Citation Nr: 24016023 Decision Date: 04/15/24 Archive Date: 04/15/24 DOCKET NO. 14-24 685 DATE: April 15, 2024 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to the service-connected posttraumatic stress disorder (PTSD), is granted. Entitlement to service connection for hypertension, to include as secondary to the service-connected PTSD, is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, it is at least as likely as not that his GERD is secondary to the service-connected PTSD. 2. Resolving reasonable doubt in the Veteran's favor, it is at least as likely as not that his hypertension is directly related to his active military service or secondary to the service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for GERD, to include as secondary to the service-connected PTSD, 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 the service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from July 1967 to April 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded this case in March 2018, November 2019, January 2022, and May 2022. Subsequently, in a November 2022 decision, the Board denied entitlement to service connection for GERD, and granted entitlement to presumptive service connection for hypertension under the Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act). In the same decision, the Board found that service connection for hypertension on direct basis or secondary to the service-connected PTSD is not warranted. The Veteran timely appealed the November 2022 Board decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2023 order, the Court granted an October 2023 Joint Motion for Partial Remand (JMPR) filed by the parties (the Veteran and the Secretary of VA), vacating the parts of the November 2022 Board decision denying entitlement to service connection for GERD and entitlement to direct service connection for hypertension, and remanded these matters back to the Board for readjudication consistent with the terms of the October 2023 JMPR. SERVICE CONNECTION Generally, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 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 also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Secondary service connection requires: (1) a service-connected disability; (2) a nonservice-connected disability; and (3) evidence that the nonservice-connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability and not due to the natural progress of the nonservice-connected disability. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt should be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt should be resolved in favor of the claimant. 38 C.F.R. § 3.102. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. Id. 1. Entitlement to service connection for GERD, to include as secondary to the service-connected PTSD. The Veteran contends that he has GERD, and it is directly related to his military service, or alternatively secondary to the service-connected PTSD. At the August 2017 Board hearing, the Veteran asserted that he had stomach knots and other gastrointestinal issues during service, which were treated by over-the-counter medication. He also asserted that stress and depression due to PTSD make GERD symptoms worse. Initially the Board notes that the Veteran has established service connection for PTSD. Thus, the question for the Board is whether the Veteran has a current disability of GERD that began during service or is related to an in-service injury, event, or disease; or alternatively proximately due to or aggravated beyond its natural progression by the service-connected PTSD. The existence of a current disability of GERD is not in question because in the November 2018 VA disability benefit questionnaire (DBQ), the examiner noted the diagnosis of GERD. As far as in-service incurrence or aggravation of GERD is concerned, the Veteran was not diagnosed with GERD during service, and there is no in-service event, disease, or injury that has plausible relationship with GERD. The May 1967 enlistment examination and the March 1971 separation examination are silent regarding GERD or any gastrointestinal symptoms. Regarding the claimed direct service connection of the Veteran's currently diagnosed GERD, in the November 2018 VA medical opinion, the examiner opined that the Veteran's GERD was less likely than not incurred in or caused by an in-service injury, event, or illness. As a supporting rationale, the examiner stated that there is no documentation of diagnosis or symptoms of GERD while the Veteran was in the military service. Regarding secondary service connection, in the November 2018 VA medical opinion, the examiner opined that it is less likely than not that the Veteran's GERD was caused by the service-connected PTSD. As a supporting rationale, the examiner stated that no conclusive studies were found for a cause and effect relationship with GERD being due to PTSD. The examiner also opined that it is less likely than not that the Veteran's GERD was permanently worsened (aggravated) by the service-connected PTSD. As a supporting rationale, the examiner stated that although the Veteran asserts that he has symptoms of his stomach going into knots when he becomes anxious, there is no conclusive evidence of GERD aggravated by PTSD. The examiner further stated that it is less than likely than not that GERD aggravated by PTSD, and there is no permanent worsening beyond the natural progression of GERD condition. Anxiety is not listed as a cause of heartburn or gastroesophageal reflux. Because the examiner, while rendering the November 2018 VA medical opinion regarding direct service connection, solely relied on the absence of a diagnosis or symptoms of GERD in the Veteran's service treatment records, the Board remanded the matter in November 2019 to obtain an addendum medical opinion. Subsequently, addendum opinions were obtained in December 2019 and October 2020. However, the examiner provided the same rationale regarding direct service connection that was provided in the November 2018 opinion, and stated that there is no documentation of a diagnosis or symptoms of GERD while the Veteran was in the military; therefore, the Veteran's GERD is less likely than not related to his military service. Thus, the Board remanded the matter again in January 2022 to obtain an addendum opinion. Consequently, another VA medical opinion was obtained in March 2022, in which the examiner opined that the claimed GERD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner stated that upon review of the medical record, he was unable to locate any service treatment records with chronic or ongoing complaint or treatment for GERD or GERD related symptom in service. Therefore, the examiner concluded that he was unable to establish a chronic condition that was caused or incurred during service. Since in the March 2022 VA medical opinion, while providing negative nexus opinion, the examiner solely relied on no in-service symptoms of GERD, the Board remanded the matter again in May 2022 to obtain an addendum medical opinion. Consequently, another VA medical opinion was obtained in May 2022, in which the examiner opined that the Veteran's GERD was less likely than not incurred in or caused by an in-service event, injury, or illness. As a supporting rationale, the examiner stated that upon review of the medical records, the records are silent for any complaints of chronic GERD and recurrent reflux where the Veteran had complaint or sought treatment for related symptoms. Given this, there is no chronic condition that was either caused by or incurred during active service. Furthermore, regarding the etiology of GERD, the examiner stated that when you swallow, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter) relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again. If the sphincter relaxes abnormally or weakens, stomach acid can flow backup into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed. The examiner enlisted different conditions that can increase risk of GERD, which include obesity, bulging of the top of the stomach up into the diaphragm (hiatal hernia), delayed stomach emptying, and connective tissue disorders such as scleroderma. Regarding secondary service connection, in the May 2022 VA medical opinion, the examiner opined that it is less likely than not that the Veteran's GERD was caused or aggravated by the service-connected PTSD. As a supporting rationale, the examiner stated that according to the Mayo Clinic, GERD is caused by frequent acid reflux. When you swallow, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter) relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again. If the sphincter relaxes abnormally or weakens, stomach acid can flow back up into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed. Conditions that can increase your risk of GERD include obesity, bulging of the top of the stomach up into the diaphragm (hiatal hernia), delayed stomach emptying, and connective tissue disorders such as scleroderma. Therefore, the examiner concluded that this condition is less likely than not caused or aggravated by a mental health condition like PTSD. Based on the May 2022 VA medical opinions, in the November 2022 decision, the Board denied entitlement to service connection for GERD. However, as noted above, the Veteran appealed the Board November 2022 decision to the Court. In the October 2023 order, the Court granted the October 2023 JMPR vacating and remanding the Board denial of service connection for GERD. In the JMPR, the parties agreed that the May 2022 VA medical opinion is inadequate because it does not substantially comply with the May 2022 Board remand directives. The examiner relied on no record of GERD from service when the Board directed to not rely solely on the absence of in-service GERD treatment. The parties also agreed that the May 2022 VA medical opinion regarding secondary service connection for GERD is inadequate because the examiner did not adequately explain how his recitation of the causes of GERD according to the Mayo Clinic applied to the Veteran's specific medical history. Thus, the parties agreed that remand is warranted for the Board to ensure that VA obtains new medical opinion on the Veteran's claim of service connection for GERD. The Board has reviewed the evidence pursuant to the Court order and consistent with the terms of the October 2023 JMPR. The Board notes that the Veteran's representative has submitted a February 2024 private medical opinion on the Veteran's diagnosed GERD, in which the examiner opined that the Veteran's service-connected PTSD more likely than not caused his GERD. As a supporting rationale, the examiner noted the treatment records in detail, and stated that the relationship between PTSD and the development of GERD has been demonstrated in a number of studies. For instance, a study examining the health impact of exposure to the September 11, 2001, World Trade Center (WTC) terrorist attacks found that among individuals without pre-existing GERD, 22.3 percent reported being diagnosed with GERD after the event, with a significant portion also reporting post-9/11 PTSD or depression. Another study focused on the WTC Health Registry enrollees who reported no pre-9/11 GERD and found that persistent GERD symptoms were more common among those with comorbid PTSD (24 percent), indicating a significant association between PTSD and GERD. Another study of WTC-exposed rescue/recovery workers highlighted a significant prevalence of GERD among those with PTSD symptoms, highlighting a link between the conditions. Furthermore, the examiner stated that among military members like the Veteran, emerging research demonstrates a link between military PTSD and the development of GERD. A 2005 study of soldiers who served in the Persian Gulf and were exposed to psychological stress found that the majority of patients with upper gastrointestinal symptom were found to have GERD or antral gastritis. A 2014 study of Iraq and Afghanistan veterans found that those with PTSD were at more than two times greater risk to develop gastrointestinal diseases such as GERD. A 2015 study found a higher prevalence of PTSD among veterans experiencing chronic gastrointestinal issues, specifically those consistent with GERD. A 2017 study found an association between self-reported PTSD and clinician-diagnosed upper and lower GI disorders in male combat veterans, further strengthening the connection. A 2020 study concluded that PTSD and GERD were bidirectionally related, i.e. each disease aggravates the other. Beyond the Veteran's anxiety and depression as a result of his PTSD, he presents with few other risk factors for the development of GERD as he is a non-smoker, his weight does not fall under the categorization of "obese" (BMI=30+), he worked in physically demanding jobs, and he was not pregnant. As the brain-gut axis is further studied, it is clear that dysregulation in this system leads to worsening of disease in both spheres. Altered stress response and changes in the gut microbiome are a part of the complex interplay between mental and physical health and play a role in GERD development among PTSD patients, as is likely the case for the Veteran. Therefore, the examiner concluded that the Veteran's PTSD, more likely than not, caused his GERD. The examiner stated the VA nurses negative opinions do not appear to demonstrate any insight into this well-established body of literature and their conclusions are contradicted by this data. Thus, upon review of the record, the Board finds the evidence of record is at least in equipoise as to whether the Veteran's current GERD is at least as likely as not secondary to the service-connected PTSD. Accordingly, after resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to service connection for GERD, to include as secondary to the service-connected PTSD, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for hypertension, to include as secondary to the service-connected PTSD. The Veteran contends that his hypertension is directly related to his military service, or alternatively secondary to the service-connected PTSD. At the August 2017 Board hearing, the Veteran asserted that his blood pressure goes up when he has PTSD symptoms, including nightmares and flashbacks. Relevant to the issue of entitlement to service connection for hypertension, if a veteran has a current, chronic disability listed in 38 C.F.R. § 3.309(a), a nexus can be presumed if there is evidence of chronic disease manifested as such during active service; or chronic disease manifested to a compensable degree within a specified period after active service (usually 1 year); or if there is competent, credible, and persuasive evidence of continuity of symptomatology since active service. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Also, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases shall be service-connected if the requirements of section 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of section 3.307(d) are also satisfied. See 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309(e). Section 3.307(a)(6) provides that the term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 C.F.R. § 3.307(a)(6)(i). Section 3.307(a)(6) also provides that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii). Initially, the Board notes that the Veteran's personnel records reflect that he served in Vietnam from December 1968 to December 1969. Therefore, he is presumed to be exposed to an herbicide agent during his service in Vietnam. Thus, the question for the Board is whether the Veteran has a current disability of hypertension that began during service or is related to an in-service injury, event, or disease, including the exposure to an herbicide agent; or alternatively proximately due to or aggravated beyond its natural progression by the service-connected PTSD. For VA compensation purposes, the term hypertension means 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 diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The existence of a current disability of hypertension is not in question because in the November 2018 VA DBQ, the examiner noted the diagnosis of hypertension with the year of diagnosis as 2011. As noted above, in the November 2022 decision, the Board granted entitlement to presumptive service connection for hypertension under the Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), which added "hypertension" to the list of illnesses that are presumed to be service connected due to herbicide exposure. See Honoring our PACT Act of 2022, Pub. L. No. 117-168, § 404(c) (2022); see also 38 U.S.C. § 1116(a)(2)(M). In the same decision, the Board found that service connection for hypertension on direct basis or secondary to the service-connected PTSD is not warranted. In denying entitlement to direct and secondary service connection for hypertension, the Board mainly relied on the May 2022 VA medical opinion in which the examiner opined that the Veteran's hypertension is less likely than not incurred in or caused by an in-service event, injury, or illness. As a supporting rationale, the examiner stated that upon review of the medical records, the records are silent for any complaints or diagnosis of chronically elevated blood pressures during active service. The Veteran was noted to have normal blood pressure of 114/74 on the March 1971 separation examination. Therefore, the examiner concluded that he is unable to establish a chronic condition that was either caused by or incurred during active service. Furthermore, the examiner stated that in taking the 2018 National Academy of Sciences study into account, he still opines that the claimed hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include exposure to herbicide agents during service. The examiner explained that according to the Mayo Clinic, for most adults, there is no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years. Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly, and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including obstructive sleep apnea; kidney disease; adrenal gland tumors; thyroid problems; certain defects you are born with (congenital) in blood vessels; certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs; and illegal drugs, such as cocaine and amphetamines. The examiner further stated that the risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65. Finally, the examiner stated that the hypertension is a very common medical condition, and based on the Veteran's previous medical history as well as other predisposing risk factors for hypertension, the examiner stated that he was unable to state that it is more than likely attributable to herbicide exposure during service in the late 1960s to early 1970s. Regarding secondary service connection, in the May 2022 VA medical opinion, the examiner opined that it is less likely than not that the Veteran's hypertension was caused by the service-connected PTSD. As a supporting rationale, the examiner stated that according to the Mayo Clinic, for most adults, there is no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension, tends to develop gradually over many years. Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly, and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including obstructive sleep apnea; kidney disease; adrenal gland tumors; thyroid problems; certain defects you are born with (congenital) in blood vessels; certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs; and illegal drugs, such as cocaine and amphetamines. The risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65. High levels of stress can lead to a temporary increase in blood pressure but has not been shown to cause chronically elevated blood pressure or hypertension. The examiner also opined that it is less likely than not that the Veteran's hypertension was aggravated by the service-connected PTSD. As a supporting rationale, the examiner stated that according to the Mayo Clinic, your body produces a surge of hormones when you are in a stressful situation. These hormones temporarily increase your blood pressure by causing your heart to beat faster and your blood vessels to narrow. This can occur in anybody with and without hypertension. There is no proof that stress by itself causes long-term high blood pressure or chronically aggravates pre-existing hypertension. As noted above, the Veteran appealed the November 2022 Board decision to the Court. In the October 2023 order, the Court granted the October 2023 JMPR vacating and remanding the Board denial of direct service connection for hypertension. In the JMPR, the parties agreed that the May 2022 VA medical opinion, on which the Board relied upon in denying direct service connection for hypertension, is inadequate. The parties agreed that in the May 2022 VA opinion, the examiner opined that the Veteran's hypertension is less likely than not incurred in or caused by service and referred to the Mayo Clinic's non-exhaustive list of causes of hypertension. The parties agreed that the examiner did not provide an adequate rationale for finding that the hypertension was not directly related to service because the examiner did not address any specifics related to the Veteran's exposure to herbicide agents and did not explain why the literature from Mayo Clinic supports his conclusion. Thus, the parties agreed that remand is warranted for the Board to obtain an adequate VA medical opinion. Additionally, the parties noted that the May 2022 VA examiner opined that it is less likely than not that the Veteran's hypertension was aggravated by his service-connected PTSD because there is "no proof that stress by itself causes long-term high blood pressure or chronically aggravates a pre-existing HTN [hypertension]." The parties noted that the Veteran submits that the examiner's rationale is contrary to Ward v. Wilkie, 31 Vet. App. 233, 240 (2019), which provides that the secondary service connection does not require the "permanent" worsening of the condition and only requires considering whether there has been any worsening, no matter how incremental it is. Therefore, the parties agreed that the Board should address this issue upon remand. The Board has reviewed the evidence pursuant to the Court order and consistent with the terms of the October 2023 JMPR. The Board notes that the Veteran's representative has submitted a February 2024 private medical opinion on the Veteran's diagnosed hypertension, in which the examiner opined that the Veteran's in-service exposure to herbicides such as Agent Orange and his service-connected PTSD, more likely than not, both resulted in his diagnosis of hypertension. As a supporting rationale, the examiner stated that Agent Orange and other herbicides used in Vietnam are now known to have been contaminated with a multitude of halogenated aromatic hydrocarbons or dioxins, the most potent is 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD). TCDD has a multitude of effects on intracellular mechanisms mainly mediated via binding to and activating the aryl hydrocarbon receptor (AhR). Once activated, the TCDD-AhR complex undergoes a conformational change and translocates into the nucleus where it can affect a variety of genes. Because of this disruption at the level of the nucleus, Agent Orange exposure can lead to a large and disparate number of diseases including diabetes, various cancers, and cardiovascular disease. These deleterious health effects of dioxin exposure are well documented and recent research continues to find increased rates of serious health problems in those exposed. Furthermore, the examiner stated that although Agent Orange exposure is a known cause of hypertension, but VA examines in this case did not mention in their analysis. The examiner explained that a 2006 Institute of Medicine report found "limited or suggestive" evidence that herbicide exposure was associated with hypertension and the medical literature on the subject continues to grow. In existence at the time of the 2006 IOM report was a 1998 epidemiologic study after the mass exposure to TCDD in Seveso, Italy that found increased rates of hypertension related deaths. A 2006 study found that odds ratios for the development of hypertension were higher in men who served in Vietnam compared to those who did not, while controlling for Vietnam service status, race, body mass index, military rank, cigarette smoking, and age at time of interview. Thus, these findings were independent from the effect of military service in Vietnam in general. The examiner explained that the mechanism by which TCDD leads to hypertension was first elucidated in a 2008 murine model which demonstrated increases in blood pressure and cardiac enlargement after sustained AhR activation by TCDD. Studies from 2012 and 2013 of Korean veterans exposed to TCDD in Vietnam demonstrated significantly elevated rates of hypertension compared to those not exposed. A 2016 study of over 3,000 Vietnam veterans concluded, "Occupational herbicide exposure history and Vietnam-service-status were significantly associated with hypertension risk." A 2018 systematic review concluded, "the findings suggest that AhR is involved in the complicated networks that regulate blood pressure." A 2018 study of male patients who had been exposed to TCDD 50 years prior found rates of hypertension that were 22 percent higher than in the general population. In 2018 the Committee to Review the Health Effects in Vietnam Veterans of Exposure to Herbicides changed their classification and concluded, "the information now assembled constitutes sufficient evidence of an association between exposure to at least one of the [chemicals of interest] and hypertension. The medical literature is coming to a clear consensus that exposure to TCDD leads to increased rates of chronic cardiovascular diseases including hypertension and its complications. Given that the Veteran does not exhibit any of the traditional risk factors for hypertension (outside of his service related PTSD), as he describes himself as a non-smoker/drinker and his age, gender, and weight at the time of his initial diagnosis were not considered risk factors, his exposure to Agent Orange more likely than not resulted in his hypertension. Studies have demonstrated that hypertension alone increases the relative risk of developing heart disease by almost three-fold. Even more concerning, the diagnosis of hypertension is associated with a 41 percent increase in all-cause mortality. Regarding relationship of PTSD and hypertension, the examiner stated that in addition to exposure to dioxins, the Veteran's duties in Vietnam exposed him to significant psychological trauma which resulted in the formal diagnosis of military related PTSD in August 2011. The examiner stated that it is estimated that only 3.6 percent of American adults aged 18 to 54 years have PTSD but that about 30 percent of Vietnam veterans developed PTSD during, or at some point shortly after, the Vietnam war. The examiner stated that although VA examiners concluded that there was no connection between the Veteran's PTSD and his hypertension, a competent review of the medical literature contradicts their conclusions. Multiple studies have demonstrated that PTSD is a significant independent risk factor for the development of hypertension. A study of a probability sample from the US National Comorbidity Survey examined the interaction between PTSD and major depression as determinants of hypertension. It concluded that PTSD was related to hypertension, independent of depression, and that this finding could also possibly explain the elevated rates of cardiovascular disease associated with PTSD. This specific relationship likely explains the high prevalence of hypertension identified amongst refugee psychiatric patients. In PTSD patients there is increased activity of the sympathetic nervous system which leads to elevated blood pressure, increased heart rate as well as sweating of the hands and other symptoms of hyperfunction of the central noradrenergic system. Furthermore, the examiner explained that a study of hypertensive individuals looked at the impacts of the September 11, 2001, attacks and found that at a population level, individuals with hypertension are at risk for increases in blood pressure as a consequence of exposure to stressful events. Similarly, a study carried out in former World War II prisoners of war found that prisoners with PTSD had a significantly increased risk of cardiovascular diseases, including hypertension and chronic ischemic heart disease, compared with individuals who had been prisoners of war but had not developed PTSD as well as non-prisoners. A meta-analysis of over 2600 individuals with PTSD found statistically significant increases in both systolic and diastolic blood pressure. A 2017 study of almost 200,000 military veterans concluded that a diagnosis of PTSD carried a 46 percent greater risk of incident hypertension. A 2018 study of U.S. military members injured in combat stated, "we found that the chronicity of PTSD diagnoses after injury and the severity of the initial injury were independent risk factors for subsequent development of hypertension." The examiner stated that a recent editorial in the journal Hypertension concluded, "evaluation of PTSD as a causative factor of hypertension should not be limited to the specific population of veterans exposed to war-related physical and psychological trauma but deserves to be investigated in patients with other forms of severe, difficult-to-control hypertension." These and other studies form a robust body of evidence which demonstrates the causal link between PTSD and the development of hypertension. Finally, the examiner stated that the conclusions and opinions of the November 2018 and May 2022 VA examiners are not supported by the medical literature. (Continued on the next page) ? Thus, upon review of the record, the Board finds the evidence of record is at least in equipoise as to whether the Veteran's current hypertension is at least as likely as not directly related to his active service or secondary to the service-connected PTSD. Accordingly, after resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection for hypertension, to include as secondary to the service-connected PTSD, is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tariq, Nadeem, 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.