Citation Nr: 0721596 Decision Date: 07/18/07 Archive Date: 08/02/07 DOCKET NO. 03-36 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for heart disease. REPRESENTATION Appellant represented by: Peter J. Meadows, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Connolly Jevtich, Counsel INTRODUCTION The veteran served on active duty from June 1966 to June 1969, and the record reflects that he had additional service in the Reserves. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2002 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the claim. The veteran provided testimony at a personal hearing before the undersigned Veterans Law Judge in June 2005, a transcript of which is of record. In an October 2006 decision, the Board denied service connection for arteriosclerotic heart disease. The veteran appealed the Board's October 2006 decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a Joint Motion for Remand, the Court, in a November 2006 Order, vacated the Board's October 2006 decision and remanded the matter to the Board. The Board concluded that additional medical expertise was needed to render an equitable decision on this claim and in April 2007 requested a medical opinion from the Veterans Health Administration (VHA) in accordance with 38 C.F.R. § 20.901(a). In conformance with 38 C.F.R. § 20.903, the veteran and his attorney were notified of the VHA opinion in a June 2007 letter and given 60 days to submit any additional evidence or argument in response to the opinion. In Padgett v. Principi, No. 02-2259 (U.S. Vet. App. July 9, 2004), the United States Court of Appeals for Veterans Claims (Court) held that the Board has the authority to obtain medical opinions, but that the Board may not consider such additional evidence without remanding a claim to the agency of original jurisdiction (AOJ) or obtaining the appellant's waiver. The veteran has responded that he waived his right to have his case remanded. Therefore, having met all due process considerations, the Board can proceed. The Board notes that in April 2005, the veteran submitted a claim for service connection for heart disease based on exposure to Agent Orange. Although the claimed condition is the same as that decided herein, the basis of the claim is entirely different. The April 2005 claim is based on a claimed relationship to the veteran's 1966-1969 period of service, as opposed to the claim decided herein which is based on the veteran's subsequent Reserve service, including in 2001. The April 2005 claim requires consideration of different laws and regulations, such as those pertaining to presumptive service connection. Therefore, to avoid any unnecessary delay to the veteran, the Board will adjudicate the service connection claim on appeal as the RO did (based on the veteran's 2001 Reserve service), and REFER to the RO the April 2005 claim based on Agent Orange exposure. If the veteran is dissatisfied with the RO's consideration of that claim, he will have to follow the steps necessary to perfect an appeal to the Board, since it is being treated as a separate claim for jurisdictional purposes. FINDING OF FACT The most probative evidence of record establishes that the veteran did not suffer a myocardial infarction while performing inactive duty training (IDT) on March 10, 2001; the cardiovascular disability initially diagnosed on March 10, 2001, is heart disease, not injury. CONCLUSION OF LAW Service connection is not warranted for heart disease. 38 U.S.C.A. §§ 101, 1110 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.6, 3.159, 3.303 (2006). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) With respect to the claimant's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Prior to the initial adjudication of the claimant's claim, VCAA letters dated in May 2002, June 2002, and August 2002 were sent to the veteran. Subsequently, another VCAA letter was issued in July 2003 (followed by readjudication of the claim in the statement of the case and a supplemental statement of the case). Cumulatively, the letters fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The letters advised the veteran what information and evidence was needed to substantiate the claim decided herein and what information and evidence must be submitted by him, namely, any additional evidence and argument concerning the claimed condition and enough information for the RO to request records from the sources identified by the veteran. In this way, he was advised of the need to submit any evidence in his possession that pertains to the claim. He was specifically told that it was his responsibility to support the claim with appropriate evidence. Finally the letters advised him what information and evidence would be obtained by VA, namely, records like medical records, employment records, and records from other Federal agencies. If there is VCAA deficiency, i.e., VCAA error, this error is presumed prejudicial to the claimant. VA may rebut this presumption by establishing that the error was not prejudicial. See Simmons v. Nicholson, No. 2006-7092 (Fed. Cir. May. 16, 2007); see also Sanders v. Nicholson, No. 2006-7001 (Fed. Cir. May. 16, 2007). The claimant's pertinent service medical records and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The pertinent evidence is contained in the claims file. The claimant has submitted a private medical opinion and a VA medical expert opinion has been obtained. See generally 38 C.F.R. § 3.159(c)(4). The records satisfy 38 C.F.R. § 3.326. The Board notes that the veteran waived initial RO review of this additional medical evidence. At this juncture, the Board notes that the veteran's appeal is limited as to whether he incurred heart disease to include a myocardial infarction while performing IDT in March 2001. The records pertaining to that event are in the claims file. The expert opinions are relevant to that matter. There is no further relevant evidence as to that specific issue. Finally, as a general due process matter, the Board notes that the veteran's attorney disagreed in April 2007 with the Board seeking an additional medical opinion, arguing that the opinion the veteran had submitted was more than enough to grant the claim. Although the veteran and his attorney contend that ample evidence exists to decide his claim favorable, determining the adequacy of the evidence is not the responsibility of the veteran or his representative. It is the responsibility of VA adjudicators, based upon their administrative experience and expertise in reviewing many claims of this nature, to determine at what point the record is sufficiently developed to support a reasonably informed decision. See 38 C.F.R. §§ 3.159, 3.326 (2006); see also Shoffner v. Principi, 16 Vet. App. 208, 213 (2002) [holding that VA has discretion to decide when additional development is necessary]. As provided in 38 C.F.R. § 3.159(c)(4) (2006), VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. Thus, the regulations clearly indicate it is the duty of VA to determine the adequacy of evidentiary development. Although the opinion submitted by the veteran's attorney was certainly a competent medical opinion, as discussed in more detail below, due to conflicts between that opinion and the other medical evidence of record, as well as the fact that the physician rendering the opinion did not necessarily have sufficient expertise in cardiology, the Board chose to further develop the record by a cardiology expert. There was also a legal/medical conflict in that Dr. B. stated cell death was not required to find a myocardial infarction, while an opinion by VA's Office of General Counsel held that a myocardial infarction is a condition in which a portion of the heart muscle dies. VAOPGCPREC 86-90. Since the Board is required to abide by opinions of the Office of General Counsel, a conflict was presented in the case, which the Board hoped to resolve from a medical standpoint by seeking further opinion. The fact that the additional opinion ultimately was not favorable to the veteran's claim does not undermine the Board adjudicative authority to seek such an opinion. All due process requirements were met when an opinion was solicited in an unbiased manner and the veteran and his attorney were notified thereof and given an opportunity to submit additional evidence. As there is no indication that any failure on the part of VA to provide additional notice of assistance reasonably affects the outcome of this case, the Board finds that such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Since the Board has concluded that the preponderance of the evidence is against the claim of service connection, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The veteran served on active duty from June 1966 to June 1969, and the record reflects that he had additional service in the Reserves. This service included a period of IDT from March 10, 2001 to March 11, 2001. The veteran contends that he incurred heart disease and had a myocardial infarction while performing IDT on March 10, 2001. His appeal is limited to that matter. As noted in the introductory portion of this decision, to the extent that the veteran has otherwise claimed service connection for heart disease, that matter is being referred to the RO for adjudicatory action. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. This includes injuries or diseases incurred during active duty for training (ADT), or injuries suffered during IDT. See 38 U.S.C.A. §§ 101(24), 106. The Veterans Benefits and Health Care Improvement Act of 2000, Pub. L. No. 106-419, § 301, was amended effective in November 2000. As amended, it redefined as active service a period of IDT during which an individual was disabled or dies from an acute myocardial infarction, cardiac arrest, or cerebrovascular accident. Only service department records can establish if and when a person was serving on active duty, ADT, or IDT. Cahall v. Brown, 7 Vet. App. 232, 237 (1994). Service department records are binding on VA for purposes of establishing service in the United States Armed Forces. Duro v. Derwinski, 2 Vet. App. 530, 532 (1992); see also 38 C.F.R. § 3.203, defining the type of evidence accepted to verify service dates. Reserve and National Guard service generally means ADT and IDT. ADT is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. IDT includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year. These drills are deemed to be part-time training. Service connection on a presumptive basis is not available where the only service performed is ADT or IDT. See Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). A claim for service connection generally requires competent evidence of a current disability; proof as to incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence, as the situation dictates; and competent evidence as to a nexus between the inservice injury or disease and the current disability. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Layno v. Brown, 6 Vet. App. 465 (1994). The Court has consistently held that, under the law cited above, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the U.S. Court of Appeals for the Federal Circuit, which has stated, "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). The veteran can attest to factual matters of which he had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the veteran as a lay person has not been shown to be capable of making medical conclusions, thus, his statements regarding causation are not competent. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Thus, while the veteran is competent to report what comes to him through his senses, he does not have medical expertise. See Layno. Therefore, he cannot provide a competent opinion regarding diagnosis and causation. The Board may not base a decision on its own unsubstantiated medical conclusions but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record. Hensley v. Brown, 5 Vet. App. 155 (1993). Neither the Board nor the veteran is competent to supplement the record with unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Conversely, health professionals are experts and are presumed to know the requirements applicable to their practice and to have taken them into account in providing a diagnosis. Cohen v. Brown, 10 Vet. App. 128 (1997). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). The service records revealed that on March 10, 2001, while on duty, the veteran reported feeling tired and worn out. On examination, he had a pulse of 112, respiration of 20 which was shallow, warm and clammy skin, and he appeared generally ill. The veteran required a level of care that could not be provided so the Fire and Rescue Squad was called. It was determined that the veteran needed to be hospitalized. On that day, March 10, 2001, the veteran was admitted to the North Ridge Medical Center with complaints of suprasternal chest pain. The veteran was admitted to the telemetry department and was placed on bed rest. A March 11, 2001 chest x-rays revealed no evidence of acute cardiopulmonary disease. An echocardiogram was normal. On March 12, 2001, a myocardial perfusion spect scintigram with LV ejection/fraction was performed. The diagnosis was rule out coronary artery disease. The impression following the procedure was no suspected LV ischemia . Post-exercise LV ejection fraction was calculated as 62 percent. The veteran was taken on March 13, 2001 in stable condition to the cardiovascular institute where he underwent a left-side cardiac catherization with single plain ventriculography. The second procedure was diagnostic arteriography and third, interpretation of an angiography. It was concluded that the veteran had severe coronary atherosclerotic heart disease involving the left anterior descending, diagonal circumflex and right coronary arteries. Coronary artery bypass graft was recommended. A March 14, 2001 carotid duplex ultrasound revealed no hemodynamically significant lesion. Thereafter, coronary artery bypass times five including a left internal mammary artery and saphenous vein graft were performed. Postoperatively, the veteran was released on March 19, 2001. The final diagnoses were severe right coronary artery disease and angina pectoris. On April 17, 2001, the veteran returned to the hospital for follow-up treatment. It was noted that the veteran had undergone a complete coronary bypass. The impression was coronary artery bypass. An April 25, 2001 echocardiogram revealed atherosclerotic heart disease, history of coronary artery bypass times five, history of hyperlipidemia, family history of cardiovascular disease, history of hernia repairs, and strong family history of heart disease. On May 15, 2001, Single Photon Emission Computer Tomography (SPECT) testing was performed which revealed no evidence of stress (exercise) related myocardial ischemia, normal left ventricular systolic function, and post stress left ventricular ejection fraction of 59 percent. In May 2002, the veteran received a cardiology consultation from Cardiology Associates of Fort Lauderdale, P.A., which noted that the veteran complained of chest pain. His significant past medical history of atherosclerotic heart disease with coronary artery bypass surgery times 5, was noted. An echocardiogram was performed which revealed normal sinus rhythm with diffuse nonspecific ST changes. A Stress Dual Isotope Study revealed good physical work capacity, chest pain which was not precipitated by exercise, appropriate heart rate and blood pressure response, negative nuclear imaging stress test for the presence of ischemia, and normal global left ventricular function, ejection fraction of approximately 67 percent. In June 2005 and in correspondence of record, the veteran presented his contentions. The veteran asserted that on March 10, 2001, while he was on duty, he was performing strenuous exercises and encountered difficulties. He had chest pain and was taken to a local hospital. At the hospital, they discovered that his arteries were blocked. This was the first time that the veteran was diagnosed as having this problem. He underwent surgery then was released to home and had to retire. The veteran maintained that he suffered a heart attack. In support of his claim, the veteran submitted a medical opinion of C.N.B., M.D., M.B.A., a board-certified Associate Professor of Radiology and Nuclear Medicine, dated in February 2007. Dr. B. stated that he had special expertise in cardiac matters. Dr. B. indicated that he had reviewed the veteran's medical records, the veteran's statements, and medical literature. He opined that the veteran had a myocardial infarction on March 10, 2001. Dr. B. stated that the veteran entered service fit for duty. He had chest pain and a cardiac work-up while on duty on March 10, 2001. He had serious cardiac problems which have required median sterontomy and bypass treatments. Dr. B. provided the opinion that it was clear that this veteran had serious cardiac problems while on duty. His assignment of a medical diagnostic code (rating) is dependent on his status in regards to covered diseases (myocardial infarction, cardiac arrest and/or cerebrovascular accident) according to the recent 2002 rating decision. He provided medical treatise information regarding the definition of myocardial infarction. It was Dr. B.'s opinion that the veteran had a myocardial infarction while on duty for the following reasons: 1. His signs and symptoms during service were consistent with myocardial infarction. 2. His angiogram on March 13, 2001 was consistent with myocardial infarction as he had a 90 percent stenosis of several vessels. 3. His nuclear medicine stress test showed 1.5 mm max depression of his ST segment consistent with myocardial ischemia. 4. Actual cell death was not required in order to use the term myocardial infarction as myocardial infarction usually refers to ischemia and the veteran had signs and symptoms of ischemia. 5. Although the veteran's echocardiogram was essentially normal, this study was insensitive to acute myocardial infarction and was known for a high percentage rate of false negative results in the setting of acute myocardial infarction. In June 2007, a VA medical expert provided a medical opinion. The VA examiner also reviewed the records. The VA examiner is also an expert in cardiac matters as he is a board- certified internist and cardiologist, among other qualifications. The VA medical expert also provided a definition of myocardial infarction and reviewed the history of the definition of myocardial infarction. The VA medical expert opined that the veteran did not suffer an acute myocardial infarction in March 2001. He did not meet the criteria for the diagnosis based on the guidelines of the American College of Cardiology. The VA examiner found several statements of Dr. B. to be erroneous. The VA medical expert indicted that with regard to biomarkers, blood samples were obtained and sent for "CPK and troponin," which are the standard biomarkers for myocardial infarction. Two sets of laboratory results were obtained on March 10, 2001 and on the following day. In both instances, "CPK isoenzymes and troponin" were within normal limits. Because of the very high sensitivity of especially the biomarker "troponin," this result was a very strong argument against an acute myocardial infarction. In conclusion, the biochemical criteria for the diagnosis of myocardial infarction were not met. With regard to the electrocardiogram, the VA medical expert reviewed that testing which was performed on March 10, March 11, March 12, and March 15, 2001. The VA medical expert stated that there were no electrocardiogram changes consistent with acute myocardial infarction. There were neither significant ST segment elevations nor ST segment depressions or T wave abnormalities that would meet the criteria for myocardial ischemia. He stated that he was aware that the March 10, 2001 electrocardiogram was interpreted as "anterior wall infraction," but he disagreed with the interpretation. The VA medical expert consulted with a staff electrophysiologist and electrocardiogram specialist who concurred. The VA medical expert concluded that the electrocardiogram criteria for a diagnosis of acute myocardial infarction were not met. With regard to imaging studies, both echocardiography and radionuclide myocardial perfusion imaging were performed. An echocardiogram was performed on March 12, 2001. The pertinent information revealed that the left ventricular ejection fraction was within normal limits with normal left ventricular function. A gated myocardial perfusion SPECT was performed on March 13, 2001 and revealed no suspected LV ischemia. The veteran developed electrocardiogram changes during this test. Such changes were very commonly seen in patients with coronary artery disease during a stress test. They were indicative of short term insufficient perfusion of areas of the heart muscle. This was caused by blockages in the coronary arteries which the veteran of course had. However, these changes were not indicative of an acute myocardial infarction which was defined as death of heart muscle. In conclusion, the imaging criteria for the diagnosis of acute myocardial infarction were not met. With regard to coronary angiogram, the statement by Dr. B. that the veteran's March 13, 2001 angiogram was consistent with a myocardial infarction as the veteran had 90 percent stenosis of several vessels was incorrect. Stenoses on several vessels were frequently seen in angiograms of patients with coronary artery disease and chest pain, but were not in itself indicative of an acute myocardial infarction. In other words, the presence of severe stenosis was not equal to death of a heart muscle. Dr. B. responded to the VA medical expert opinion. Dr. B. implied that the physician may not have actually signed the opinion. Dr. B. opined that the opinion was incorrect when it stated that several of his opinions were erroneous. Dr. B. again indicated that the March 2001 angiogram was consistent with a myocardial infarction because the vast majority of patients with a myocardial infarction have angiograms with high grade stenosis in vessels and the veteran had a 90 percent stenosis in several vessels. Dr. B. indicated that the following supported a finding of myocardial infarction: the veteran's positive echocardiogram changes on March 10, 2001; the veteran had a clinical picture consistent with myocardial infarction; echocardiogram changes of 1.5 mm ST segment depression during stress imaging on March 13, 2001; the interpretation that the echocardiogram was an anterior wall myocardial infarction; and angiogram with 90 percent stenosis of several vessels; and Dr. B.'s prior opinion. Dr. B. stated that it was very likely (more than 50 percent) that the veteran had a myocardial infarction in March 2001, based on the constellation of medical data. The veteran, as a lay person, has not been shown to be capable of making medical conclusions, thus, his statements regarding causation are not competent. Espiritu. The veteran as a lay person is competent to report information of which he/she has personal knowledge, i.e., information that he can gather through his senses. See Layno. The Board notes that while the veteran is competent to report what came to him through his senses, he does not have medical expertise. The veteran is competent to report that he had chest pain, that he felt tired, and that he felt ill. However, he is not competent to provide a competent opinion regarding diagnosis and causation. Specifically, he is not competent to state that he had a myocardial infarction on March 10, 2001. The Board must weigh the credibility and probative value of the medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider's knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Black v. Brown, 10 Vet. App. 279, 284 (1997). The veteran maintains that he had a myocardial infarction while performing IDT on March 10, 2001. The competent medical evidence that supports his contention is the medical opinion of Dr. B. Conversely, a VA medical expert has opined that the veteran did not suffer a myocardial infarction on March 10, 2001. Both Dr. B. and the VA medical expert are competent as they are medical professionals. Both indicated that they have special training in cardiology. In reviewing those qualifications, Dr. B. indicated that with regard to cardiac specialization, he has performed a myriad of cardiac tests such as x-rays, computed tomography (CT) scans, nuclear medicine scans, angiograms, echocardiograms, and magnetic resonance imaging (MRI) scans. He indicated that he was sub board certified in cardiac matters by his radiology boards. The VA medical expert, on the other hand, is a cardiologist, an assistant Professor of Medicine in the division of cardiology at a university; had 8 years of training in cardiology; specifically practices cardiology both for VA and private facilities; performs and supervises cardiology consultations; performs noninvasive cardiac procedures such as echocardiograms, stress tests, and CT angiographies; teaches general cardiology to cardiology fellows and medicine residents; and evaluates patients daily who have chest pain for acute myocardial infarction. First of all, the Board does not question that the physician who provided the VA medical expert opinion actually signed that report, as was implied by Dr. B. Although Dr. B. listed extensive medical qualifications, his primary specialty was not identified as cardiology. The Board does not question that he has medical knowledge in this area and is competent to render an opinion. However, with regard to specialization and training, the VA medical exert is a cardiologist and has more extensive expertise in the field of cardiology. As such, his qualifications in cardiology are more specific and extensive than those of Dr. B. Both Dr. B. and the VA medical expert had access to the medical records and the statements of the veteran as well as medical literature. Their opinions conflict. The Board finds that the VA medical expert's opinion is more persuasive in this case. The Board finds that the VA medical expert's opinion is of greater probative value because the VA medical expert is specifically a specialist in cardiology. In addition, his medical opinion is more thorough and complete. It addressed the laboratory findings/biomarkers which did not show myocardial infarction. Dr. B. did not address this matter. The VA medical expert and Dr. B. disagreed over the findings on the electrocardiograms, imaging studies, and coronary angiogram. Both provided rationale. They disputed each other's findings, essentially point by point. However, the Board finds that the VA medical expert's opinion is more probative due to his medical expertise and the more extensive explanation and discussion in the medical opinion. In addition, in reviewing the hospital reports, his findings are supported. One electrocardiogram was interpreted as "anterior wall infraction," which the VA medical expert refuted. However, the other testing did not reveal myocardial ischemia which Dr. B. indicated was present. The SPECT testings were specifically negative for myocardial ischemia. The echocardiography and radionuclide myocardial perfusion imaging were performed which yielded findings within normal limits. The VA medical expert explained that while the March 13, 2001 angiogram showed 90 percent stenosis of several vessels, this was due to the coronary artery disease , but were not in itself indicative of an acute myocardial infarction. Clearly the veteran had blocked arteries, hence the need for the bypass surgery times 5. Dr. B. argued that the vast majority of patients with a myocardial infarction have angiograms with high grade stenosis. However, as pointed out by the VA medical expert, it is not a definitive indicator for myocardial infarction. Further, the VA medical expert's opinion is most consistent with the documentary record for the March 2001 medical treatment of the veteran. A review of the private hospitalization and surgical reports do not show that the final diagnosis and impression was that the veteran had suffered a myocardial infarction. Rather, they show that he had severe coronary artery disease/atherosclerotic heart disease. The diagnostic impression was not myocardial infarction. The follow-up treatment did not reflect that the veteran had suffered a myocardial infarction on March 10, 2001. The follow-up and subsequent medical records all refer to the coronary artery disease and/or bypass surgery. There is no notation in those records that the veteran's past cardiac medical history was significant for a myocardial infarction. As previously cited, the veteran's significant medical history was noted in several reports to include both cardiac and non-cardiac issues, but there was no documentation of any past myocardial infarction and the veteran was being seen for cardiovascular treatment in those evaluations. Thus, an omission of a prior and recent myocardial infarction is unlikely and would be contraindicated given the nature of the treatment being provided to the veteran. Accordingly, although Dr. B. opined that the veteran suffered a myocardial infarction on March 10, 2001, his opinion is outweighed by the VA medical expert opinion which was rendered by a physician with more specialized expertise in the area of cardiology, and whose opinion is supported by the documentary record regarding the March 10, 2001 hospitalization report and subsequent treatment records. The Board attaches the most probative value to the VA medical expert opinion as it is well reasoned, detailed, and consistent with other evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion.) The veteran did not suffer a myocardial infarction on March 10, 2001, while performing IDT. The record is negative for any competent medical evidence reflecting a diagnosis of cardiac arrest or cerebrovascular accident. Although he was initially diagnosed with cardiovascular disability, service connection is not warranted as the diagnosed cardiovascular disability is disease and not injury. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the veteran's claim, and it must be denied. ORDER Entitlement to service connection for heart disease is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs