Citation Nr: 1306056 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 05-13 943A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for hypertension, claimed as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for coronary artery disease, to include as due to Agent Orange, and as secondary to service-connected PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from April 1966 to April 1968. This matter comes to the Board on appeal from a March 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Cleveland, Ohio. This matter is before the Board of Veterans' Appeals (Board) following remands to the Agency of Original Jurisdiction (AOJ) in December 2008, August 2009 and February 2011. The Veteran provided testimony at a March 2009 Board hearing before the undersigned Acting Veterans Law Judge. A transcript of the hearing is associated with the claims file. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. At the time of the February 2011 Board remand, the issues of entitlement to an evaluation in excess of 50 percent for PTSD and entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) were also on appeal. By rating decision dated in August 2012, a 100 percent evaluation was assigned for the Veteran's PTSD effective March 15, 2011. By rating decision dated in September 2012, a 70 percent evaluation was assigned for the Veteran's PTSD effective May 16, 2006, and a TDIU was granted effective April 10, 2007. A veteran is presumed to seek the maximum available benefit for a disability. AB v. Brown, 6 Vet. App. 35, 38 (1993). In this case, as the maximum evaluation has been assigned for the Veteran's PTSD and a TDIU has been granted. There remains on appeal as to these issues. Neither the Veteran nor his representative has expressed disagreement with the resolution of these aspects of his appeal by seeking, for example, an earlier effective date for a TDIU or for a 100 percent rating for PTSD. Rather, the issues indicated on the title page of this decision are the same as those stated as the issues presented for review by the Veteran's representative in a November 5, 2012, Appellant's Post-Remand Brief. The Veteran's representative stated specifically in the Appellant's Post-Remand Brief that "VA rating decisions dated August 13, 2012 and September 17, 2012, resolved two of the issues on appeal." FINDINGS OF FACT 1. The preponderance of the evidence of record indicates that the Veteran's hypertension was not caused or aggravated by the Veteran's active duty service or by a service-connected PTSD. 2. The preponderance of the evidence of record indicates that the Veteran does not have coronary artery disease; thus there is no current disability shown as caused or aggravated by the Veteran's active duty service, to include his presumed exposure to Agent Orange in Vietnam, or by a service-connected disability. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by active service, and is not proximately due to or aggravated by service-connected PTSD. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. Absent a showing of current disability, the criteria for service connection for coronary artery disease are not met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matter Pursuant to the Board's August 2009 Remand, the RO obtained the Veteran's SSA records and readjudicated the Veteran's claim under provision of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) as discussed in more detail below, and issued a Supplemental Statement of the Case. Pursuant to the Board's February 2011 Remand, the Appeals Management Center (AMC) obtained ongoing VA treatment records dating from July 2009, requested that the Veteran identify all relevant records of treatment for heart disease and hypertension not in the claims file, scheduled the Veteran for a VA cardiovascular examination, readjudicated the Veteran's claim under the provisions of the VCAA, and issued a Supplemental Statement of the Case. Based on the foregoing actions, the Board finds that there has been compliance with the Board's August 2009 and February 2011 Remands. Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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; and (3) that the claimant is expected to provide. With respect to service connection claims, the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has met the statutory and regulatory notice and duty to assist provisions. Letters dated in March 2005 and July 2012 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 6 Vet. App. at 183, Dingess, 19 Vet. App. at 473. The March 2005 letter informed the Veteran of the evidence necessary to substantiate his claims, and his and VA's role in seeking and obtaining evidence. The July 2012 letter informed the appellant of as to how VA determines disability ratings and effective dates. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Ideally, the notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Although that was not done in this case, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. The appellant been afforded a meaningful opportunity to participate effectively in the processing of his claims and given ample time to respond, and the AOJ also readjudicated the claims after the notice was provided. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ). For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. The Veteran's service treatment records, VA medical treatment records, Social Security Administration (SSA) 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. There is no indication in the record that any additional evidence, relevant to the issues decided herein, is available and not part of the claims file. Moreover, during the March 2009 Board hearing, the undersigned explained the issues on appeal and asked questions designed to elicit evidence that may have been overlooked with regard to the issues on appeal. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was accorded VA examinations in February 2006 and March 2011; and a medical opinion was rendered by a VA cardiologist in August 2010. 38 C.F.R. § 3.159(c)(4). The March 2011 VA examiner addressed the existence and etiology of hypertension and coronary artery disease in conjunction with a review of the claims file and physical examination of and interview with the Veteran. The March 2011 VA examination report is thorough, factually consistent with the evidence of record, and sets forth fully reasoned explanations for the opinions provided ; thus this examination is adequate upon which to base a decision and of a high probative weight. 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, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prevail on the merits on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances lay, evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established by chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b). Continuity of symptomatology may establish service connection if a claimant can demonstrate that (1) a condition was "noted" during service; (2) there is postservice evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet. App. 488, 495-96 (1997)). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The first question that must be addressed is whether incurrence of hypertension or coronary artery disease is factually shown during service. In this case, the Veteran does not contend, and the evidence does not demonstrate, hypertension or coronary artery disease existed during service. The Board notes that at the March 2011 VA examination, the Veteran stated that he was diagnosed with cardiovascular disease in the 1990s but indicated that his memory was not good anymore. The service treatment records are absent complaints, findings or diagnoses of hypertension and coronary artery disease during service. Prior to his entrance into service, in conjunction with his physical examination in January 1966, the Veteran reported a history of high or low blood pressure. On examination, the Veteran's blood pressure reading was 120/60. The examiner noted, "high BP OK here." On the clinical examination for separation from service in January 1968, the Veteran's heart and vascular system were evaluated as normal, although the section of the report for noting blood pressure at the time of examination was left blank. On the Report of Medical History completed by the Veteran in conjunction with his separation physical, the veteran denied ever having high or low blood pressure, pain or pressure in his chest, and palpitation or pounding heart. There is no contemporaneous medical evidence that shows that the Veteran suffered from hypertension and coronary artery disease during service. As for statutory presumptions, service connection may also be established for a current disability on the basis of a presumption under the law that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307 and 3.309(a) (2012). Cardiovascular disease, including hypertension, can be service-connected on such a basis. The Veteran does not contend, and the record does not demonstrate, that he had hypertension or coronary artery disease within the first year after discharge from service. Applicable law provides that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, and has a disease listed at 38 C.F.R. § 3.309(e), shall be presumed to have been exposed during such service to a herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a). Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina) is listed at 38 C.F.R. § 3.309(e). The term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. See 38 C.F.R. § 3.309(e), Note 3. In addition, the United States Court of Appeals for the Federal Circuit has held that a veteran is not precluded by presumptive laws and regulations from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Alternatively, when a chronic disease is not present during service, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of continuity of symptomatology. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); 38 C.F.R. § 3.303(b). Such evidence is lacking here. As indicated above, neither disorder was "noted" during service. In addition, the Veteran has not reported, and the evidence does not demonstrate, continuity of symptoms from active service forward.. When a disease is first diagnosed after service, service connection can still be granted for that condition if the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury pursuant to 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). With respect to coronary artery disease, a review of the Veteran's post-service treatment records indicates that he was admitted to a private hospital with complaints of chest pains in July 2003. EKG was sinus rhythm, heart rate was 95 per minute, PPR and chest x-ray were normal. L2, L3, and AVF showed nonspecific ST-T changes. Stress test revealed normal coronary angiogram, normal left ventricular function, and mild mitral valve prolapsed. Two-D echo revealed normal left ventricular function with normal ejection fracture. There was no evidence of pericardial effusion. The conclusion was normal coronary angiogram, normal left ventricular function, mild mitral valve prolapse. In November 2004, the Veteran was again seen for complaints of chest pain. Stress myocardial perfusion SPECT scan showed no evidence of exercise-induced reversible myocardial ischemia and normal left ventricular systolic function with ejection fraction of 64 percent by gated SPECT. M-Mode, 2D echocardiography and Doppler color flow study showed, "the cardiac chambers are normal in cavity size. Normal valvular structures. No pericardial effusion. Normal right and left ventricular systolic function and ejection fraction. Color flow Doppler shows a trace of mitral regurgitation and a trace of tricuspid regurgitation." Chest x-ray showed normal cardiac size. The Veteran underwent VA examination in February 2006 at which time the examiner determined that there was no clear evidence of hypertensive heart disease. The Veteran denied chest pain or pressure at that time. Cardiovascular examination demonstrated regular rate and rhythm without murmurs, gallops, rubs, or bruits. Cardiac size was normal by physical examination, Point of Maximal Impulse (PMI), and previous x-rays. Previous EKGs note repolarization and possible left ventricular hypertrophy. Stress echo from November 2004 showed cardiac chambers were normal in cavity size and had normal valvular structures and normal right and left ventricular systolic function with normal ejection fraction. There was no pericardial effusion, and color flow Doppler showed trace of mitral regurgitation and trace of tricuspid regurgitation. Stress myocardial perfusion gated SPECT scan concluded there was no evidence of exercise-induced reversible myocardial ischemia and normal LV systolic function with ejection fraction of 64 percent by gated SPECT. The Veteran achieved 97 percent of his predicted maximum heart rate. The Veteran underwent VA examination in March 2011 at which time the examiner noted that the Veteran was asymptomatic with regard to any symptoms that could be deemed related/associated/secondary to cardiac condition and that the Veteran denied chest pain, palpitations, shortness of breath, orthopneas, and PND. The examiner noted that the Veteran was taken to the Emergency Room in November 2004 with chest pains. He had negative troponins which excluded a myocardial infarction. He had an ECHO that showed cardiac chambers normal in cavity size and normal valvular structures, normal right and left ventricular systolic function with normal ejection fraction, and no pericardial effusion. Color flow Doppler showed trace mitral regurgitation and trace tricuspid regurgitation. Stress myocardial perfusion gated SPECT scan was also normal. The Veteran's cardiovascular examination was normal, with normally located PMI, regular rate and rhythm, and no murmurs, gallops or rubs. ECG was normal, and there were no left ventricular hypertrophy criteria or any evidence of old infarcts or ischemic changes. The Veteran's labs showed BUN of 10 and creatinine of 0.8, both completely normal, conclusively excluding a hypertension that has been either hard to control or progressed beyond normal rate of progression. The examiner noted in an addendum that a stress test conducted at the end of March 2011 was normal with no evidence of stress-induced ischemia or infarct and normal ventricular function. The examiner summarized that the Veteran had no data to support a diagnosis of coronary artery disease as he had a normal stress test. The Board acknowledges the Veteran's assertions that he experienced chest pains prior to filing his claim for coronary artery disease. Chest pain, however, are actually just reported symptomatology. Without a recognized injury or disease entity, VA is not authorized to award compensation for reported symptomatology. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a) (Service connection is awarded for "a particular injury or disease resulting in disability..."); see also Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); aff'd in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356, 1363 (Fed. Cir. 2001) (The CAVC held that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted.) In the absence of competent evidence which suggests that the Veteran's chest pains constitute a chronic coronary artery disability, the Board has no basis on which to consider the Veteran's chest pains as more than medical findings or symptoms. The Veteran's own assertions to the contrary do not constitute competent medical evidence in support of his claim. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Absent a showing of a current chronic coronary artery disability which could be related to service, entitlement to service connection for coronary artery disease must be denied. With respect to hypertension, the Veteran has a current diagnosis. The remaining question is whether there is medical evidence of a relationship between the current disability and military service. The Veteran underwent VA examination in February 2006 at which time the examiner noted, As discussed with the veteran and his wife today, I am aware of no medical evidence that PTSD causes or aggravates hypertension .... While it is possible that anxiety and panic attacks may increase blood pressure for short periods of time, the veteran has a history of chronic stable increase in blood pressure and this points to a diagnosis of essential hypertension. In addition, he has an over 50-pack-year smoking history and this is more likely to have contributed to ... hypertension than his PTSD. ... In a letter written on behalf of the Veteran in April 2009, the Veteran's readjustment therapist, N.A.C., M.Ed., LPCC, states, "... It is also very apparent that the prolonged stress related to dealing with chronic PTSD symptoms and the life problems they cause, also seriously exacerbates [the Veteran's] multiple health problems of the past 40+ years. ..." In addition, the Veteran has submitted a handwritten letter dated in December 2009 from Dr. S.B. which states, "This is to notify that [the Veteran] has PTSD [and hypertension]. Uncontrolled stress [and] PTSD can worsen [hypertension] (high b[lood] p[ressure])." In July 2010, the Board requested a medical expert opinion as to whether the Veteran's hypertension was caused or aggravated by his service-connected PTSD. In August, the Board received a medical opinion from a VA staff cardiologist which states, It is well documented that inhalation of tobacco smoke for years substantially increases the likelihood that the person will develop obstructive atherosclerotic arterial disease and hypertension. It is also well documented that exercise, acute anxiety, and panic attacks usually increase the systolic blood pressure briefly (and only briefly) in healthy people who have normal blood pressure the majority of the time. Based on this veteran's medical records, he appears to have abnormal and chronically elevated blood pressure that is treated with drugs. I am not aware of any well documented evidence that PTSD causes or aggravates the disease of chronically elevated blood pressure. At the March 2011 VA examination, the Veteran's blood pressure reading was 136/70. The examiner opined that the Veteran's PTSD had not caused or aggravated the Veteran's hypertension. The examiner noted that the Veteran did have hypertension but it had been well controlled with few medications, no admissions with poorly controlled hypertension, no emergency room visits, no need to uptitrate hypertension medication, and no evidence of end-organ damage some or all of which would have happened if PTSD were to be implicated in its control. In support of his claim, the Veteran also submitted an excerpt from the book, Breathe Well, Be Well by Robert Fried, Ph.D. in which he states, Stress: Some people react to stress with a temporary rise in blood pressure. Whether stress can cause chronic hypertension, though, is not completely proven, but many physicians do suspect that stress plays a role in many such cases of high blood pressure. High levels of stress over a long period of time may boost pressure by activating your involuntary nervous system. The Board notes that there is a difference of opinion among the medical professionals. In deciding whether the Veteran's PTSD caused or aggravated his hypertension, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Evans v. West, 12 Vet. App. 22, 30 (1998). That responsibility is particularly onerous where medical opinions diverge. At the same time, the Board is mindful that it cannot make its own independent medical determinations and that there must be plausible reasons for favoring one medical opinion over another. Id. Here, there are legitimate reasons for accepting the unfavorable medical opinions over the favorable medical opinions. With regard to medical evidence, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. The weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. See, e.g., Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (neither a VA examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions; most of the probative value of a medical opinion comes from its reasoning). In this case, the favorable opinions of N.A.C. and Dr. S.B. which indicate that the Veteran's stress from PTSD caused or worsened the Veteran's hypertension are not accompanied by supporting clinical data or a fully reasoned rationale. As such, they are afforded a relatively low probative weight. In contrast, the unfavorable opinions of the VA examiners provide such rationale. The February 2006 VA examiner acknowledged although it was possible that anxiety and panic attacks may increase blood pressure for short periods of time, that the Veteran's stable increase in blood pressure points to essential hypertension. Essential hypertension, as defined by Stedman's Medical Dictionary, 856, (27th ed., 2000) as an idiopathic, primary hypertension without a known cause. The February 2006 examiner also offered that the Veteran's history of smoking was more likely to have contributed to the Veteran's hypertension than his PTSD. The February 2006 medical opinion is fully explained and is generally consistent with the evidence of record, and therefore is of a high probative value. The March 2011 VA examiner, also a VA cardiologist, noted that the Veteran's hypertension was well controlled with few medications, that there were no admissions with poorly-controlled hypertension, no emergency room visits, no need to uptitrate hypertension medication, and no evidence of end-organ damage some or all of which would have happened if PTSD were to be implicated in its control. Further, the VA examiners' opinions appear to be corroborated by private and VA physicians. On a prescription sheet, Dr. Fedorko, the Veteran's treating physician, indicated in April 2005 that he was being treated for idiopathic hypertension and anxiety. A VA cardiologist provided his opinion that acute anxiety and panic attacks usually increase the systolic blood pressure briefly. The cardiologist also addressed the smoking connection to hypertension. With respect to the excerpt from the Dr. Fried's book, the Board assigns it very little probative value. The Court of Appeals for Veterans Claims has determined that generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive; however, medical treatise evidence can provide important support when combined with an opinion of a medical professional. The statement which acknowledges that it has not been completely proven that stress can cause chronic hypertension provides little support for the Veteran's claim, other than to imply that such a connection may be plausible. The statements that many physicians do suspect that stress plays a role in many such cases of high blood pressure, and that high levels of stress over a long period of time may boost pressure by activating the involuntary nervous system are too speculative in nature and do not provide a sufficient basis upon which to support a claim. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In this case, the Board finds more probative the unfavorable opinions of the three VA examiners, for the reason that they provided supporting clinical data and fully and carefully reasoned rationales that are consistent with the underlying evidence of record. In sum, the record is absent medical evidence of or a contention of coronary artery disease or hypertension during service or within one year after discharge from service. Further, the record is absent medical evidence of or a contention of continuity of symptoms of coronary artery disease or hypertension from active service forward. As the preponderance of the evidence shows that the Veteran does not have coronary artery disease, service connection is not warranted for this claimed disability, notwithstanding that the Veteran was exposed to certain herbicide agents, including Agent Orange, during active service in Vietnam. Further, under the specific facts of this case, the preponderance of the evidence is against a medical nexus between the Veteran's current hypertension and any incident of active service or his currently diagnosed PTSD. The preponderance of the probative medical evidence on this point indicates that the Veteran's hypertension is neither caused nor aggravated by his service-connected PTSD. Accordingly, the Board concludes that the preponderance of the evidence is against the claims for service connection for hypertension and coronary artery disease, and that for this reason the benefit of the doubt rule set forth at 38 U.S.C.A. § 5107(b) is not for application in resolution of this appeal. ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for coronary artery disease is denied. ______________________________________________ STEPHEN L. HIGGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs