Citation Nr: 0002198 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 94-26 244 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for a cardiovascular disability, to include hypertension. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, his spouse, and a friend ATTORNEY FOR THE BOARD Thomas D. Jones, Associate Counsel INTRODUCTION The veteran served on active duty from November 1954 to January 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1993 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the veteran's claim for service connection for hypertension and a cerebrovascular accident. The veteran filed a timely notice of disagreement, initiating this appeal. This appeal was originally presented to the Board in November 1996, at which time it was remanded for additional development. The appeal was then returned to the Board. When the Board initially received the claim in June 1999, an expert medical opinion, based on the evidence of record, was requested. A VA physician prepared a September 1999 medical opinion letter, and the claim was again returned to the Board. FINDINGS OF FACT 1. The veteran had a cerebrovascular accident in 1988, due to or resulting from hypertension, and he now has residual impairment. 2. The preponderance of the medical evidence does not establish that the veteran first incurred hypertension, or any other cardiovascular disability, during service, or within a year thereafter. CONCLUSION OF LAW Service connection for a cardiovascular disability, to include hypertension, is denied. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background According to the veteran's November 1954 service entrance examination, he had no prior history of hypertension or cardiovascular disability at the time he entered service, and none was noted at that time. His blood pressure was 124/70. In March 1968, the veteran was hospitalized at a military facility for an unrelated orthopedic disability, and blood pressure readings of 150/102 were noted. An impression of borderline hypertension was recorded, and he was transferred to another facility for evaluation. At the second military hospital, the veteran's blood pressure was monitored by internal medicine personnel, and a reading of 150/84 was recorded. His blood pressure was described as "not significantly elevated." In September 1968, the veteran was afforded a annual physical examination, and blood pressure readings of 132/80 sitting, 134/80 lying down, and 128/86 standing were noted. His previous high blood pressure readings from 1966 were noted; however, these were described as resolved, with no complications or sequela. The veteran was described as a "vascular hyperreactor." A November 1970 annual physical was afforded him which recorded blood pressure of 130/80 sitting, 132/82 standing. At the time of his August 1974 service retirement physical evaluation, the veteran's blood pressure was 132/68 sitting, and 130/80 standing. Prior elevated blood pressure readings, without treatment or medication, were noted, but the current readings were within normal limits, and no cardiovascular disability, including hypertension, was diagnosed. The veteran retired from active military service in January 1975. The veteran has received extensive VA treatment since his 1988 cardiovascular accident, according to the medical evidence of record. He has also been treated at numerous private medical facilities. His diagnoses have included a history of cerebrovascular accident, hypertension, deep vein thrombosis, gastrointestinal bleeding, bronchitis, pneumonia, a seizure disorder, right side paresis, and peripheral vascular disease. The veteran's medical care, both private and VA, is both extensive and ongoing. He is currently taking several medications. In February 1993, the veteran filed a claim for service connection for residuals of a cerebrovascular accident, secondary to hypertension, which he asserted as initially incurred during active military service. The RO considered the evidence of record and issued an August 1993 rating decision, denying the veteran's claim for service connection for hypertension and a residual cerebrovascular accident. The veteran's representative filed a September 1993 notice of disagreement, initiating this appeal. The RO sent the veteran a November 1993 statement of the case, and he filed a November 1993 VA Form 9, perfecting his appeal. A personal hearing before a hearing officer at the RO was also requested. A personal hearing at the RO was afforded the veteran in February 1994. He was accompanied by his spouse and a friend. The veteran's representative asserted that the service medical records clearly reflect the onset of hypertension during service. Additionally, the veteran sought treatment for hypertension within a year of his service retirement, which would warrant service connection on a presumptive basis. A second personal hearing at the RO was afforded the veteran in October 1994. He was again accompanied by his spouse and a friend. He testified that he was first diagnosed with hypertension during service, and has been on medication for this disease at all times since then. After his retirement from service, his hypertension medication was provided by the VA medical center in Oakland, according to the hearing testimony. The veteran's claim was first presented to the Board in November 1996, at which time it was remanded for additional development. In response to the Board's remand, the RO sent a letter to the veteran requesting any information he may have regarding any medical treatment he received following service. The RO also conducted a search for the pre-1989 medical treatment records discussed by the veteran at his personal hearings. He stated he was treated at the "Oakland VA medical center," an apparent reference to the VA Acute Care Clinic adjacent to the Oakland campus of the University of Pittsburgh in Pittsburgh, PA. In a February 1999 statement, this VA medical center confirmed the lack of medical records for the veteran prior to 1989. The claim was returned to the Board in June 1999. When the Board initially received the claim, an expert medical opinion, based on the evidence of record, was requested, and the Board sent a July 1999 letter to that effect to the Boston VA medical center. A VA physician prepared a September 1999 medical opinion letter, and the claim was again returned to the Board. The September 1999 VA medical opinion was authored by the chief physician of the Renal Section of the VA medical center in Boston, Mass., and was based upon his review of the full medical record, including the service medical records. The VA doctor discussed the veteran's blood pressure readings during service, including those from March and April 1968. He noted that at that time, the veteran was being hospitalized for malunion of a bone fracture, and there was no evidence that the veteran was treated or placed on medication for hypertension following the early 1968 readings. Moreover, the remainder of the veteran's blood pressure readings were within normal limits, according to the VA examiner. Regarding the description of the veteran in the service medical records as a "vascular hyperreactor," the VA physician stated this was "a non- medical term and carries no specific diagnosis." He further concluded that while it was difficult to say, based on the evidence, that "the patient DID NOT have hypertension while in the service, the absence of therapy and subsequent normal blood pressures suggest sustained hypertension developed at a later date." Additionally, it was "probable that this patient may have had a predilection for the development of hypertension." Analysis The veteran seeks service connection for a cardiovascular disability, to include hypertension. Service connection will be awarded for any disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). Additionally, certain statutorily enumerated disabilities, such as hypertension, will also be granted service connection if they manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1112, 1113 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). In evaluating a claim, the VA must extend the benefit of the doubt to any claimant whenever the evidence is in balance between the positive and the negative. 38 U.S.C.A. § 5107(b) (West 1991). As an initial matter, the appellant's claim is well grounded, meaning it is plausible. All relevant evidence has been obtained with regard to the claim and no further assistance to the appellant is required to comply with the VA's duty to assist him. 38 U.S.C.A. § 5107(a) (West 1991). The veteran has stated that he received treatment, both private and VA, for hypertension immediately following service and continuing up to and beyond 1988, but those medical records have not been obtained and associated with the claims folder. He has stated he was treated at the "Oakland VA medical center," an apparent reference to the VA Acute Care Clinic adjacent to the Oakland campus of the University of Pittsburgh; however, in a February 1999 statement, personnel at the Pittsburgh VA medical center confirmed a lack of medical records for the veteran prior to 1989 showing treatment at the Oakland Clinic. The veteran has also stated he saw private physicians in several locations, including overseas, immediately subsequent to service for his hypertension, but he has not submitted evidence of such treatment. The veteran was sent a letter in November 1996 asking for the any additional information regarding his treatment for hypertension between his 1975 retirement from service and his 1988 cerebrovascular accident, but none has thus far been provided. Without additional information, the VA is unable to obtain these private medical records, and has no further duties in this matter. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). As a preliminary matter, the veteran's representative has argued in the November 1999 written brief presentation that the September 1999 VA medical opinion letter fails to address the questions posed by the Board in its July 1999 letter. According to the representative, this failure is a violation of the Court's holding in Stegall v. West, 11 Vet. App. 268 (1998), in which Court stated the Board's remand orders carry the weight of law and require strict compliance. Stegall at 271. Disregarding for now the question of whether the Stegall holding, concerning as it does Board remand orders, also applies to requests for medical opinion statements, the Board will consider the merits of the representative's assertion. He argues that because the VA physician did not explicitly refer to all of the veteran's in-service 1968 blood pressure readings, there was noncompliance with the Board's directives. The Board disagrees. According to the VA physician's September 1999 statement, he reviewed all the medical evidence of record, including the service medical records. The mere fact that he did not explicitly cite all the veteran's 1968 blood pressure readings insufficient to find him in noncompliance with the Board's directives. After review of all evidence of record, the preponderance of the evidence is against the veteran's claim for service connection for a cardiovascular disability, to include hypertension, and it must be denied. The veteran asserts that he initially developed hypertension during active military service, and this disability resulted in his 1988 cerebrovascular accident and resulting impairment. In support of his claim, the veteran has submitted voluminous medical records, both private and VA, establishing a current diagnosis of hypertension, as well as right side paresis due to a cerebrovascular accident. These medical facts have been rendered by competent medical experts and are uncontroverted in the record; thus, a current disability of hypertension and a cerebrovascular accident, with residual impairment, is conceded by the Board. The issue becomes whether the veteran's well-established current disability results from a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). According to the service medical records, hypertension was suspected during the veteran's service period, and he was afforded a regular schedule of blood pressure readings for evaluation in April 1968. An initial impression of borderline hypertension was noted. However, upon further evaluation, his blood pressure readings were "not significantly elevated," according to an April 1968 military hospitalization report, and hypertension was not diagnosed, and no treatment or medication thereto was recommended. At the time of his August 1974 service retirement physical evaluation, the veteran's blood pressure was 132/68 sitting, and 130/80 standing. Prior elevated blood pressure readings, without treatment or medication, were noted, but the current readings were within normal limits, and no cardiovascular disability, including hypertension, was diagnosed. When the appeal was returned to the Board in June 1999, it was sent out for an expert medical opinion regarding the etiology of the veteran's hypertension. A VA physician prepared a September 1999 medical opinion letter, detailed above, based upon his review of the full medical record, including the service medical records. The VA doctor discussed the veteran's blood pressure readings during service, including those from March and April 1968. He noted that at that time, the veteran was being hospitalized for malunion of a bone fracture, and there was no evidence that the veteran was treated or placed on medication for hypertension following the early 1968 readings. Moreover, the remainder of the veteran's blood pressure readings were within normal limits, according to the VA examiner. Regarding the description of the veteran in the service medical records as a "vascular hyperreactor," the VA physician stated this was "a non-medical term and carries no specific diagnosis." He further concluded that while it was difficult to say, based on the evidence, that "the patient DID NOT have hypertension while in the service, the absence of therapy and subsequent normal blood pressures suggest sustained hypertension developed at a later date." Additionally, it was "probable that this patient may have had a predilection for the development of hypertension." As there is no medical evidence to the contrary, the preponderance of the evidence clearly indicates the veteran's high blood pressure readings during service were acute and transitory in nature, and not indicative of chronic hypertension. Subsequent to service, the veteran's medical records reveal the 1988 onset of a cerebrovascular accident, due in part to hypertension, with residual right side paresis. Neither the 1988 medical diagnosis of hypertension, nor any other medical evidence of record, places the date of onset of hypertension or any other cardiovascular disability to the veteran's period of service, or within a year thereafter. As the record currently stands, there is no medical evidence to bridge the more than 10 year gap between the veteran's 1975 retirement and his 1988 cerebrovascular accident. Thus, the preponderance of the evidence is against the veteran's claim. The veteran and his accredited representative have repeatedly argued that the veteran's hypertension began during service, and was chronic thereafter. This disability ultimately resulted in his 1988 cerebrovascular accident, and his residual impairment. However, because neither the veteran nor his accredited representative are demonstrated to be competent medical experts, their assertions are not binding on the Board, and are insufficient to overcome the medical evidence of record. See Pearlman v. West, 11 Vet. App. 443, 447 (1998) [citing Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992)]. In conclusion, the preponderance of the evidence is against the veteran's assertions that he first had the onset of chronic hypertension, or any other cardiovascular disability, during service, or within a year thereafter. As such, his claim must be denied. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (1999). ORDER Service connection is denied for a cardiovascular disability, to include hypertension. G. H. SHUFELT Member, Board of Veterans' Appeals