HYPERTENSION

Summary

The Veteran, a Veteran who served from August 1989 to December 1993, appeals the denial of service connection for hypertension. The Veteran claims his hypertension is secondary to his service-connected sleep apnea. The case has a complex procedural history, including multiple remands from the Board of Veterans' Appeals (Board) and the United States Court of Appeals for Veterans Claims (CAVC). The Board previously denied service connection for hypertension in March 2021, which was vacated and remanded by the CAVC in November 2021. Subsequent remands in April 2022 and January 2023 noted the claim was intertwined with the sleep apnea claim, which was ultimately granted service connection in August 2023. The Board reviewed conflicting medical opinions regarding the secondary service connection of hypertension to sleep apnea. An October 2020 VA examination opined a positive nexus, citing medical literature supporting the link. However, a subsequent August 2023 VA examination and November 2023 addendum opined a negative nexus, stating no medical literature supports sleep apnea causing hypertension. The Board found the October 2020 opinion more probative due to its detailed rationale and citation of supporting literature, and it also considered the theory of obesity as an intermediate step, which the later examiner did not. The Board found the evidence in approximate balance and resolved all doubt in the Veteran's favor, granting service connection for hypertension secondary to sleep apnea.

Rationale

Veteran diagnosed with hypertension.; Veteran service-connected for obstructive sleep apnea.; October 2020 VA opinion found positive nexus between sleep apnea and hypertension.; October 2020 opinion cited medical literature supporting the connection.; October 2020 opinion considered obesity as intermediate step.; August 2023/November 2023 opinions found negative nexus.; Board found October 2020 opinion more probative.; Evidence in approximate balance, doubt resolved in Veteran's favor.

Full Decision Text

Citation Nr: 24002969
Decision Date: 01/19/24	Archive Date: 01/19/24

DOCKET NO. 12-28 067
DATE: January 19, 2024

ORDER

Entitlement to service connection for hypertension is granted.

FINDING OF FACT

There is an approximate balance of positive and negative evidence as to whether the Veteran's hypertension is proximately due to his service-connected sleep apnea.

CONCLUSION OF LAW

The criteria for service connection for hypertension as secondary to service-connected sleep apnea is met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from August 1989 to December 1993.

This matter was initially before the Board of Veterans' Appeal (Board) on appeal from a March 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). 

In March 2021, the Board of Veterans' Appeal (Board) denied service connection for hypertension. The Veteran appealed to the United States Court of Appeals for Veterans Claims (CAVC). 

In November 2021, CAVC vacated the March 2021 Board decision and remanded the claims. In April 2022 and January 2023, the Board remanded this matter as it is inextricably intertwined with the Veteran's claim for entitlement to service connection for sleep apnea.  In August 2023, the RO granted the Veteran's claim for entitlement to service connection for sleep apnea. Now, the Veteran's claim for entitlement to service connection for hypertension is again back before the Board. The Board finds there has been substantial compliance with the January 2023 Board remand and the Board will proceed with adjudication of these claims. See Stegall v. West, 11 Vet. App. 268 (1998).

Entitlement to service connection for hypertension is granted. 

The Veteran contends that his hypertension is secondary to his now service-connected sleep apnea. Moreover, the Veteran contends that the new August 2023 and November 2023 addendum to the medical opinion was unnecessary considering the opinion issued by the October 2020 VA medical examiner. See November 2023 Third Party Correspondence. 

Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). To establish secondary service connection there must be evidence: (1) of a current disability (for which secondary service connection is sought); (2) of an already service-connected disability; and (3) that the current disability for which service connection is sought was either (a) caused or (b) aggravated by the service- connected disability. 38 C.F.R. § 3.310(a); see Allen v. Brown, 7 Vet. App. 439 (1995) (en banc).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

First, the Veteran has been diagnosed with hypertension. See December 2016 VA Examination. Thus, the first element of secondary service connection has been met.  Second, the Veteran is service connected for obstructive sleep apnea (hereinafter "sleep apnea"). See August 2023 Rating Decision. Thus, the second element of secondary service connection has been met. 

The question before the Board is whether the Veteran's hypertension was either caused or aggravated by the Veteran's service-connected sleep apnea. 

In October 2020, the Veteran underwent a VA examination in connection with this claim. The VA examiner opined that the Veteran's hypertension is as likely as not proximately due to or the result of the Veteran's sleep apnea. The VA examiner reasoned that sleep apnea causes disrupted breathing while asleep which then causes drop in oxygen levels causing an increase in blood flow and thus putting pressure on the blood vessels' wall which causes elevated blood pressure levels. The VA examiner also noted that blood pressure levels are not only elevated at night. Moreover, the VA examiner noted that studies have confirmed that there is an etiological nexus between sleep apnea and hypertension.  These studies were specifically cited in the VA examiner's medical opinion. 

The Board notes that at the time of the October 2020 VA examination, the Veteran's sleep apnea was not yet service-connected. However, the Board notes that at the time of October 2020 VA examination
 of the Veteran's sleep apnea. The VA examiner reasoned that sleep apnea causes disrupted breathing while asleep which then causes drop in oxygen levels causing an increase in blood flow and thus putting pressure on the blood vessels' wall which causes elevated blood pressure levels. The VA examiner also noted that blood pressure levels are not only elevated at night. Moreover, the VA examiner noted that studies have confirmed that there is an etiological nexus between sleep apnea and hypertension.  These studies were specifically cited in the VA examiner's medical opinion. 

The Board notes that at the time of the October 2020 VA examination, the Veteran's sleep apnea was not yet service-connected. However, the Board notes that at the time of October 2020 VA examination, a sleep apnea diagnosis has been confirmed. 

Following the RO's grant of entitlement of service connection for sleep apnea in August 2023, the Veteran underwent another VA examination in August 2023. The August 2023 VA examiner opined that the Veteran's hypertension is less likely than not caused by the Veteran's sleep apnea reasoning that sleep apnea does not medically cause hypertension. In a November 2023 addendum to the medical opinion, the VA examiner noted that there "is no medical literature that sleep apnea causes hypertension."  The VA examiner noted that sleep apnea and hypertension often coexist since hypertension is present in 60 percent of the general adult population.  Ultimately, the examiner noted that there is no positive nexus opinion since there is a lack of "peer reviewed medical literature that states sleep apnea neither causes or aggravates hypertension." 

The Board finds the October 2020 medical opinion more probative than the August 2023 medical opinion and November 2023 addendum to the medical opinion. The October 2020 medical opinion's rationale was based on the review of the whole record and based on an examination of the Veteran and the examiners' knowledge and expertise as medical professionals. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.)

Unlike the October 2020 medical opinion, the August 2023 and November 2023 VA examiner did not consider the theory of obesity as an intermediate step to the Veteran' s hypertension and sleep apnea. Moreover, contrary to the VA examiner's statement that there are no medical literature to support the connection between hypertension and sleep apnea, the October 2020 VA examiner specifically cited to the medical literature which shows that there is a connection between the two. 

The Board also notes that the Veteran was also afforded a Toxic Exposure Risk Activity (TERA) VA examination in October 2023. The VA examiner opined that the Veteran's hypertension is less likely than not caused by toxic exposure risk activities by the Veteran. While the Board acknowledges the October 2023 VA examination, the Board notes that the Veteran has not made any assertions that his hypertension is due to toxic exposure risk activities. 

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Overall, the Board finds the evidence to be at least in approximate balance as to whether the Veteran's current hypertension is proximately due to his service-connected sleep apnea. The October 2020 medical opinion stating that the Veteran's hypertension caused the Veteran's sleep apnea is more probative than the VA examiner's medical opinion. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for hypertension is warranted, and the claim is granted.

 

 

M. Mills

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. Mendoza, 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.