HYPERTENSION

TIFFANY DAWSON · 2025 · Case ID: A25034893

MIXED

Summary

The Veteran, who served from June 1996 to June 2000, appeals the denial of service connection for hypertension, claimed as secondary to service-connected obstructive sleep apnea (OSA) and major depressive disorder (MDD). The Board reviewed the evidence under the modernized review system, noting that only evidence of record at the time of the agency of original jurisdiction's decision could be considered. The Veteran's service treatment records and separation examination were silent regarding hypertension. A VA examination in April 2024 opined that the Veteran's hypertension was less likely than not related to toxic exposure risk activities, and a subsequent August 2024 VA examination agreed, finding no medical relationship between hypertension and toxic exposure. However, the April 2024 VA examiner provided a positive opinion, stating hypertension was at least as likely as not proximately due to OSA, citing mechanisms like intermittent hypoxia and stress response activation. The August 2024 VA examiner found no medical relationship between hypertension and OSA, but this opinion was deemed inadequate due to factual inaccuracies and failure to address the April 2024 opinion. A September 2024 VA examination found hypertension less likely than not related to MDD, but this opinion was also deemed inadequate. Resolving reasonable doubt in the Veteran's favor, the Board found the April 2024 opinion persuasive, establishing secondary service connection for hypertension due to OSA. The claims for direct service connection and secondary connection due to MDD were denied.

Rationale

April 2024 VA examiner provided positive opinion linking hypertension to OSA; OSA mechanisms (hypoxia, stress response) contribute to hypertension; August 2024 VA opinion deemed inadequate due to factual errors and failure to address April opinion

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240929-477490

Full Decision Text

Citation Nr: A25034893
Decision Date: 04/16/25 Archive Date: 04/16/25

DOCKET NO. 240929-477490
DATE: April 16, 2025

ORDER

Entitlement to service connection for hypertension as secondary to service-connected obstructive sleep apnea is granted.

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, his hypertension is at least as likely as not caused by his service-connected obstructive sleep apnea.

CONCLUSION OF LAW

The criteria for entitlement to service connection for hypertension as secondary to service connected obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from June 1996 to June 2000.

The rating decision on appeal was issued in September 2024 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the September 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the September 2024 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Under 38 C.F.R. § 20.202(c)(2) the Veteran has a year of notification of the rating decision on appeal to modify his choice of Board appeal lanes, and the "Board ordinarily may not decide an appeal before this time period is up." See Williams v. McDonough, 37 Vet. App. 305 (2024). However, because in this matter a full grant of the issue on appeal is warranted, the Veteran is not prejudiced by the Board issuing the decision without such a delay.

Entitlement to service connection for hypertension, to include as secondary to service-connected obstructive sleep apnea and/or major depressive disorder.

The Veteran seeks service connection for hypertension, to include as secondary to service-connected obstructive sleep apnea and/or major depressive disorder. See April 2024 VA Form 21-526.

Service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for a disability, there must be (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).

Secondary service connection is granted where a service-connected disability causes or aggravates a nonservice-connected disability. See 38?C.F.R. §?3.310; see also Allen v. Brown, 7?Vet. App.?439, 448 (1995). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38?C.F.R. §?3.310(b).

The threshold legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence that the disability for which service connection is sought is proximately due to, or aggravated by, the service-connected disability. See Wallin v. West, 11?Vet. App.?509, 512 (1998).

The AOJ conceded the Veteran's current diagnosis for hypertension; toxic exposure risk activity
without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38?C.F.R. §?3.310(b).

The AOJ conceded the Veteran's current diagnosis for hypertension; toxic exposure risk activity (TERA), including in the Southwest Asia theater of operations and exposure to sanding, painting, solvents, and hazardous chemicals; and that the Veteran is service connected for obstructive sleep apnea and major depressive disorder. The Board is bout by these favorable findings. 38 C.F.R. § 3.104(c).

Direct Service Connection

With regard to direct service connection, the Veteran's service treatment records are silent for any complaints, treatment, and diagnoses related to his hypertension. The Veteran's April 2000 separation examination is also silent for any complaints, treatment, and diagnoses related to his hypertension.

The Veteran was afforded a VA examination in April 2024. The Veteran reported the approximate date of onset for his hypertension was in 2005. See April 2024 VA examination. The VA examiner noted the Veteran began taking medication to treat his hypertension in 2018. Id. The VA examiner opined that the Veteran's hypertension was less likely than not caused by the indicated toxic exposure risk activities after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. Id. In August 2024, a VA examiner agreed with the April 2024 VA examiner's opinion. See August 2024 VA medical opinion. As rationale, the August 2024 VA examiner noted there was no evidence that supports the correlation and the development of hypertension. Id.

In light of the April and August 2024 VA medical opinions, the Board finds that direct service connection is not warranted. Additionally, the Veteran's VA treatment records do not indicate the Veteran's hypertension is directly related to his service, to include any toxic risk activity exposure. Moreover, the Veteran did not provide any argument or evidence to support a finding that direct service connection is warranted. Accordingly, service connection on a direct basis is not warranted. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

Secondary Service Connection

With regard to secondary service connection, as noted, the Veteran was afforded a VA examination in April 2024. The VA examiner opined that the Veteran's hypertension was at least as likely as not proximately due to or the result of service-connected obstructive sleep apnea. See April 2024 VA medical opinion. As rationale, the VA examiner noted sleep apnea exerts a strong influence on the development of hypertension through several mechanisms; during apnea episodes, there is a temporary cessation of breathing that causes an increase in heart rate and blood pressure; repeated episodes of apnea result in fragmented sleep and activation of the body's stress response which can contribute to hypertension; intermittent hypoxia and oxidative stress associated with sleep apnea can contribute to risk factors for hypertension; and overall, the chronic intermittent hypoxia, sympathetic activation, sleep disruption, and cardiovascular consequences of sleep apnea collectively contribute to the development and worsening of hypertension. Id.

In August 2024, a separate VA examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of his obstructive sleep apnea. See August 2024 VA medical opinion. As rationale, the VA examiner noted the conditions of hypertension and obstructive sleep apnea are not medically related; hypertension is a separate entity from obstructive sleep apnea; a review of medical literature failed to demonstrate a causal relationship; and the Veteran was already diagnosed with hypertension many years before obstructive sleep apnea, noting that he was diagnosed with hypertension in 2005 and sleep apnea in 2023. Id. The VA examiner also opined that it was not at least as likely as not that his hypertension was aggravated by service connected obstructive sleep apnea. Id. As rationale, the VA examiner noted the Veteran's blood pressure had not been recorded in the claims file since the diagnosis of obstructive sleep apnea in 2023 and the most recent blood pressure was noted in the claims file in
are not medically related; hypertension is a separate entity from obstructive sleep apnea; a review of medical literature failed to demonstrate a causal relationship; and the Veteran was already diagnosed with hypertension many years before obstructive sleep apnea, noting that he was diagnosed with hypertension in 2005 and sleep apnea in 2023. Id. The VA examiner also opined that it was not at least as likely as not that his hypertension was aggravated by service connected obstructive sleep apnea. Id. As rationale, the VA examiner noted the Veteran's blood pressure had not been recorded in the claims file since the diagnosis of obstructive sleep apnea in 2023 and the most recent blood pressure was noted in the claims file in January 2019, 4 years prior to the obstructive sleep apnea diagnosis. Id. However, the VA examiner did not address the April 2024 VA examiner's positive opinion finding that the Veteran's hypertension was at least as likely as not proximately due to his obstructive sleep apnea. Additionally, in a December 2023 VA examination, the Veteran reported that the onset of his obstructive sleep apnea was in 1996; and that he had sleep issues during service, including trouble sleeping, snoring, periods of apnea, and gasping for air. The August 2024 VA examiner did not address the Veteran's lay statements of onset of his sleep apnea in 1996, which preceded his diagnosis for hypertension in 2005. Moreover, the August 2024 VA examiner inaccurately stated that there were no blood pressure readings after the Veteran's diagnosis of sleep apnea in 2023 as the Veteran's blood pressure was taken at the April 2024 VA examination. As such, the Board finds the August 2024 VA medical opinion inadequate for decision making purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008).

In September 2024, a VA examiner opined that the Veteran's hypertension was less likely than not proximately due or the result of service-connected major depressive disorder. See September 2024 VA medical opinion. As rationale, the VA examiner noted the conditions of hypertension and major depressive disorder are not medically related and a review of medical literature failed to demonstrate a causal relationship. Id. The VA examiner further noted that obesity is a major cause of hypertension; however, the Veteran's major depressive disorder does not preclude him from all forms of exercise and the VA examiner was unable to state that the Veteran's obesity would not have occurred if the Veteran did not have major depressive disorder. Id. The VA examiner did not provide a medical opinion with regard to secondary aggravation. As such, the Board finds the September 2024 VA medical opinion inadequate for decision making purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008).

Based on the foregoing, the Board finds that the most persuasive and conclusive evidence of record shows that the Veteran's hypertension was at least as likely as not caused by his service-connected obstructive sleep apnea. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the April 2024 VA examiner provided a positive medical opinion finding the Veteran's hypertension was at least as likely caused by service-connected obstructive sleep apnea and provided an adequate rationale. See Nieves-Rodrigues v. Peake, 22 Vet. App. at 302. The August 2024 VA medical opinion is inadequate for decision making purposes and there is no other evidence to the contrary. In resolving any doubt in the Veteran's favor, the Board finds that secondary service connection is established. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Wallin, 11?Vet. App. at 512; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, service connection for hypertension as secondary to service-connected obstructive sleep apnea is warranted.

Tiffany Dawson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Moore, Carlin

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.

Vet. App. at 512; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, service connection for hypertension as secondary to service-connected obstructive sleep apnea is warranted.

Tiffany Dawson

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Moore, Carlin

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