HYPERTENSION

Summary

The veteran, who served from July 1978 to January 2006, appeals the denial of service connection for hypertension, both directly and as secondary to his service-connected PTSD and TBI. The veteran testified that he was diagnosed with hypertension at separation and prescribed medication, but service treatment records showed normal blood pressure readings and no diagnosis or treatment for hypertension during service. Post-service records indicated a diagnosis of essential hypertension in July 2007, with medication initiated. VA examinations in September 2019 and November 2020 both opined that the hypertension was less likely than not related to service, citing risk factors such as genetics, family history, age, and obesity, rather than TBI or PTSD. The Board found these opinions probative, noting the absence of in-service treatment or diagnosis and the presence of multiple risk factors. The Board also considered and rejected presumptive service connection for hypertension and Persian Gulf War undiagnosed illnesses. The veteran's lay testimony regarding the etiology of his hypertension was given little weight as he is not competent to opine on complex medical causation. The Board found the evidence preponderated against service connection, and therefore, the benefit of the doubt doctrine was not applicable. Service connection for hypertension was denied.

Rationale

Service treatment records negative for hypertension diagnosis or treatment.; Post-service diagnosis of hypertension in July 2007.; VA examiners opined less likely than not related to service or secondary to PTSD/TBI.; Examiners cited genetics, family history, age, obesity, and inactivity as primary risk factors.; No presumptive service connection warranted.; Veteran's lay opinion on causation given little probative value.

Full Decision Text

Citation Nr: 22013735
Decision Date: 03/10/22	Archive Date: 03/10/22

DOCKET NO. 13-34 577
DATE: March 10, 2022

ORDER

Service connection for hypertension, to include as secondary to a service-connected disability, is denied.

FINDINGS OF FACT

1. Hypertension first manifested more than one year after service and has not otherwise been found to be related to his service.

2. Hypertension is not proximately due to, or aggravated by, a service-connected disability.

CONCLUSION OF LAW

The criteria for service connection for hypertension have not been 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 on active duty from July 1978 to January 2006.

This matter comes before the Board of Veterans' Appeals (Board) from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California which, in part, denied service connection for hypertension.

The Veteran testified before a Veterans Law Judge (VLJ) at a Board videoconference hearing in March 2017.  A copy of the March 2017 transcript has been reviewed and associated with the claims file.  The VLJ has since retired.  The Board sent a letter to the Veteran in August 2020, advising him of his right to request a second hearing, and to do so within 30 days or the Board would move forward with a decision.  He did not respond to this letter requesting a second hearing.  

The above matter was before the Board in June 2018, October 2020, and May 2021 at which times it was remanded for additional evidentiary development.

Legal Criteria

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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).     

Certain chronic diseases, such as hypertension, will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause.  38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a).

Service connection may also be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service 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 which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.  38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1) (VA has issued an interim final rule extending this date to December 31, 2026).

Secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury.  38 C.F.R. § 3.310(a). To establish service connection for a disability on a secondary basis, there must be evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability.  See Allen v. Brown, 7 Vet. App. 439, 448 (2006).  Additionally, for claims received after October 10, 2006, when aggravation of a nonservice-connected disability is proximately due to or the result of a service-connected disorder, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  Id.; see also 38 C.F.R. § 3.310(b).

Analysis

The
 service connection for a disability on a secondary basis, there must be evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability.  See Allen v. Brown, 7 Vet. App. 439, 448 (2006).  Additionally, for claims received after October 10, 2006, when aggravation of a nonservice-connected disability is proximately due to or the result of a service-connected disorder, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  Id.; see also 38 C.F.R. § 3.310(b).

Analysis

The Veteran contends that he has hypertension which is related to his military service.  Specifically, during the March 2017 Board hearing, the Veteran testified that he was first told he had hypertension at the time of his separation from military service and was prescribed medication to treat his hypertension at that time.  He has also contended that his hypertension is either secondary to and/or aggravated by his service-connected posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI).   

Hypertension is defined as high arterial blood pressure.  Dorland's Illustrated Medical Dictionary 801 (28th ed. 1994).  Various criteria for its threshold have been suggested, ranging from 140 systolic and 90 diastolic to as high as 200 systolic and 110 diastolic.  Id.  For purposes of rating the disease, VA defines the term as meaning "that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm."  See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1).

A review of the Veteran's service treatment records primarily shows blood pressure readings in the normal ranges but do contain some elevated readings.  Specifically, in January 2004, his blood pressure was recorded as 140/88, in September 2004, it was 132/90 and, in March 2005, it was 134/86.  However, the Veteran had a normal blood pressure reading of 124/67 on separation examination in September 2005.  At no time was hypertension reported or diagnosed. 

Post service treatment records show a diagnosis of essential hypertension as early as July 2007.  At that time, it was noted that since he retired from active duty, he had gained 50 pounds and was started on hypertension medication. 

The Veteran submitted an initial claim for service connection for hypertension in January 2012.  In connection with this claim, he was afforded a VA hypertension examination in September 2019 and the examiner noted a diagnosis of hypertension with an onset in July 2007.  Significantly, the examiner opined that it was less likely than not (less than 50 percent or greater probability) that the Veteran's hypertension had its onset during active service or within one year of service separation.  As rationale for this opinion, the examiner noted that hypertension is a common vascular condition that has multiple causes and risk factors such as being overweight, lack of physical activity, and advancing age above 40 years as well as genetic factors.  The Veteran was never seen or treated for his hypertension condition during active-duty service with no blood pressure serial monitoring.  The diagnosis was rendered approximately 18 months after separation.  

In its October 2020 remand, the Board noted that the September 2019 VA examiner failed to provide an opinion as to whether the Veteran's hypertension was secondary to his service-connected TBI and/or PTSD.  As such, the Veteran was afforded a second VA hypertension examination in November 2020.  With regard to direct service connection, the November 2020 VA examiner opined that the Veteran's hypertension was less likely than not incurred during his active service.  As rationale for this opinion, the examiner noted that the Veteran's September 2005 separation examination is negative for a diagnosis of hypertension and/or medications for hypertension.  The first indication of hypertension is a treatment record showing that the Veteran had been prescribed antihypertensive medication, Lotrel (amlodipine/benazepril) in July 2007, 19 months after his separation, although there is no treatment note corresponding to this prescription, nor what blood pressure this prescription was written for.  The medication just appears for first time on a July 2007 medication list.  There is no blood pressure taken on that note, nor the previous note.

With regard to secondary service connection, the November 2020 VA examiner opined that the Veteran's hypertension was less likely than
 Veteran's September 2005 separation examination is negative for a diagnosis of hypertension and/or medications for hypertension.  The first indication of hypertension is a treatment record showing that the Veteran had been prescribed antihypertensive medication, Lotrel (amlodipine/benazepril) in July 2007, 19 months after his separation, although there is no treatment note corresponding to this prescription, nor what blood pressure this prescription was written for.  The medication just appears for first time on a July 2007 medication list.  There is no blood pressure taken on that note, nor the previous note.

With regard to secondary service connection, the November 2020 VA examiner opined that the Veteran's hypertension was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected disabilities, particularly his TBI and/or PTSD.  As rationale for this opinion, the examiner noted that the Veteran has several causative risk factors for hypertension, such as being middle aged when first prescribed antihypertensive medication, obesity (weight of 212 pounds, 65 inches, and a BMI (body mass index) of 35 in July 2007), inactivity, as well as genetic and family history.  The strongest risk factor for hypertension is genetic/family history.  Almost all of his immediate family had/has hypertension (both parents and two siblings).  He was also middle aged and obese when started on hypertension medication.  As such, his hypertension is more likely due to these risk factors.  Furthermore, the medical literature does not support TBI or PTSD as a primary cause of hypertension.  He has essential hypertension, "essential," meaning not caused by another condition.

With regard to aggravation by a service-connected condition, the November 2020 VA examiner opined that the Veteran's hypertension was less likely than not, aggravated beyond natural progression by the Veteran's service-connected TBI or PTSD.  As rationale for this opinion, the examiner noted that the Veteran was first prescribed antihypertensive medication in July 2007, Amlodipine and Benazepril and is currently taking Lisinopril.  Lisinopril is the same class of medication as Benazepril.  This means he has been on essentially the same, simple uncomplicated regimen of two blood pressure medications for the last 13 years, without complications.  This does not support the contention of aggravation beyond natural progression.

In its May 2021 remand, the Board noted that the October 2020 VA examiner did not discuss whether the Veteran's TBI or PTSD caused or contributed to the Veteran's obesity which then lead to hypertension.  See ElAmin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (holding that, when multiple theories of entitlement are at issue, the Board must ensure that the medical opinions of record directly address all theories reasonably raised by the record).  Specifically, it was noted that on January 6, 2017, VA's General Counsel issued a precedential opinion which held that obesity could be an "intermediate step" between a service-connected disability and a current disability and thus satisfy the causal link between the two. VAOGCPREC 1-2017.  In such cases where the issue is raised, the adjudicator should resolve three issues: (1) whether the service-connected disability caused the Veteran to become obese; (2) if so, whether the obesity was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for the obesity caused by the service-connected disability. VAOGCPREC 1-2017.  Additionally, when providing the opinion, it should be noted that in Ward v. Wilkie, 31 Vet. App. 233 (2019) the United States Court of Appeals for Veterans Claims (Court) provided a new definition of aggravation which now includes a temporary worsening of a disability.

As such, an addendum medical opinion was obtained in August 2021.  Significantly, the August 2021 VA opinion found that the Veteran' hypertension is less likely than not, caused by this service-connected PTSD and/or TBI.  As rationale for this opinion, the examiner noted that PTSD causes mental symptoms such as avoidance behavior and bad dreams.  TBI causes neurological symptoms.  There is insufficient evidence that TBI and/or PTSD caused weight gain, and insufficient evidence that weight gain is the primary cause of hypertension.  The medical literature says family history, and genetics are the primary causes of hypertension.  The Veteran has a very high familial risk factor, with several family members with hypertension.  His genetic and familial risk factor is likely than not the main cause of his hypertension.  It is less likely than not that hypertension is caused by
2021 VA opinion found that the Veteran' hypertension is less likely than not, caused by this service-connected PTSD and/or TBI.  As rationale for this opinion, the examiner noted that PTSD causes mental symptoms such as avoidance behavior and bad dreams.  TBI causes neurological symptoms.  There is insufficient evidence that TBI and/or PTSD caused weight gain, and insufficient evidence that weight gain is the primary cause of hypertension.  The medical literature says family history, and genetics are the primary causes of hypertension.  The Veteran has a very high familial risk factor, with several family members with hypertension.  His genetic and familial risk factor is likely than not the main cause of his hypertension.  It is less likely than not that hypertension is caused by weigh gain due to service-connected disabilities.  He had several causative risk factors for hypertension other than weight gain, when he was first prescribed antihypertensive medication.  These are genetics, family history, and being middle aged.  It is not possible to attribute weight gain to the Veteran's service-connected conditions.  Weight gain is complicated, and it is not possible to objectively ascertain the cause on one's weight gain, as there are so many unobservable and unmeasurable factors involved.  

Also of record are VA and private treatment records dated through April 2021 showing treatment for the Veteran's hypertension.  However, none of these treatment records speculate as to the etiology of the Veteran's hypertension.  

Initially, the Board has considered whether service connection is warranted on a presumptive basis.  Significantly, while hypertension is listed as a presumptive condition under 38 C.F.R. § 3.309, it was not diagnosed until July 2007, approximately 19 months after the Veteran's discharge from service.  Also, with regard to the Persian Gulf presumption, as the Veteran has been diagnosed with hypertension, there is no indication of an "undiagnosed illness."  As such, presumptive service connection is not warranted pursuant to 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309, 3.317.

Furthermore, the claim must be denied on a direct basis.  As above, while service treatment records do show some elevated blood pressure readings, the majority of these records show normal blood pressure readings and are negative for a diagnosis of hypertension.  While the Veteran has at times alleged being placed on medication at separation, the contemporaneous medical records do not corroborate that assertion. Rather, his blood pressure was noted to be normal at separation. Second, the earliest evidence of hypertension is dated in July 2007.  Moreover, there is no medical opinion linking the Veteran's hypertension to his service on a direct basis.  As above, both the September 2019 and November 2020 VA examiners opined that the Veteran's hypertension was not related to his military service and, instead, related the Veteran's hypertension to being overweight, lack of physical activity, advancing age above 40 years, as well as genetic factors.  These opinions are highly probative of the medical question before the Board, as they are based on accurate facts, relevant service data, and pertinent medical risk factors.

The Board also finds that service connection for hypertension as secondary to a service-connected disability is not warranted.  In this regard, the November 2020 and May 2021 VA opinions found that the Veteran's hypertension is neither secondary to nor aggravated by the Veteran's service-connected disabilities, particularly his PTSD and TBI, even considering any weight gain related to these disabilities, as genetic and familial risk factor is more likely than not the main cause of the Veteran's hypertension.  In support of these findings, the examiners have noted the stable nature of the Veteran's hypertension since diagnosis. Again, given the accurate history and that the examiners have included the underlying reasons for the conclusions based, the Board finds these opinions highly probative.

While the Veteran contends that his hypertension is related to his military service, the Board accords his statements regarding the etiology of this disorder little probative value as he is not competent to opine on such complex medical questions.  Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue.  See Jones v. West, 12 Vet. App. 460, 465 (1999).  In this regard, the question of causation and aggravation of hypertension involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship.  As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence.  See Jandreau v. Nicholson, 492 F.3d 1372, 137
 complex medical questions.  Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue.  See Jones v. West, 12 Vet. App. 460, 465 (1999).  In this regard, the question of causation and aggravation of hypertension involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship.  As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions).  

Therefore, based on the foregoing, the Board finds that service connection for hypertension is not warranted.  In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine.  However, the persuasive evidence does not support the Veteran's claim.  As such, that doctrine is not applicable.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.  The appeal is denied.

 

 

Bethany L. Buck

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	April Maddox, 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.