disability resulting from an undiagnosed illness or illnesses, provided that such disability (1) became manifest in service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (2) by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. To fulfill the requirement of chronicity, the illness must have persisted for six months. 38 U.S.C. § 1117; 38 C.F.R. § 3.317.

Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317 (b).

Entitlement to service connection for hypertension

The Veteran contends that his hypertension disorder is related to his exposure to environmental hazards while deployed on active duty service in Iraq.

May 1998 STRS reveal a normal blood pressure reading of 124/76.

March 2002 treatment records reveal a normal blood pressure reading of 129/84.

March 2004 treatment records reveal a normal blood pressure reading of 119/83.

May 2008 STRs reveal that the Veteran's blood pressure was noted as normal with 124/83. Cholesterol was noted as elevated with hyperlipidemia diagnosed. Lifestyle changes such as exercise and smoking cessation were recommended. Dental records show some systolic readings around 140 prior to dental treatment in service.

October 2008 STRs indicate that the Veteran reported shortness of breath.

In a May 2010 VA hypertension examination, the examiner noted blood pressure reading at 142/92, 142/92, and 142/90.  The examiner diagnosed the Veteran as negative for hypertension but did note a history of elevated blood pressure.

In a May 2010 addendum opinion, the examiner noted that the Veteran's symptoms were consistent with hypertensive heart disease with an EF of 55 percent with METS at 8-10 percent.

July 2012 to January 2014 VA outpatient treatment records indicate hypertension as an active problem.

In a November 2017 VA hypertension disability benefits questionnaire, the examiner noted a diagnosis of hypertension from May 2010.  The Veteran's blood pressure was noted at146/71, 148/78, and 122/85.  The examiner noted lightheadedness, dizziness, headaches, and slow focusing when blood pressure is high.  The examiner also noted that the Veteran did not meet the VA criteria of the of two blood pressure on the same day for three different days. However, she noted that going through the claims file there is sufficient evidence of elevated blood pressure and continued treatment for hypertension over the years to diagnose hypertension on the day of the examination.

In a March 2018 VA private treatment examination, the examiner noted that the Veteran's service-connected PTSD caused the onset of his hypertension.  The examiner explained that the brain-stem is an extension of the brain base and contains areas that control cardiac function.  Therefore, it influences the blood pressure and cardiovascular function.  The examiner opined that it is absolutely more likely than not that an increased blood pressure and a diagnosis of hypertension is due to the Veteran's service-connected PTSD.

In an October 2019 hearing before the undersigned, the Veteran testified that he did not think his hypertension was secondary to his PTSD.  His contention is that his hypertension is related to his exposure to environmental hazards while deployed in Iraq. The Veteran reported experiencing symptoms of dizziness and energy loss while deployed in Iraq. During the hearing, the Veteran also reported that he was diagnosed with elevated blood pressure in-service and treated for hypertension.  He reported that upon return from Iraq he was sent to Fort Hood for treatment of high blood pressure and was given medication at that point. 

As noted above, in January 2020
 absolutely more likely than not that an increased blood pressure and a diagnosis of hypertension is due to the Veteran's service-connected PTSD.

In an October 2019 hearing before the undersigned, the Veteran testified that he did not think his hypertension was secondary to his PTSD.  His contention is that his hypertension is related to his exposure to environmental hazards while deployed in Iraq. The Veteran reported experiencing symptoms of dizziness and energy loss while deployed in Iraq. During the hearing, the Veteran also reported that he was diagnosed with elevated blood pressure in-service and treated for hypertension.  He reported that upon return from Iraq he was sent to Fort Hood for treatment of high blood pressure and was given medication at that point. 

As noted above, in January 2020 the Board remanded the Veteran's claim for additional development. Specifically, a request was made for reported private treatment records and an additional examiner opinion concerning the Veteran's hypertension.

A February 2020 request was made by the regional office for the Veteran's reported private treatment records for hypertension. No records concerning private treatment for hypertension in-service have since been submitted by the Veteran.  He did not return release forms to allow any records to be obtained, and VA is without authority to obtain such records without consent.

Records on file from Fort Hood during service do not show treatment for hypertension, but rather other pathology.

In a September 2020 VA examiner opinion, the examiner noted that no chronic diagnosis was made for hypertension during the Veteran's period of active duty. The examiner opined that the Veteran's hypertension is less likely than not related to an injury in-service, proximately due to, or aggravated by the following service connected disorders: radiculopathy of the lower and upper extremities; PTSD; cervical strain; degenerative joint disease of the lumbar spine; TBI with migraines; and erectile dysfunction. The examiner also opined that the Veteran's hypertension is less likely than not related to the Veteran's active duty service in South West Asia, nor is the Veteran's hypertension the manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness. 

Concerning radiculopathy of the upper and lower extremities, the examiner explained that hypertension and radiculopathy of the upper and lower extremities are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and radiculopathy of the upper and lower extremities. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined that the well-established causes of hypertension does not include a radiculopathy disorder. Thus, a nexus has not been established.

Concerning a nexus between the Veteran's hypertension and his service connected PTSD, the examiner explained that hypertension and PTSD are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and PTSD. The examiner noted that the 2018 examiner opinion concerning the brain stems relation to the onset of the Veteran's hypertension is not supported by medical literature. The examiner noted that the private examiner is a chiropractor and has not completed traditional medical training and is not qualified to make a medical diagnosis or recommend medical treatment concerning a diagnosis of hypertension. Moreover, the examiner noted that hypertension is a peripheral vascular not cardiac function. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include  mental health disorders.

Concerning a nexus between the Veteran's hypertension and his TBI with migraines, the examiner explained that hypertension and TBI with migraines are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and TBI with migraines.  The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include TBI disorders. Thus, a nexus has not been established.

Concerning a nexus between the Veteran's hypertension and his cervical strain disorder, the examiner explained that hypertension and a cervical strain disorder are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and a cervical strain disorder. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include an orthopedic neck disorder. Thus, a nexus has not been established.

Concerning a nexus between the Veteran's hypertension and his erectile dysfunction disorder, the examiner explained that hypertension and an erectile dysfunction disorder are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and an erectile dysfunction disorder. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes
 relationship between hypertension and a cervical strain disorder. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include an orthopedic neck disorder. Thus, a nexus has not been established.

Concerning a nexus between the Veteran's hypertension and his erectile dysfunction disorder, the examiner explained that hypertension and an erectile dysfunction disorder are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and an erectile dysfunction disorder. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include an orthopedic disorder. Thus, a nexus has not been established.

Concerning a nexus between the Veteran's hypertension and his degenerative joint disease of the lumbar spine disorder, the examiner explained that hypertension and degenerative joint disease of the lumbar spine disorder are not medically related. The examiner also noted that medical literature does not demonstrate a causal relationship between hypertension and a degenerative joint disease of the lumbar spine. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include an orthopedic disorder. Thus, a nexus has not been established.

The foregoing summary of the treatment record reveals no possibility for service connection for hypertension. Although the Veteran contends that his exposure to environmental contaminants in Southwest Asia brought on the onset of his hypertension his STRs do not reveal any complaints, diagnosis, or treatment for hypertension. 

The Board also reviewed the Veteran's lay statements and hearing testimony that his hypertension is related to his exposure to environmental contaminants in Southwest Asia, or secondary to his service connected disorders. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to hypertension as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1) (2018). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).

In sum, the Board finds that the record does not establish service connection for hypertension. While the Veteran has asserted that the etiology of his hypertension is related to his exposure to environmental contaminants in Southwest Asia, or secondary to his service connected disorders, this is not found to be probative when considering the other evidence of the record. As determined by the September 2020 VA examiner opinion, the examiner opined that the Veteran's hypertension is less likely than not related to an injury in-service, proximately due to, or aggravated by the following service connected disorders: radiculopathy of the lower and upper extremities; PTSD; cervical strain; degenerative joint disease of the lumbar spine; TBI with migraines; and erectile dysfunction. The examiner also opined that the Veteran's hypertension is less likely than not related to the Veteran's active duty service in South West Asia, nor is it due to an undiagnosed illness or medically unexplained chronic multi-symptom illness. The examiner explained that medical literature has determined that hypertension occurs when there is peripheral resistance in the vascular system. The examiner also noted that medical literature has determined the well-established causes of hypertension which does not include an orthopedic, cervical, cardiac, or brain stem function. Thus, a nexus has not been established between the Veteran's hypertension and his service connected disorders.

 

Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3.

 

 

MICHAEL D. LYON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Elliot. Harris

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.