Citation Nr: 0812243 Decision Date: 04/14/08 Archive Date: 05/01/08 DOCKET NO. 05-35 701A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for osteoarthritis of the right shoulder. 2. Entitlement to service connection for a heart condition, to include coronary artery disease (CAD), mitral valve prolapse, tricuspid regurgitation, atrial fibrillation and aortic valve sclerosis. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K.A. Kennerly, Associate Counsel INTRODUCTION The veteran served on active duty from December 1947 to December 1953 and had service in the United States Air Force Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2004 rating decision of the Milwaukee, Wisconsin, Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2003, the veteran filed claims of entitlement to service connection for varicose veins of the right and left lower extremity, adhesive bowel disease (ABD), right ankle pain, osteoarthritis of the right and left knee, stomach problems (to include peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD)), a heart condition, right shoulder rotator cuff tear and blepharitis of the left eye. In the aforementioned March 2004 rating decision, the RO granted the veteran's claims for varicose veins, assigning a 10 percent disability rating for each extremity and ADB, assigning a 10 percent disability rating. The remaining claims were denied. In April 2004, the veteran filed a notice of disagreement with all of the aforementioned issues. He was then provided with a statement of the case in September 2005 and he subsequently perfected his appeal in November 2005. The Board notes that the November 2005 statement from the veteran was accepted in lieu of the VA-Form 9. In the same statement, the veteran withdrew his claims of entitlement to increased ratings for varicose veins and ADB, as well as his claims of entitlement to service connection for a right ankle disability and right knee osteoporosis. The veteran was also afforded a Decision Review Officer informal conference in November 2005. The report of this proceeding has been associated with the veteran's claims file. In April 2006, the veteran submitted a statement indicating that he wished to withdraw his claim of entitlement to service connection for stomach problems (to include PUD and GERD). In September 2006, a rating decision increased the veteran's disability rating for varicose veins (from 10 to 20 percent disabling for both lower extremities), granted service connection for medial and lateral meniscus tear of the left knee (20 percent disabling), granted a separate 10 percent disability rating for degenerative joint disease (DJD) of the left knee, granted service connection for the partial rotator cuff tear and tendonitis of the right shoulder (40 percent disabling), granted service connection for benign paroxysmal arrhythmia (30 percent disabling) and granted service connection for chronic blepharitis of the left eye (10 percent disabling). As such, the veteran's appeal regarding the service connection claims for osteoarthritis of the left knee and chronic blepharitis of the left eye has been satisfied. Similarly, the withdrawn claims of entitlement to increased disability ratings for varicose veins and ADB and service connection claims for right ankle disability, right knee osteoarthritis and stomach problems (to include PUD and GERD) are no longer before the Board and will not be addressed further. FINDINGS OF FACT 1. The preponderance of the evidence does not support a finding that osteoarthritis of the right shoulder is the result of a disease or injury in service, nor did it become manifest to a degree of 10 percent or more within one year of discharge. 2. The preponderance of the evidence does not support a finding that a heart condition, to include coronary artery disease, mitral valve prolapse, tricuspid regurgitation, atrial fibrillation and aortic valve sclerosis, is the result of a disease or injury in service, nor did it become manifest to a degree of 10 percent or more within one year of discharge. CONCLUSIONS OF LAW 1. Osteoarthritis of the right shoulder was not incurred in or aggravated by active military service and may not be presumed to be related thereto. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2007). 2. A heart condition, to include CAD, mitral valve prolapse, tricuspid regurgitation, atrial fibrillation and aortic valve sclerosis, was not incurred in or aggravated by active military service and may not be presumed to be related thereto. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the veteran or on his or her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the veteran's claims decided herein, VA has addressed the statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2007). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. Prior to the initial adjudication of the veteran's claims, a letter dated in November 2003 addressed the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2007); Quartuccio, at 187. The November 2003 letter informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-21. However, the November 2003 letter failed to provide notice of the fourth element, viz., that the claimant should provide any evidence relevant to the claims in his possession to VA. See Pelegrini II, supra. Failure to provide pre-adjudicative notice of any of the four elements is presumed to create prejudicial error. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). The Secretary has the burden to show that this error was not prejudicial to the veteran. Id., at 17. Lack of prejudicial harm may be shown in three ways: (1) that any defect was cured by actual knowledge on the part of the claimant, (2) that a reasonable person could be expected to understand from the notice what was needed, or (3) that a benefit could not have been awarded as a matter of law. Id., at 14; see also Mayfield v. Nicholson, 19 Vet. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The November 2003 letter informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA and provided examples of the types of evidence, both medical and lay, that could be submitted. The Board concludes that a reasonable person could be expected to understand that any relevant evidence should be submitted during the development of the claims. See Pelegrini II, at 120-21. Accordingly, the Board concludes that the failure to provide VCAA compliant notice was harmless. The Board may proceed with consideration of the claims on the merits. See Sanders, supra; see also Simmons v. Nicholson, 487 F.3d 892 (Fed. Cir. 2007). In March 2006, the veteran was provided with notice as to how VA determines disability ratings and effective dates, consistent with the holding in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The veteran was also provided with a subsequent adjudication of his claims in October 2006. Id. The Board also concludes VA's duty to assist has been satisfied. The veteran's service medical records and VA medical records are in the file. Private medical records identified by the veteran have been obtained, to the extent possible. The veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. See veteran's statement, November 2003. The veteran was afforded VA medical examinations in February 2004 and August 2006 to obtain opinions as to whether his osteoarthritis of the right shoulder and heart condition could be directly attributed to service. Further examination or opinion is not needed on the aforementioned claims because, at a minimum, there is no persuasive and competent evidence that the claimed conditions may be associated with the veteran's military service. This is discussed in more detail below. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any 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). II. The Merits of the Claims The veteran alleges that his current osteoarthritis of the right shoulder and his existing heart condition are the result of his time in service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (West 2002). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. See 38 C.F.R. § 3.303(b) (2007). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2007). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests arthritis and/or a heart condition to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2007). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The Board notes that the veteran has already been granted service connection for a partial rotator cuff tear and tendonitis of the right shoulder and benign paroxysmal arrhythmia. As these issues did not include osteoarthritis of the right shoulder and heart conditions, to include CAD, mitral valve prolapse, tricuspid regurgitation, atrial fibrillation and aortic valve sclerosis, these issues are the subject of this decision. Review of the veteran's service medical records reveals that on May 7th, 1949, the veteran complained of chest pains. See Standard Form (SF) 55D, May 7, 1949. A chest x-ray revealed no cardiac enlargement with normal heart and lungs. See radiographic report, May 25, 1949. A second chest x-ray was taken several days later, again revealing normal heart and lungs. See radiographic report, May 27, 1949. The corresponding electrocardiogram (EKG) revealed sinus arrhythmia. See EKG, May 31, 1949. An undated medical summary indicated that no cardiac disease was found. In October 1950, the veteran complained of "pains in the heart" or "cramps in the heart." Examination was normal and the veteran was diagnosed with cardiac neurosis. See service medical record, October 10, 1950. In November 1950, the veteran complained of chest pain for the past three weeks. The veteran was diagnosed with intercostal neuritis. See service medical record, November 16, 1950. The discharge and re-enlistment examination conducted in December 1950 was normal. The veteran denied any illnesses, injuries or operations. See SF 88, discharge and re-enlistment examination, December 29, 1950. In July 1952, a routine chest x-ray was negative. See radiographic report, July 9, 1952. In November 1953, the veteran complained of right shoulder pain radiating from his shoulder to his elbow. He denied any history of injury, stating that the pain had come on suddenly while he was sitting in a chair. There was slight pain on abduction but no pain on deep palpation and no tenderness. X-rays of the right shoulder were negative and the veteran was diagnosed with peripheral neuritis. The veteran was seen later in November and in December, 1953, with continuing diagnoses of peripheral neuritis. See service medical records, November 3, 1953 to December 5, 1953. The service discharge examination in December 1953 noted the upper extremities and heart to be normal. Peripheral neuritis of the left arm and shoulder in November 1953 was noted as normal with no residuals. It was also noted that the veteran was hospitalized in May 1949, for questionable heart trouble though the subsequent heart examination and EKG were negative. No cardiac pathology was found. See SF 88, service discharge examination, December 28, 1953. Upon enlistment into the Air Force Reserves, the medical examination noted normal heart and upper extremities. It was noted that the veteran experienced palpitations of the heart, indicated occasionally in 1949, 1950 and 1951 after heavy drinking. Mild pain was also diagnosed in the right shoulder in 1953, as neuritis by a local physician, which lasted six months. The veteran reported that he did not currently suffer from right shoulder pain. See U.S. Air Force Reserves enlistment examination, December 6, 1954. The veteran reported that he suffered from heart palpitations. He specifically denied suffering from a painful or trick shoulder or elbow. See SF 89, U.S. Air Force Reserves enlistment examination, December 6, 1954. The first evidence of record addressing a right shoulder disability was dated in 1990. Reports from the Fine-Lando Clinic indicated the veteran had an x-ray of the right shoulder, which revealed no evidence of a fracture, dislocation or other bony abnormality. The veteran's right shoulder was considered normal. See Fine-Lando Clinic record, Ronald E. Grossman, M.D., October 19, 1990. The first evidence of record demonstrating any cardiac difficulty was also noted in 1990. An EKG was noted to be normal with a borderline slow rate. The veteran was also given a Holter monitor for 24 hours, the results of which were premature atrial contractions with at least two runs of supraventricular tachycardia. Other serious arrhythmias were not noted. See Trinity Memorial Hospital records, April 23- 24, 1990. An EKG report in March 1991 noted that IV conduction was in the upper limits and the tracing was basically normal. See Trinity Memorial Hospital records, March 15, 1991. In July 1991, the veteran participated in a treadmill test due to reported chest pain and palpitations. EKG results were "probably normal." See Trinity Memorial Hospital records, July 24, 1991. The subsequent nuclear cardiac stress Thallium study revealed findings consistent with an area of reversible ischemia involving the apical inferior aspect of the left ventricular wall. Incidentally, the previous Thallium stress cardiac study dated August 12, 1985, was considered to be within normal limits (1985 stress test not of record.) See Trinity Memorial Hospital records, July 25, 1991. In August 1991, the veteran was seen for evaluation of chest pain and palpitations. The veteran reported a history of palpitations (probably due to supraventricular tachycardia (SVT)) for the prior year and a half. Past history included hiatal hernia and PUD but no other major medical problems were noted. The veteran was ultimately diagnosed with possible CAD with anginal syndrome, SVT of a paroxysmal nature and sinus rhythm function class II. See private medical record, Eddy D. Co, M.D., August 1, 1991. The subsequent chest x-ray was normal. See Trinity Memorial Hospital record, August 4, 1991. The veteran then underwent a heart catheterization. The clinical impression was CAD with anginal syndrome. See Trinity Memorial Hospital, Diagnostic Heart Catheterization Report, August 5, 1991. Later in August 1991, the veteran was again seen with complaints of chest pain. See Trinity Memorial Hospital record, August 21, 1991. A chest x-ray performed in December 1992 revealed the heart, lungs and mediastinum to be normal. See Trinity Memorial Hospital record, December 16, 1992. Contrary to the 1995 test results, the November 1996 nuclear medicine myocardial perfusion testing revealed a normal myocardial perfusion scan with no evidence of reversible ischemia or myocardial infarction. See Trinity Memorial Hospital record, November 6, 1996. In May 1999, the veteran was seen by J.P. Carroll, M.D., at the Aurora Medical Clinic. Dr. Carroll noted that the veteran participated in a stress test, which had associated neck pain, suggestive of angina, with ST wave depression that was nondiagnostic. The veteran was noted to be relatively asymptomatic, although he complained of continuous chest pain. See Aurora Medical Clinic record, J.P. Carroll, M.D., May 17, 1999. In June 1999, Dr. Carroll indicated that the veteran was not a candidate for heart catheterization. The assessment was heart palpitations. See Medical Clinic record, J.P. Carroll, M.D., June 15, 1999. In August 2002, the veteran reported exquisite pain to the right shoulder; later diagnosed as presumed calcific tendonitis. He was subsequently scheduled for magnetic resonance imaging (MRI) of the right shoulder. The impression included the following: mild osteoarthritic changes of the acromioclavicular joint; edema and inflammatory changes involving the rotator cuff insertion and underlying subcortical bone, i.e. tendinopathy; an early or mild tear/abrasion of the articular surface at the rotator cuff; and mild subacromial subdeltoid bursitis. See Kenosha Open MRI, MRI of the right shoulder, August 23, 2002. In October 2003, Dr. Carroll diagnosed the veteran with mitral regurgitation. See Aurora Medical Clinic record, October 27, 2003. Also in October 2003, the veteran was given a Holter monitor for 24 hours, based on the veteran's complaints of chest pain, erratic heartbeat and dizziness. After the 24-hour recording period, the impression was a normal sinus tachycardia and a short run of atrial bigeminy. See Aurora Medical Clinic, Holter monitor report, October 30, 2003. In December 2003, an EKG noted mild aortic regurgitation. See VA Medical Center (VAMC) treatment records, EKG, December 2, 2003. In June 2005, the veteran had an EKG and underwent a stress test. The results indicated no dysrhythmias or angina. The EKG was considered negative. See VAMC treatment record, EKG and stress test, June 23, 2005. During January and February of 2006, the veteran was treated by the Aurora Medical Clinic and St. Luke's Hospital. In February 2006, an EKG revealed mitral calcification, aortic valve stenosis and preserved ventricular function. A left heart catheterization was performed with coronary angiography and left ventriculography. Based on these results, the veteran had surgery for a two-vessel bypass. Review of all of the aforementioned medical evidence has established that the veteran expressed complaints of heart and right shoulder problems in service and that he has current diagnoses of these disabilities. However, the evidence fails to provide a positive medical nexus linking his heart and right shoulder disabilities to service. See Hickson, supra. The Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). In the present case, the Board finds the VA medical opinions of 2004 and 2006 to be the only medical evidence of record to address the questions of medical nexus. In February 2004, the veteran was afforded a VA heart examination. The examiner essentially repeated all of the medical history summarized above. The examiner diagnosed the veteran with CAD with stable angina and paroxysmal SVT. The examiner opined there was no evidence suggestive of mitral valve prolapse. During the veteran's military service, he was seen for vague complaints of palpitations with chest pain, but no cardiac origin was determined. The examiner noted that according to medical literature, many factors can cause palpitations such as: smoking, caffeine, alcohol use, stress, anxiety or cardiac arrhythmias. The veteran was a smoker at the time his palpitations began and according to his Reserve enlistment physical examination in December 1954, the history of palpitations occurred at times of "heavy drinking." The examiner concluded that since the veteran was not diagnosed with paroxysmal SVT until 1989 (more than 30 years after discharge from service); his current heart condition was not likely related to the symptoms and treatment shown in service. See VA examination report, February 11, 2004. The February 2004 VA joints examination recounted the veteran's right shoulder treatment in service, as detailed above. The veteran reported that in the early 1970s, he suffered a right clavicle fracture while ice-skating. He reported the fracture healed well and he did not have physical therapy. In 1996, after digging a hole in his backyard, the veteran developed pain in the right shoulder. The veteran stated that he used a heating pad and the pain subsided. He reports that since 1996, he has not been able to move his right shoulder by itself, requiring him to use the left hand to move the right shoulder. In 2002, as noted above, he was diagnosed with a right rotator cuff tear. The examiner found the veteran's right shoulder pain to be located anteriorly. It was an uncomfortable, intense, aching pain at the beginning of a flare-up that later diminished. Pressure and motion aggravated this pain. Upon physical examination, the right biceps muscle had a ruptured biceps tendon residual, though there was no heat or swelling of the shoulder joint. X-rays revealed an old, healed fracture deformity to the right mid clavicle and there was a suggestion of minor osteoarthritis in both shoulders. In conclusion, the examiner opined that the veteran's gleno- humeral joints were normal and acromio-humeral head distance was slightly decreased bilaterally. The examiner found the veteran to have minor degenerative changes (osteoarthritis) in both shoulders, equally. The right shoulder did not have advanced osteoarthritis. The service-connected neuritis did not have any effect on the presence of osteoarthritis of the right shoulder. See VA joints examination, February 10, 2004. In September 2006, the veteran was afforded additional VA examinations. During the VA heart examination, again, the examiner provided a summary of the information noted above. The examiner concluded that the veteran suffered from benign paroxysmal arrhythmias, with onset during service and arteriosclerotic heart disease status post coronary artery bypass grafting, which was not service related. The examiner noted that atrial fibrillation, multiform and couplet PVSs were now resolved. See VA examination report, September 12, 2006. The Board notes that the diagnosed benign paroxysmal arrhythmias are the subject of a separate RO decision, in which service connection was granted. During the September 2006 VA joints examination, the veteran indicated that his right shoulder had pain intensity of five to six on a scale of one to 10 and was weak and stiff. During flare-ups, his pain was reported as eight or nine and he would not move his shoulder during those times. The veteran reported no surgery or dislocation of the right shoulder and there were no constitutional symptoms. He reported that this condition affected his daily activities; he was forced to do many activities with his left hand and arm. Examination of the right shoulder revealed tenderness to palpation at the right biceps tendon. There was more diffuse tenderness to palpation superior and posterior of the right shoulder. Muscle atrophy was noted about the right shoulder. The examiner concluded that the diagnoses of tendonitis and rotator cuff injury were at least as likely as not related to the veteran's in-service injury. (This is the subject of a separate RO grant of service connection.) DJD of the right shoulder was not related to the rotator cuff injury, as it was present in both shoulders. See VA examination report, August 31, 2006. The Board also notes the veteran's claim that mitral valve prolapse is related to his time in service. However, the veteran has not been diagnosed with this condition. In order to be considered for service connection, a claimant must first have a disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). In the absence of diagnosed mitral valve prolapse, service connection may not be granted. See also Degmetich v. Brown, 104 F. 3d 1328 (Fed. Cir. 1997). The only remaining evidence in support of the veteran's claims is lay statements alleging that the veteran's current heart and right shoulder disabilities are related to service. The Board acknowledges that the veteran is competent to give evidence about what he experiences; for example, he is competent to discuss what he remembers from service. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). The Board acknowledges the lay statements of H.S., submitted by the veteran, indicating that contrary to the veteran's separation examination, he was not a heavy drinker in service. The Board finds this testimony to be credible; however, it does not alter the outcome of the veteran's claims. With regard to the decades-long evidentiary gap in this case between active service and the earliest heart and right shoulder complaints, the Board notes that this absence of evidence constitutes negative evidence tending to disprove the claims that the veteran had injuries or diseases in service, which resulted in chronic disabilities or persistent symptoms thereafter. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also 38 C.F.R. § 3.102 (noting that reasonable doubt exists because of an approximate balance of positive and "negative" evidence). Thus, the lack of any objective evidence of continuing heart and right shoulder complaints, symptoms, or findings for over 30 years between the period of active duty and the medical reports dated in 1990 is itself evidence which tends to show that these disabilities did not have their onset in service or for many years thereafter. A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service, which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id.; cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003). The evidence of record fails to show the veteran's current heart condition and osteoarthritis of the right shoulder to a compensable degree within one year of discharge from service. See 38 C.F.R. §§ 3.307, 3.309 (2007). Based on the VA medical opinions in 2004 and 2006, there is no medical evidence that the veteran's current heart condition and osteoarthritis of the right shoulder are related to his time in service. Accordingly, the Board concludes that the preponderance of the evidence is against the claims for service connection, and the benefit of the doubt rule enunciated in 38 U.S.C.A. § 5107(b) is not for application. In this case, for the reasons and bases discussed above, a reasonable doubt does not exist regarding the veteran's claims that his current heart and right shoulder disabilities are related to service. There is not an approximate balance of evidence. ORDER Entitlement to service connection for osteoarthritis of the right shoulder is denied. Entitlement to service connection for a heart condition, to include coronary artery disease (CAD), mitral valve prolapse, tricuspid regurgitation, atrial fibrillation and aortic valve sclerosis, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs