HYPERTENSION

Summary

The veteran, who served in the U.S. Army across multiple periods including January 2002 to November 2007, appeals the denial of service connection for hypertension and obstructive sleep apnea (OSA). The veteran contended these conditions were related to PTSD or toxic exposure during service in Southwest Asia. The Board reviewed the evidence, noting the absence of in-service symptoms or treatment for hypertension and OSA, with reported onsets many years after service. While no direct VA examination specifically for service connection nexus was conducted, the Board found no duty to do so given the lack of in-service incidents and late onset. The Board also considered VA examinations from August 2023, November 2023, February 2024, and November 2024, which all concluded that hypertension and OSA were less likely than not related to toxic exposure during service. These opinions cited the multifactorial nature of hypertension and OSA, with genetics and lifestyle factors being primary contributors, and found no widely recognized causal link to toxic exposures. The Board also reviewed a private medical opinion that attempted to link the conditions to PTSD but found it unpersuasive due to its general nature and lack of specific application to the veteran's facts. The Board afforded significant weight to the VA examiners' opinions, finding them well-reasoned and based on current medical knowledge. The veteran's own statements regarding etiology were found to lack competency. Ultimately, the Board concluded the evidence was persuasively against the claim, and the benefit-of-the-doubt doctrine was not applicable as the evidence was not in approximate balance. Service connection for hypertension and obstructive sleep apnea was denied.

Rationale

No in-service onset or treatment; VA exams found less likely than not related to toxic exposure; Private opinion lacked specific nexus to veteran's facts; No nexus to PTSD established

Full Decision Text

Citation Nr: A26026787
Decision Date: 03/25/26	Archive Date: 03/25/26

DOCKET NO. 250812-576666
DATE: March 25, 2026

ORDER

Entitlement to service connection for hypertension, to include as due to toxic exposure or secondary to PTSD, is denied.

Entitlement to service connection for obstructive sleep apnea, to include as due to toxic exposure or secondary to PTSD, is denied.

FINDINGS OF FACT

1. The Veteran's hypertension is not proximately due to his service-connected PTSD or otherwise etiologically related to service.  

2. The Veteran's obstructive sleep apnea is not proximately due to his service-connected PTSD or otherwise etiologically related to service.  

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for hypertension have not been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

2. The criteria for entitlement to service connection for obstructive sleep apnea have not been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably in the United States Army from March 1988 to July 1988, from November 1990 to May 1991, and from January 2002 to November 2007 with additional service in the Army Reserve.  This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2023 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO).  In January 2024, the Veteran submitted a VA Form 20-0995 (Supplemental Claim Application) resulting in a May 2024 rating decision.  In June 2024, the Veteran submitted a request for a Higher-Level Review (HLR) of the May 2024 decision.  The agency of original jurisdiction (AOJ) issued a February 2025 HLR decision.  

In the August 2025 VA Form 10182, 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 February 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. 

Service Connection

Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131; 5107 (b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303 (a), 3.304, 3.307, 3.309, 3.310.  Generally, the evidence 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.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995).

A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury.  See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310.

1. Entitlement to service connection for hypertension.

2. Entitlement to service connection for obstructive sleep apnea.

The Veteran contends that his hypertension and obstructive sleep apnea are related to his PTSD.  After a review of the evidence, the Board finds that service connection is not warranted.

As an initial matter the clinical evidence, to include service treatment records, does not show symptoms or treatment for hypertension or sleep apnea during service or until many years after
 result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury.  See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310.

1. Entitlement to service connection for hypertension.

2. Entitlement to service connection for obstructive sleep apnea.

The Veteran contends that his hypertension and obstructive sleep apnea are related to his PTSD.  After a review of the evidence, the Board finds that service connection is not warranted.

As an initial matter the clinical evidence, to include service treatment records, does not show symptoms or treatment for hypertension or sleep apnea during service or until many years after separation from service, and the Veteran has not truly asserted as much.  Indeed, the Veteran has reported an onset of hypertension in 2010, 3 removed from active service.  He also reported at his August 2023 VA examination that his wife had complained within the past year that he would stop breathing at times during sleep.  He estimated an onset of 10 years prior but admitted that he did not know.  Regardless, an onset of 2013 would be more than 5 years after separation from service.  Hence, the medical and lay evidence of record does not indicate the onset of hypertension or sleep apnea symptoms until several years after separation from service.

As to nexus, the Board observes that the Veteran has not been afforded a VA examination specifically to address service connection for hypertension or sleep apnea on a direct basis.  However, given the lack of any in-service incident, illness, or injury to which the disabilities may be linked combined with the absence of evidence of symptoms for many years after separation from active service, the duty to assist did not require such development at the time of the February 2025 rating decision.  38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006).  Here, the evidence does not show the onset of the Veteran's hypertension or sleep apnea until many years after separation from active service.  As such, based on the evidence of record, the Board finds that a nexus has not been established for either condition on a direct basis.

As to secondary service connection, the Veteran was afforded VA examinations in August 2023 to determine if his hypertension or sleep apnea were related to his confirmed exposure to environmental toxins during service in Southwest Asia.  After a review of the evidence the examiner determined that the Veteran's hypertension and sleep apnea were less likely than not related to the in-service exposure.  

With regard to hypertension, the examiner reasoned that hypertension is a chronic medical condition characterized by a persistently elevated arterial pressure and most cases are considered essential or idiopathic.  There are numerous mechanisms recognized as leading to hypertension including increased salt absorption resulting in volume expansion, an impaired response of the renin-angiotensin-aldosterone system, and increased activation of the sympathetic nervous system.  Genetics are recognized as a strong predictor of the development of hypertension and other known risk factors include advanced age, smoking, obstructive sleep apnea, excessive alcohol intake, physical inactivity, and obesity.  A review of medical literature did not uncover toxic risk exposures as widely recognized causes of hypertension.

As to the Veteran's sleep apnea, the examiner reasoned that the causes of OSA are often multifactorial.  However, some level of anatomic upper airway impairment is essential.  Examples include having a narrow pharyngeal airway or an increased airway length.  The medical literature states that non-anatomical contributors include impaired pharyngeal dilator muscle function, premature awakening to mild airway narrowing (low respiratory arousal threshold), and unstable control of breathing.  A review of medical literature did not uncover toxic risk exposure(s) as a widely recognized direct cause obstructive sleep apnea.

In support of his claim, the Veteran submitted a January 2024 private medical opinion linking his hypertension and sleep apnea to his PTSD.  The Board is not persuaded by the conclusions set forth in the private opinion.  Specifically, the opinion cites to a plethora of evidence describing the interaction of PTSD with hypertension and sleep apnea in general but does not state how this relates to the Veteran.

As to hypertension, the private examiner cited to numerous scientific studies with equivocal conclusions regarding a relationship with PTSD.  For instance, conclusions drawn from the articles state that traumatic events "may" generate the development of hypertension", pathways underlying the relation between psychological trauma and subsequent development of hypertension are "probably" deeply intertwined.  Moreover, the examiner does not point to any facts of record that demonstrate the relevance of the cited studies to the Veteran in this case.  

With regard to the Veteran's sleep apnea, the examiner cites a multitude of studies supporting the
 the private opinion.  Specifically, the opinion cites to a plethora of evidence describing the interaction of PTSD with hypertension and sleep apnea in general but does not state how this relates to the Veteran.

As to hypertension, the private examiner cited to numerous scientific studies with equivocal conclusions regarding a relationship with PTSD.  For instance, conclusions drawn from the articles state that traumatic events "may" generate the development of hypertension", pathways underlying the relation between psychological trauma and subsequent development of hypertension are "probably" deeply intertwined.  Moreover, the examiner does not point to any facts of record that demonstrate the relevance of the cited studies to the Veteran in this case.  

With regard to the Veteran's sleep apnea, the examiner cites a multitude of studies supporting the conclusion that "individuals with OSA often likely have hyperarousal concerns-a low threshold for arousal-which is an underlying mechanism of obstructive sleep apnea.  Individuals have difficulty activating the muscles and stabilizing breathing in a normal fashion.  PTSD can lead to this hyperarousal."  However, this is a general statement and the examiner does not state how this general statement pertaining to some individuals relates to the Veteran.  The examiner does not point to any facts of record indicating that the Veteran's sleep apnea has been affected by hyperarousal.  Overall, the opinion amounts to a general discussion of possible relationships between sleep apnea and PTSD in some individuals without pointing to any facts that relate to the Veteran.  In addition, the examiner concludes that the Veteran's sleep apnea has been aggravated by his PTSD without pointing to any facts which would indicate a worsening of sleep apnea symptoms.

The Veteran was afforded another VA examination in October 2024.   On that occasion, the examiner determined that his hypertension and sleep apnea were not caused or aggravated by his PTSD.  The examiner reasoned that more than one billion adults worldwide have hypertension, with up to 45 percent of the adult populace being affected by the disease.  The high prevalence of hypertension is consistent across all socio-economic and income strata.  Also, obstructive sleep apnea is a structural condition caused by obstruction of velopharynx or oropharynx, resulting in periods of breathing cessation.  The examiner noted specific risk factors that contribute to the development of sleep apnea such as the Veteran's male sex and advancing age.  Finally, the examiner noted that a review of medical literature did not reveal a causative relationship between PTSD and hypertension or sleep apnea.

The examiner also noted that medical records showed the Veteran's hypertension is well controlled on the current regimen of Lisinopril 20mg Daily.  There is also no increase in treatment regimen or increased medical visits regarding his sleep apnea.  Hence, the evidence did not show any worsening of the Veteran's hypertension or sleep apnea since onset.

The Board affords significant probative weight to the opinion rendered by the October 2024 VA examiner.  The opinion was provided by a qualified medical professional after review of the claims file and application of the facts to current medical knowledge.  On the other hand, the private medical opinion simply discussed general relationships between PTSD and hypertension/sleep apnea without discussing how they may pertain to this particular Veteran.  Accordingly, a nexus has not been established between the Veteran's PTSD and his sleep apnea or hypertension.

Finally, several VA medical opinions were obtained to determine whether a relationship existed between the Veteran's development of sleep apnea or hypertension and his presumed exposure to environmental toxins during service in the Southwest Theatre of Operations.  

In August 2023, a VA examiner opined that neither the Veteran's hypertension nor sleep apnea was related to toxic exposure during service.  The examiner reasoned that most cases of hypertension are considered essential or idiopathic.  There are numerous mechanisms recognized as leading to hypertension including increased salt absorption resulting in volume expansion, an impaired response of the renin-angiotensin-aldosterone system, and increased activation of the sympathetic nervous system.  Genetics are recognized as a strong predictor of the development of hypertension and other known risk factors include advanced age, smoking, obstructive sleep apnea, excessive alcohol intake, physical inactivity, and obesity.  A review of medical literature did not uncover toxic risk exposures as widely recognized causes of hypertension.  The examiner also reasoned that the causes of obstructive sleep apnea are often multifactorial, however some level of anatomic upper airway impairment is essential.  A review of medical literature did not uncover toxic risk exposure(s) as a widely recognized direct cause of sleep apnea.

In November 2023, a different VA examiner agreed that the Veteran's presumed in-service exposure was not related to his development of hypertension or sleep apnea.  The examiner reasoned that many internal and external factors can cause temporary changes in blood pressure.  However, the condition of hypertension is multifactorial.  Although research suggests a relationship between toxic
 and obesity.  A review of medical literature did not uncover toxic risk exposures as widely recognized causes of hypertension.  The examiner also reasoned that the causes of obstructive sleep apnea are often multifactorial, however some level of anatomic upper airway impairment is essential.  A review of medical literature did not uncover toxic risk exposure(s) as a widely recognized direct cause of sleep apnea.

In November 2023, a different VA examiner agreed that the Veteran's presumed in-service exposure was not related to his development of hypertension or sleep apnea.  The examiner reasoned that many internal and external factors can cause temporary changes in blood pressure.  However, the condition of hypertension is multifactorial.  Although research suggests a relationship between toxic exposure and hypertension, a causal relationship has not been fully elucidated.  The medical literature does not support a causal relationship.  With regard to sleep apnea, the examiner noted that associative data has explored the relationship between obstructive sleep apnea and exposure to toxins.  However, exposure to toxic chemicals has not been shown to cause upper airway obstruction and obstructive sleep apnea.  A thorough review of medical literature failed to demonstrate a causal relationship.

In February 2024, another VA examiner opined that there is no objective evidence to support the Veteran's hypertension being due to or the result of his toxic exposure risk activities.  According to medical literature, risk factors for the development of hypertension include age, obesity, family history, race, reduced nephron number, high sodium diet, excessive alcohol consumption, physical inactivity, insufficient sleep, and social determinants; exposure to environmental toxins is not a risk factor for the development of condition. 

In November 2024, a fourth VA examiner determined that the Veteran's development of hypertension and obstructive sleep apnea was not related to in-service exposure to toxins.  The examiner reiterated that a review of the medical literature did not show a causal relationship.

The Board affords significant probative weight to the opinions rendered by the August 2023, November 2023, February 2024, and November 2024 VA examiners.  The opinions were provided by qualified medical professionals after review of the claims file and application of the facts to current medical knowledge.  Accordingly, a nexus has not been established the Veteran's in-service exposure and his hypertension or sleep apnea.

In reaching this conclusion, the Board has considered the statements made by the Veteran regarding a relation between his hypertension and sleep apnea and either his PTSD or active service.  However, in this case the Veteran is not competent to testify regarding the etiology of his hypertension or sleep apnea.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  The diagnosis and evaluation of such disorders requires the expertise of a qualified medical professional.  Thus, the unsubstantiated statements made by the Veteran are found to lack competency.

In conclusion, the evidence is persuasively against the claim.  As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for hypertension and sleep apnea is not warranted.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.  The claim is denied.  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.

 

 

B.T. KNOPE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	DB