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Sleep Apnea & Hypertension

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Michael Lostritto: Welcome everyone to another edition of CCK Live. My name is Michael Lostritto, I’m an attorney here at the firm. Today, we’re going to be discussing hypertension and sleep apnea, and how those two conditions are connected and interrelated. With us today, we have Attorneys Amy Odom and also Kaitlyn Degnan. Why don’t we jump right in? Amy, why don’t we get started with you? Could you give us a little bit of information as to what is hypertension? What does the medical community think hypertension is? What is VA think, hypertension is, and can you describe that a little bit for us?

Amy Odom: Sure, Mike. So, hypertension means high blood pressure, and blood pressure is the pressure of the blood pushing up against the walls of your arteries. It’s measured using two numbers: Systolic blood pressure, and Diastolic blood pressure. Systolic blood pressure is the pressure in your arteries when the heartbeats, and Diastolic blood pressure is the pressure in your arteries between heartbeats. Generally, a normal blood pressure level is less than 120 Systolic, and 80 Diastolic.

The American Heart Association recognizes hypertension at Systolic pressure of 130 or higher, and Diastolic pressure of 80 or higher, but VA does not recognize hypertension as a disabling condition until Systolic pressure is to 160 or higher, or Diastolic pressure is 90 or higher. It will rate the disability based on Systolic and Diastolic pressure. The big thing about hypertension is that it presents a greater risk for heart problems and stroke if it’s left untreated.

Michael: So, that’s a great point, Amy. I think, what I hear you saying is that a veteran may think or they’re treating, a private doctor may say they have high blood pressure, but in VA’s eyes, that might not actually be the case in order for it to be service-connected and rated, is that correct?

Amy: Unless your hypertension blood pressure is at least 90 Diastolic or 160 Systolic, VA will not recognize it as a current disability.

Michael: Yeah, and that’s a great point. I know I’ve seen veterans in my practice, I’m sure we all have. They have high blood pressure, according to their doctor and they can’t understand why VA doesn’t recognize that. The reason really is because the regulations state that that’s not the standard. It’s a little bit different of a standard for VA to consider it a disabling condition. That’s a critical difference in a good point.

Amy: Now the American Heart Association’s definition of 80 Diastolic or higher, that’s relatively new in the past few years. So, maybe in the near future, VA’s regulations will catch up with medicine, but until that happens, you’re kind of out of luck unless you have these particular blood pressure readings.

Michael: Yeah. Thanks, Amy. So, Kaitlyn, turning to you, the second condition that we’re talking about today is sleep apnea. So, maybe you can talk to us a little bit about what is sleep apnea? Are there different types of sleep apnea? What are those different types? Can you talk to us a little bit about that?

Kaitlyn Degnan: Sure. So, sleep apnea is a potentially serious sleep disorder where a person’s breathing is repeatedly interrupted during the course of their sleep. There are three main types of sleep apnea. The first and most common is Obstructive Sleep Apnea, which occurs when the throat muscles intermittently relax and block your airway while you’re asleep. The second is Central Sleep Apnea, which occurs when your brain does not send the proper signals to the muscles that control that breathing, and the third type is Complex or Mixed Sleep Apnea, which basically means that you have symptoms of both Obstructive Sleep Apnea and Central Sleep Apnea.

Michael: Yeah, and I think it’s important to note that despite there being three different main types of sleep apnea, they all kind of have very similar signs and symptoms, and Veterans really-, because oftentimes they’re laypeople, right? They don’t have medical knowledge. They’re not expected necessarily to know which condition they have, or which type they have and claim that specifically. But, all of the signs and symptoms are more or less the same and somewhat overlap. So, some common symptoms include bowed snoring, gasping for air during sleep, awakening with a dry mouth, having a morning headache, insomnia – that might result from sleep apnea, having difficulty concentrating. These are all kinds of symptoms and things that a veteran might experience that would relate to any one of those three types of sleep apnea, Kaitlyn, that you just talked about. So, Amy, turning back to you, how is sleep apnea diagnosed?

Amy: Generally, a veteran will seek treatment for the symptoms that you just mentioned. Like the snoring, usually, somebody in the house is complaining about how loud the snoring is, or some of these witnessing these moments in the night where the veteran is gasping for air. And so, the veteran will seek treatment for these particular symptoms. The doctors will consider sleep apnea as a possible explanation for the symptoms and send the veteran for a sleep study, which is usually overnight, and a team of doctors monitors the veteran’s sleep and oxygen levels during sleep.

Based on that study, the doctor will diagnose sleep apnea or something else. But for VA purposes, it’s really important that you actually have the sleep study done. Just a doctor saying, “Well, this veteran has these symptoms of snoring, and choking, and gasping, and headaches.” And so, it sounds like sleep apnea isn’t going to be sufficient for the VA. They’re going to require that there has been an actually confirmatory sleep study done.

Michael: Yeah, that’s a point. I see that a lot of our veterans may obviously not know what happens during their sleep, but they might have a spouse or a family member or friend even that would write a lay statement in support of their claim. But without the diagnosis, without a sleep study, it’s going to be difficult in many cases for veterans to actually get the condition service-connected. So, that’s a really critical piece here. In terms of rating the condition, one service connection has been established for sleep apnea, there are various ratings depending on the severity of the condition. They range from 0% to 30, to 50, all the way up to a 100% rating, again, based on the severity of the condition according to the applicable regulation.

Kaitlyn, turning back to you again, now that we’ve talked about the two conditions, generally speaking, hypertension and sleep apnea. Can you talk to us a little bit about the relationship between those conditions? How they impact the other? Are there any trends or medical evidence that shows that there’s a relationship between hypertension and sleep apnea?

Kaitlyn: Sure. So, research by the American Heart Association and others have shown or has suggested at least that, Obstructive Sleep Apnea is highly relevant to patients with hypertension. That translates to an estimated 50% of patients with hypertension also having Obstructive Sleep Apnea and that condition represents one of the most prevalent secondary contributors to hypertension. Another study has also found that people with untreated sleep apnea, 2.6 times more likely to experience cardiovascular complications, which included hypertension.

Researchers believe that when breathing is restricted, oxygen levels in the body decrease, and that causes an increase in blood flow and missed increased blood flow places additional pressure on the blood vessels walls, ultimately causing higher than normal blood pressure levels, and overall, there appears to be a causal relationship between sleep apnea and the development of hypertension, or at least the research suggests that there is.

Michael: Yeah, and that leads into the next point here. If there is medical research that shows that hypertension, or rather sleep apnea can impact or cause maybe hypertension in some way, Is there an ability for veterans to seek compensation service connection for their hypertension based on sleep apnea? Here, we’re looking at what’s known as secondary service connection for hypertension based on sleep apnea, both sleep apnea hypertension may be granted service connection independently if a veteran can prove that the condition began in or was caused by something that happened during service.

Advocates and VA typically calls that direct service connection. Something happened in service that directly leads to, or causes in layman’s terms, the conditions sleep apnea or hypertension. But there’s another avenue available to veterans and it speaks to that relationship that you were just discussing. And so, that is what’s known as secondary service connection. So, secondary service connection is essential, if a veteran has a condition, that service-connected, and that service-connected condition causes or contributes to causing, or aggravating another condition, then that secondary condition can be service-connected on its own right based on that primary, or first condition that was service-connected. So, for our purposes here, it is possible to get hypertension service-connected secondarily to a veteran’s already service-connected sleep apnea. And so with secondary service connection, the medical nexus opinion that a private physician or an expert offers, or maybe even a VA examiner offers has to link the veterans’ secondary disability, in this case, hypertension, to the veterans already service-connected sleep apnea.

So, that really is a critical point here because of the relationship Kaitlyn, that you discussed, and even if a veteran may not be able to prove that their hypertension on its own directly was related to something that occurred in service, there’s another path here. There’s another avenue for Veterans Advocates to consider. So with that in mind, Amy, turning back to you, how does one prove that hypertension is actually secondary to sleep apnea? How do we apply these concepts to make it more concrete in actually proving the claim?

Amy: Well, you have to have a medical nexus opinion like you mentioned, Mike. It’s not enough to just have a diagnosis of hypertension, even one that meets these criteria and sleep apnea, confirmed by a sleep study. You also have to have medical evidence linking the two conditions and that, in most cases, is going to need to be in the form of a medical nexus opinion by a competent medical professional who can say that based on your history, your specific history, the sleep apnea has caused or aggravated that hypertension.

Michael: And so, Kaitlyn, when we’re thinking about practically, how we submit this evidence or the types of evidence that we want to submit and what goes into that, can you talk to us a little bit about how a veteran would want to go about doing that? What they would want to keep in mind? The types of evidence that they’d want to submit?

Kaitlyn: Yeah, so as Amy said, you need a competent medical nexus opinion. So, one thing that you can do is that, if your doctor does believe that there’s a relationship between your sleep apnea and your hypertension, he or she could provide an opinion that saves. It is at least as likely as not that hypertension is caused by sleep apnea. You can also submit relevant medical records that might show associations between the two conditions. You can submit medical articles that talk about the relationship between the two conditions. And you can also submit late evidence. Now, veterans as laypersons can’t render an opinion of themselves, but they can talk about their experiences with the two conditions that could inform that kind of opinion.

Michael: Yeah, that’s an excellent point. Another point that I’ve seen here representing veterans is if a veteran has compensation and pension examination for their hypertension, or really any condition, but in this context hypertension, the examiner may very well opine on service connection on a direct basis or maybe even a presumptive basis. But oftentimes, what I see is they don’t consider secondary service connection as a theory and so they’re not offering an opinion on it. And so, if that is in fact the case in a particular veteran’s case, they should push back on that, they should make sure that a VA examiner is considering that theory and any evidence related to that theory is considered. The failure to do so should be something that may be a veteran looks to appeal or asks for a new examination to consider that evidence and those theories of service connection.

Amy: Right, Mike. I think the important takeaway here is that in most cases you’re going to have that medical opinion either by a VA examiner, or your own doctor saying that there’s a link, but this other evidence like the medical records and the medical articles can provide a good way to prove to the VA that you should get that opinion and might provide if you get a bad opinion from the VA examiner or I should say, a negative opinion, the medical articles in the medical records might contradict the examiner’s rationale for the unfavorable opinion and provide a basis for appeal.

Michael: Yeah. Well, I think that actually does it for this edition of CCK Live. Thank you for joining us, as always. And for more information on the topics mentioned in this video, please visit our blog, or check out our other videos on YouTube. Also, please don’t forget to follow us on social media but thanks for tuning in and we’ll see you next time.