Secondary Conditions to Hypertension

Hypertension is rated under Diagnostic Code 7101, and the levels above 10 percent need diastolic readings predominantly 110 or more, or systolic readings predominantly 200 or more, so the hypertension rating itself is often modest. Years of high blood pressure damage the heart, kidneys and brain, though, and under 38 CFR § 3.310 a condition caused or worsened by your service-connected hypertension is service connected too and rated under its own code. This page covers what you can claim, the research behind each link, including where it runs the other way, which claims to file first, and how the ratings combine.

What can you claim secondary to hypertension?

Any condition a doctor can tie to your hypertension, with reasoning, can be claimed. In the Board's 2021 to 2026 decisions the most common were these.

• Heart disease.
• Sleep apnea. See sleep apnea secondary to hypertension.
• Kidney disease. See kidney disease secondary to hypertension.
• Erectile dysfunction.
• Stroke.
• Migraines.
• Diabetes. See diabetes secondary to hypertension.

The Board section further down lists every condition claimed secondary to hypertension with enough rulings to show, with its count and grant rate. Hypertension can also be the claimed condition: see hypertension secondary to PTSD.

How secondary service connection works for hypertension

VA grants a secondary claim in two ways under 38 CFR § 3.310.

• Caused by. Your service-connected hypertension caused the condition, at least as likely as not.
• Aggravated by. The condition is worse because of your hypertension, meaning it would be less severe but for the hypertension (M21-1 V.ii.2.D). VA rates only the part above the condition's baseline before the aggravation.

The text of § 3.310(b) still tells VA to subtract "natural progress," but VA's current claims manual (M21-1 V.ii.2.D, revised after Spicer v. McDonough) no longer applies that part, and the worsening does not have to be permanent. VA still needs a baseline shown by medical evidence, and it rates the difference between that baseline and the current level.

The file needs service-connected hypertension, a current diagnosis of the secondary condition, and a medical opinion linking the two with reasoning. Timing matters more here than in most chains: if the other condition came first, the opinion has to say why hypertension still caused or worsened it. An opinion that answers only "caused by" and skips aggravation is inadequate (El-Amin v. Shinseki, 26 Vet. App. 136 (2013)).

The most common secondary conditions to hypertension

Heart disease

The strongest evidence comes from treatment trials. A meta-analysis of 123 studies with 613,815 participants (Ettehad and colleagues, Lancet, 2016) found that every 10 mm Hg drop in systolic pressure lowered the risk of major cardiovascular events by 20 percent, coronary heart disease by 17 percent and heart failure by 28 percent. If lowering blood pressure prevents heart disease, high blood pressure helps cause it.

Note (3) to Diagnostic Code 7101 says to rate hypertension separately from hypertensive heart disease and other heart disease. Heart disease is rated on the workload (METs) that brings on symptoms: 10 percent at 7.1 to 10.0 METs or when continuous medication is required, 30 percent at 5.1 to 7.0 METs or with cardiac hypertrophy or dilatation confirmed by echocardiogram, and 60 and 100 percent at lower workloads. Cardiac hypertrophy (a thickened heart muscle) on an echocardiogram is enough for 30 percent by itself.

Kidney disease

In 332,544 men followed for an average of 16 years (Klag and colleagues, New England Journal of Medicine, 1996), the risk of end-stage kidney disease rose steadily with both systolic and diastolic pressure, independent of age, race, income, diabetes medication, cholesterol and smoking. Men with the highest pressures had 22.1 times the risk of men with optimal pressure. The trial evidence is weaker: in the Ettehad meta-analysis, lowering blood pressure did not significantly reduce kidney failure. An opinion should cite your own pattern of blood pressure and kidney labs over time.

Kidney damage from high blood pressure (arteriolar nephrosclerosis, Diagnostic Code 7507) is rated by its main symptoms, as renal dysfunction, hypertension or heart disease. Renal dysfunction under 38 CFR § 4.115a turns on kidney filtration rate (GFR) held for three consecutive months in the past year: 30 percent for 45 to 59, 60 percent for 30 to 44, 80 percent for 15 to 29 and 100 percent below 15 or with dialysis. See kidney disease.

Sleep apnea

Here the research mostly runs the other way. In the Wisconsin Sleep Cohort (Peppard and colleagues, New England Journal of Medicine, 2000), 709 adults had sleep studies, and those with an apnea-hypopnea index of 15 or more at the start had 2.89 times the odds of hypertension four years later, after adjusting for weight and other factors. The authors concluded sleep apnea is likely a risk factor for high blood pressure, not the reverse.

The evidence for hypertension worsening sleep apnea is narrower. In 40 people with treated hypertension (Friedman and colleagues, Hypertension, 2010), apnea severity tracked how much fluid shifted from the legs toward the neck overnight, and both were greater in drug-resistant hypertension. In an open-label study of 12 people with resistant hypertension (Gaddam and colleagues, Journal of Human Hypertension, 2010), adding the aldosterone blocker spironolactone cut the apnea-hypopnea index from 39.8 to 22.0 events per hour; the authors called it preliminary. A claim fits best when your blood pressure was hard to control and documented before the sleep apnea, and an aggravation argument is often the stronger one. Sleep apnea that requires a CPAP rates 50 percent under Diagnostic Code 6847.

Erectile dysfunction

A review (Kloner, International Journal of Impotence Research, 2007) reports that about 67 to 68 percent of men with hypertension have some degree of erectile dysfunction, and that thiazide diuretics and beta-blockers may contribute. A later network meta-analysis of randomized trials (Farmakis and colleagues, Cardiovascular Drugs and Therapy, 2022) found no blood pressure drug class had a significant effect on erectile function, though most trials had a high risk of bias. The argument built on the blood pressure itself is usually stronger than the one built on the medication. Erectile dysfunction rates 0 percent under Diagnostic Code 7522, and the code's footnote sends VA to review special monthly compensation (SMC-K) under 38 CFR § 3.350.

Stroke

In INTERSTROKE, a study of 26,919 people in 32 countries (O'Donnell and colleagues, Lancet, 2016), a history of hypertension or a reading of 140/90 or higher carried 2.98 times the odds of stroke and accounted for 47.9 percent of the population risk, the largest of ten factors. In the Ettehad meta-analysis, every 10 mm Hg drop in systolic pressure cut stroke risk by 27 percent. A stroke is rated 100 percent for six months under Diagnostic Codes 8007 to 8009, then on its residuals, with a 10 percent minimum.

Migraines

Observational studies of blood pressure and migraine disagree. A genetic study (Guo and colleagues, Nature Communications, 2020) found that each 10 mm Hg of genetically higher diastolic pressure raised the odds of migraine by 20 percent, with a smaller effect for systolic pressure. That supports a role for blood pressure, but it is a genetic estimate rather than a study of people treated for hypertension, so the opinion has to show the migraines followed or worsened with your hypertension. Migraines are rated under Diagnostic Code 8100 at 0, 10, 30 or 50 percent, by how often prostrating attacks occur.

Diabetes

In a cohort of 4.1 million adults (Emdin and colleagues, Journal of the American College of Cardiology, 2015), 20 mm Hg higher systolic pressure was tied to a 58 percent higher risk of new diabetes; the authors say it is not yet known whether lowering pressure changes that risk. Blood pressure medicine is the other path: a network meta-analysis of 22 trials (Elliott and Meyer, Lancet, 2007) found new diabetes least often with ARBs and ACE inhibitors and most often with beta-blockers and diuretics. If you were prescribed a diuretic or beta-blocker for service-connected hypertension and later developed diabetes, the opinion can build on that.

Which secondary claims to file first

Three questions sort the claims worth filing.

1. Is there a current diagnosis? Heart disease needs an echocardiogram or stress test, kidney disease repeated labs, sleep apnea a sleep study.
2. Can it be rated on its own? Heart disease, kidney disease, sleep apnea, migraines, diabetes and stroke residuals have their own ratings. Erectile dysfunction rates 0 percent apart from SMC-K.
3. Will a doctor explain the link and the timing? Heart and kidney claims have the strongest research. Sleep apnea and diabetes claims need opinions that deal with which came first and with weight.

Raven Nexus organizes your blood pressure history, labs and the relevant research into a draft your doctor can review, and C&P exam prep helps you prepare for a heart or kidney exam.

How secondary ratings combine with hypertension

VA combines ratings under 38 CFR § 4.25, largest first, and each smaller rating takes its share of what remains. Take hypertension at 10 percent, hypertensive heart disease at 30 percent for a thickened heart muscle on echocardiogram, and kidney disease at 30 percent for a GFR of 45 to 59. The two 30s combine to 51, and the hypertension brings that to about 56, which VA rounds to 60 percent. A 10 percent condition anchors a 60 percent combined rating once the damage it caused is service connected. Secondary conditions also count toward TDIU.

Questions veterans ask about secondary conditions to hypertension

What conditions are secondary to hypertension?

The most common in Board decisions are heart disease, sleep apnea, kidney disease, erectile dysfunction, stroke, migraines and diabetes. Any condition a doctor can tie to your hypertension with reasoning can be claimed.

Is heart disease rated separately from hypertension?

Yes. Note (3) to Diagnostic Code 7101 says to rate hypertension separately from hypertensive heart disease and other heart disease.

Can sleep apnea be secondary to hypertension?

It can, but most research shows sleep apnea raising blood pressure rather than the reverse. A claim fits best when hard-to-control hypertension came first, and the opinion should address aggravation.

Can kidney disease be secondary to high blood pressure?

Yes. A cohort of 332,544 men tied higher blood pressure to a steadily higher risk of kidney failure, and the opinion should show your kidney labs declining during years of high blood pressure.

Can diabetes be secondary to hypertension?

It can. Higher blood pressure is tied to a higher risk of new diabetes, and in trials, diuretics and beta-blockers were tied to more new diabetes than other blood pressure drugs.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one; Spicer v. McDonough (Federal Circuit).
• 38 CFR § 4.104, Diagnostic Code 7101 and its Note (3), and the General Rating Formula for Diseases of the Heart; 38 CFR § 4.115a, renal dysfunction; 38 CFR § 4.115b, Diagnostic Codes 7507 and 7522; 38 CFR § 3.350(a).
• 38 CFR § 4.97, Diagnostic Code 6847; 38 CFR § 4.124a, Diagnostic Codes 8007 to 8009 and 8100; 38 CFR § 4.25, combined ratings.
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387(10022):957-967. PMID 26724178.
• Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. New England Journal of Medicine. 1996;334(1):13-18. PMID 7494564.
• Peppard PE, Young T, Palta M, et al. Prospective study of the association between sleep-disordered breathing and hypertension. New England Journal of Medicine. 2000;342(19):1378-1384. PMID 10805822.
• Friedman O, Bradley TD, Chan CT, et al. Relationship between overnight rostral fluid shift and obstructive sleep apnea in drug-resistant hypertension. Hypertension. 2010;56(6):1077-1082. PMID 21060007.
• Gaddam K, Pimenta E, Thomas SJ, et al. Spironolactone reduces severity of obstructive sleep apnoea in patients with resistant hypertension: a preliminary report. Journal of Human Hypertension. 2010;24(8):532-537. PMID 20016520.
• Kloner R. Erectile dysfunction and hypertension. International Journal of Impotence Research. 2007;19(3):296-302. PMID 17151696.
• Farmakis IT, Pyrgidis N, Doundoulakis I, et al. Effects of Major Antihypertensive Drug Classes on Erectile Function: a Network Meta-analysis. Cardiovascular Drugs and Therapy. 2022;36(5):903-914. PMID 33945044.
• O'Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388(10046):761-775. PMID 27431356.
• Guo Y, Rist PM, Daghlas I, et al. A genome-wide cross-phenotype meta-analysis of the association of blood pressure with migraine. Nature Communications. 2020;11(1):3368. PMID 32632093.
• Emdin CA, Anderson SG, Woodward M, et al. Usual Blood Pressure and Risk of New-Onset Diabetes: Evidence From 4.1 Million Adults and a Meta-Analysis of Prospective Studies. Journal of the American College of Cardiology. 2015;66(14):1552-1562. PMID 26429079.
• Elliott WJ, Meyer PM. Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet. 2007;369(9557):201-207. PMID 17240286.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds.