HYPERTENSIVE HEART DISEASE

Summary

The Veteran, who served in the U.S. Army with multiple periods of service including November 1970 to March 1973, November 1990 to August 1991, and January 1992 to August 1992, with subsequent National Guard service, appeals the granting of service connection for several conditions. The Veteran sought service connection for a heart disability, hypertension, and diabetes mellitus, claiming they were secondary to chronic sleep impairment stemming from service-connected PTSD with Major Depressive Disorder (MDD). He also claimed prostate disability (including erectile dysfunction) and eye disability (diabetic retinopathy and cataracts) secondary to diabetes mellitus, and rectal disability (hemorrhoids) based on in-service onset. The Board found the evidence in approximate balance regarding the secondary relationship of the heart, hypertension, and diabetes to PTSD-related sleep impairment. Citing medical treatises and the benefit-of-the-doubt doctrine, the Board granted these claims. For the prostate and eye conditions, the Board relied on favorable VA examiner opinions from July and August 2021, respectively, which linked these conditions to diabetes mellitus, noting no contrary opinions. For hemorrhoids, the Board found the Veteran's lay reports of in-service onset credible and persistent, despite negative VA medical opinions, and resolved doubt in his favor. Service connection was granted for all claimed conditions.

Rationale

Evidence in approximate balance regarding secondary relationship to PTSD/MDD; Benefit-of-the-doubt doctrine applied; Medical treatises cited linking PTSD/sleep impairment to cardiovascular disease

Full Decision Text

Citation Nr: 25004992
Decision Date: 04/11/25	Archive Date: 04/11/25

DOCKET NO. 96-22 109
DATE: April 11, 2025

ORDER

Entitlement to service connection for a heart disability, to include as secondary to posttraumatic stress disorder (PTSD) with major depressive disorder (MDD), is granted.

Entitlement to service connection for hypertension, to include as secondary to PTSD with MDD, is granted.

Entitlement to service connection for diabetes mellitus, to include as secondary to PTSD with MDD, is granted.

Entitlement to service connection for a prostate disability, to include erectile dysfunction, as secondary to diabetes mellitus, is granted. 

Entitlement to service connection for an eye disability, to include diabetic retinopathy and cataracts, as secondary to diabetes mellitus, is granted. 

Entitlement to service connection for a rectal disability, to include hemorrhoids, is granted. 

FINDINGS OF FACT

1. Resolving all reasonable doubt in the Veteran's favor, his heart disability is etiologically related to his chronic sleep impairment, a symptom of his service-connected PTSD with MDD.

2. Resolving all reasonable doubt in the Veteran's favor, his hypertension is etiologically related to his chronic sleep impairment, a symptom of his service-connected PTSD with MDD.

3. Resolving all reasonable doubt in the Veteran's favor, his diabetes mellitus is etiologically related to his now service-connected heart disability and hypertension.

4. Resolving all reasonable doubt in the Veteran's favor, his prostate disability, including erectile dysfunction, is etiologically related to his now service-connected diabetes mellitus. 

5. Resolving all reasonable doubt in the Veteran's favor, his eye disability, including diabetic retinopathy and cataracts, is etiologically related to his now service-connected diabetes mellitus. 

6. Resolving all reasonable doubt in the Veteran's favor, his hemorrhoids had their onset during service. 

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a heart disability, to include as secondary to PTSD with MDD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for entitlement to service connection for hypertension, to include as secondary to PTSD with MDD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for entitlement to service connection for diabetes mellitus, to include as secondary to a heart disability and hypertension, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

4. The criteria for entitlement to service connection for a prostate disability, including erectile dysfunction, as secondary to diabetes mellitus, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for entitlement to service connection for an eye disability, including diabetic retinopathy and cataracts, as secondary to diabetes mellitus, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

6. The criteria for entitlement to service connection for a rectal disability, to include hemorrhoids, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the U.S. Army from November 1970 to March 1973, from November 1990 to August 1991, and from January 1992 to August 1992, with additional service in the New York Army National Guard.

This appeal has been pending for a significant period of time. The Board sincerely thanks the Veteran for his patience. Most recently, in August 2023, the Board of Veterans' Appeals (Board) remanded the matters on appeal for additional evidentiary development. As the actions specified in the remand have been completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998).

Service Connection

Service connection may be granted for disability
1970 to March 1973, from November 1990 to August 1991, and from January 1992 to August 1992, with additional service in the New York Army National Guard.

This appeal has been pending for a significant period of time. The Board sincerely thanks the Veteran for his patience. Most recently, in August 2023, the Board of Veterans' Appeals (Board) remanded the matters on appeal for additional evidentiary development. As the actions specified in the remand have been completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998).

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, 3.304. 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 be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439 (1995).

In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. That is, the claimant is entitled to the benefit of the doubt when the evidence is in "approximate" balance, i.e., "nearly equal," but does not require that the evidence be in exact equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

1. Entitlement to service connection for a heart disability, to include as secondary to PTSD with MDD, is granted.

2. Entitlement to service connection for hypertension, to include as secondary to PTSD with MDD, is granted.

3. Entitlement to service connection for diabetes mellitus, to include as secondary to PTSD with MDD, is granted.

The Veteran maintains entitlement to service connection for a heart disability, hypertension, and diabetes mellitus, all of which he believes are secondary to chronic sleep impairment, a symptom of his service-connected acquired psychiatric disability.

As an initial matter, the Board finds that the Veteran has current diagnoses of atherosclerotic cardiovascular disease, status-post coronary artery stent replacement residuals and mitral regurgitation, diabetes mellitus, and hypertension. He is also service connected for PTSD with MDD; one of the significant symptoms of this disability is chronic sleep impairment. Thus, the Board finds that the first and second elements of service connection are met for each of these claims. At issue in this case is whether there is an etiological relationship between the Veteran's claimed disabilities and the symptoms of his service connected PTSD with MDD, specifically his documented chronic sleep impairment. 

To that end, the Board finds that the evidence is at least in equipoise. In that regard, the law is clear. Pursuant to the "benefit-of-the-doubt" rule, where there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. 38 U.S.C. § 5107. 

The Board acknowledges that there is evidence against the claim. However, the Veteran's representative has proffered medical treatise evidence from The Open Cardiovascular Medicine Journal which concludes that "...persons with PTSD have been reported to have an increased risk of hypertension, hyperlipidemia, obesity, and cardiovascular disease." He also cited a note from the Centers for Disease Control (CDC) which observes that sleep impairment has wide ranging effects on health, including the development of chronic disease, indicating that "...insufficient sleep has been linked to the development and management of a number of chronic diseases and conditions, including diabetes [and] cardiovascular disease..." He also pointed the Board to a WebMD article which observes that the consequences of sleep deprivation include high blood pressure (hypertension), heart attack, heart
 evidence against the claim. However, the Veteran's representative has proffered medical treatise evidence from The Open Cardiovascular Medicine Journal which concludes that "...persons with PTSD have been reported to have an increased risk of hypertension, hyperlipidemia, obesity, and cardiovascular disease." He also cited a note from the Centers for Disease Control (CDC) which observes that sleep impairment has wide ranging effects on health, including the development of chronic disease, indicating that "...insufficient sleep has been linked to the development and management of a number of chronic diseases and conditions, including diabetes [and] cardiovascular disease..." He also pointed the Board to a WebMD article which observes that the consequences of sleep deprivation include high blood pressure (hypertension), heart attack, heart failure, stroke, obesity, etcetera. The article reports that, "...many people do not realize that a lack of sleep-especially on a regular basis-is associated with long-term health consequences, including chronic medical conditions like diabetes, high blood pressure, and heart disease..." Finally, the Veteran's representative referenced a Healthy Sleep article from Harvard University which explains that various studies have found that a single night of inadequate sleep in people who have existing hypertension can cause elevated blood pressure the following day, noting that this effect may begin to explain the relationship between poor sleep and cardiovascular disease. 

Scholarly Medical articles and treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). But the Board acknowledges that treatise materials are generally not specific enough to show nexus. Id. Medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). However, in this case, in the nearly two decades that this case has been pending, the Board finds that the majority of the negative VA medical opinions, particularly those received in response to the August 2023 remand, which have ostensibly been directed at this particular Veteran have been just as broad sweeping and general in their rationale as the cited treatise evidence. As such, the Board resolves all reasonable doubt in the Veteran's favor and awards service connection for a heart disability, hypertension, and diabetes mellitus, all as secondary to the chronic sleep impairment caused by his service-connected PTSD with MDD. The claims are granted.  

4. Entitlement to service connection for a prostate disability, to include erectile dysfunction, as secondary to diabetes mellitus, is granted. 

5. Entitlement to service connection for an eye disability, to include diabetic retinopathy and cataracts, as secondary to diabetes mellitus, is granted.

The Veteran maintains entitlement to service connection for a prostate disability and an eye disability, both as secondary to diabetes mellitus.

As an initial matter, the Board finds that the Veteran has current diagnoses of erectile dysfunction, cataracts, and diabetic retinopathy. Additionally, he has been service connected for diabetes mellitus in this decision. Thus, the Board finds that the first and second elements of service connection are met for each of these claims. At issue in this case is whether there is an etiological relationship between the Veteran's claimed disabilities and his now service connected diabetes mellitus. 

Concerning the Veteran's diagnosed erectile dysfunction, in July 2021, a VA examiner who reviewed the claims file and examined the Veteran found that this disability is a result of his diabetes mellitus. Regarding the Veteran's diagnosed diabetic retinopathy and cataracts, in August 2021, a VA examiner who reviewed the claims file and examined the Veteran found that his diagnosed diabetic and retinopathy can be attributed to his systemic diabetes mellitus, citing medical treatise evidence, and reasoning at claimants with diabetes often develop ophthalmic complications, such as corneal abnormalities, glaucoma, iris neovascularization, cataracts, and neuropathies, with the most common being diabetic retinopathy.

The Board finds the July and August 2021 opinions probative as they were written by medical professionals who reviewed the Veteran's medical record and provided clinical evaluations of the claimed condition. Importantly, there are no contrary opinions of record regarding these secondary relationships. In summary, the Board finds that service connection for both disabilities, to include as secondary to diabetes mellitus, is warranted. The claims are granted. 

6. Entitlement to service connection for a rectal disability, to include hemorrhoids, is granted.

The Veteran maintains entitlement to service connection for a rectal disability, to include his
 abnormalities, glaucoma, iris neovascularization, cataracts, and neuropathies, with the most common being diabetic retinopathy.

The Board finds the July and August 2021 opinions probative as they were written by medical professionals who reviewed the Veteran's medical record and provided clinical evaluations of the claimed condition. Importantly, there are no contrary opinions of record regarding these secondary relationships. In summary, the Board finds that service connection for both disabilities, to include as secondary to diabetes mellitus, is warranted. The claims are granted. 

6. Entitlement to service connection for a rectal disability, to include hemorrhoids, is granted.

The Veteran maintains entitlement to service connection for a rectal disability, to include his diagnosed hemorrhoids. 

The Veteran has a documented post-service diagnosis of hemorrhoids and has provide competent, credible lay reports that he first noticed hemorrhoid symptoms (which are generally within the scope of lay observation) during service in 1971.  Moreover, he has also contended that he continues to suffer from hemorrhoids to this day. While VA medical opinions of record are largely negative, they completely ignore the Veteran's competency to observe and report hemorrhoids and their symptoms, as they are fairly commonly known and recognizable, and instead improperly predicate their opinions on the absence of corroborating medical records in service. Therefore, the Board finds them inadequate for rating purposes and of little probative value here.

Resolving any remaining doubt in the Veteran's favor, the Board finds the approximate balance of the evidence supports awarding service connection for hemorrhoids based on symptoms that began in service and have persisted recurrently to this day. The claim is granted.  

 

Melanie J. Mann

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	L. Roberts

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.