Citation Nr: 1310451 Decision Date: 03/29/13 Archive Date: 04/09/13 DOCKET NO. 07-27 520 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for cardiac disorder, status post cardiac bypass with residual scarring. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran served on active duty from July 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In November 2009, the Veteran appeared and testified at a Board hearing before a Veterans Law Judge held at the RO. A transcript of the proceeding is of record. In August 2011, the Veteran was notified that the Veterans Law Judge who held the November 2009 hearing was no longer with the Board and he was provided with an opportunity for another hearing, to which he responded he desired to have another hearing before a Veterans Law Judge at the RO. Thereafter, in May 2012, the Veteran appeared and testified at a Board hearing held at the RO before the undersigned Veterans Law Judge. A copy of the transcript of this hearing has been associated with the claims file. A review of the transcript demonstrates that the Veterans Law Judge complied with the requirements set forth in Bryant v. Shinseki, 23 Vet. App. 488, 491-93 (2010). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2). FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's current cardiac disorder (diagnosed as coronary artery disease), which is status post coronary bypass times two with residual scarring, is related to his military service. CONCLUSION OF LAW A cardiac disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1131, 1137, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance Requirements VA's duties to notify and assist claimants in substantiating a claim for VA benefits are set forth in 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete 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 notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present case, notice was provided to the Veteran in July 2005, prior to the initial AOJ decision on his claim. Additional notice compliant with Dingess v. Nicholson, 19 Vet. App. 473 (2006), was provided to the Veteran in January 2007. The Board finds that the notices provided fully comply with VA's duty to notify as to content but not as to timing as the Dingess notice was provided after the initial adjudication of the Veteran's claim. However, the Board finds that any deficiency as to timing has been cured by appropriate notice and subsequent adjudication in August 2007. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (defects in timing of notice may be cured by affording the Veteran appropriate notice and subsequent adjudication). Furthermore, the Board finds that the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. He was told it was his responsibility to support the claim with appropriate evidence and has been given the regulations applicable to VA's duty to notify and assist. Indeed, the Veteran submitted information and evidence in connection with his claim demonstrating his actual knowledge of the need to support his claim with evidence. Thus, the Board finds that the purposes behind VA's notice requirement have been satisfied, and VA has satisfied its "duty to notify" the Veteran, and any error in this regard is harmless. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the veteran has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and attainable evidence, and VA has notified the Veteran of any evidence that could not be obtained. The Veteran has not identified any additional evidence that would support his claim that has not already been obtained. VA, therefore, has made every reasonable effort to obtain all records relevant to the Veteran's claim. 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. The Veteran was afforded VA examination on his claim in November 2006. In addition, the Board obtained VHA medical expert opinions in July 2010 and December 2012. As will be discussed in further detail below, any defects in the medical opinions obtained have been resolved by the December 2012 VHA medical expert opinion. The Veteran was provided an opportunity to submit additional comment and/or evidence in relation to the December 2012 VHA medical expert opinion. No response has been received from him to date. Thus, the Board may proceed to adjudicate the Veteran's claim without prejudice to him. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case. Additional efforts to assist or notify him would serve no useful purpose. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Service connection means that the facts establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Subsection (a) also refers to "each disabling condition...for which [a veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." Walker. A second way to establish direct service connection is set forth in § 3.303(b). In Walker, the Court of Appeals for the Federal Circuit (Federal Circuit) found that, unlike subsection (a), which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). In May 2005, the Veteran filed a claim seeking service connection for "coronary artery disease s/p CABG," which he stated began in July 1967 and was treated in August 1989 to the present. In a statement attached with his claim, the Veteran stated that, in 1967, he began having exertional chest pain with associated premature ventricular contractions with bigeminy that occurred when walking from his quarters to the hospital (less than one mile) and when walking back. He related that over the years he would become extremely dyspneic with exertion, such as digging a hole to plant a small tree, before completing the task and had to rest 10 to 15 minutes. In his forties, the chest pains and dyspnea gradually became more frequent and more intense. Subsequent he was diagnosed with severe coronary artery disease including a 90 plus percent occlusion of the left main coronary necessitating a triple coronary artery bypass graft in 1989. In addition to the left main lesion, there was essentially a total occlusion of the left anterior descending and a 60 to 70 percent occlusive, ulcerative lesion in the right coronary artery. He stated he continued to have exertional angina. In addition, he has hypertension. He stated it is his belief that his coronary artery disease was already present while he was in the military. The official service treatment records do not demonstrate any treatment for chest pains or a diagnosis of coronary artery disease while the Veteran was in service, and the Veteran admitted he did not seek treatment nor did he need treatment in service. At his separation examination in March 1969, however, he reported having pain or pressure in the chest in July 1967 associated with runs of premature ventricular beats. He also reported a history of high blood pressure in September 1956 that required no treatment and his blood pressure was normal thereafter. On physical examination, electrocardiogram (EKG) was normal and chest X-ray was normal. Along with his claim, the Veteran submitted private treatment records from 1989 to 2001 along with duplicate copies of service treatment records. The private treatment records show that the Veteran was admitted to a private hospital on September 1, 1989, with complaints of having had an episode of chest tightness and shortness of breath while walking on the beach the prior weekend, which was relieved with rest. A summary of this hospitalization shows he had a positive treadmill test and was admitted for cardiac catheterization and further treatment. The Veteran reported a positive family history of coronary artery disease and hyperlipidemia. His past medical history was noted to be significant for hypercholesterolemia and glaucoma. On September 1, 1989, he was taken to the CAT lab which showed 95 percent left main coronary stenosis with 100 percent occlusion of his LAD (left anterior descending) artery and severe stenosis in the right coronary artery. Thereafter, he was taken to the operating room for emergency coronary revascularization and had a triple coronary bypass. Post surgically, he had no significant problems and was discharged from the hospital on September 7, 1989. Discharge diagnoses included unstable angina and critical left main coronary stenosis with right coronary stenosis. An October 2001 stress echocardiogram report was abnormal but showed that a moderately-high workload was achieved. There was mild mitral regurgitation (1+). The stress results show the Veteran achieved a Target Heart Rate of 133 beats per minute (maximum predicted heart rate was 156 bpm). Stress duration was 420 seconds and METS achieved was 11. It was noted that the Veteran exhibited chest pain during exercise and there was a maximum 1.5mm ST segment depression. Normal protocol was used. Resting electrocardiogram was normal. The left ventricle was normal in size, and the ejection fraction was normal (60 to 65 percent). The Veteran underwent VA examination in November 2005. The examiner noted the Veteran's reported history of having angina with bigeminy in service while walking to the hospital in the mornings and that he told them about this on his exit physical examination. The examiner also noted that the Veteran never saw anyone on active duty about this, and the separation examination did not indicate any problems with his heart. The Veteran reported that since service, if he exerts himself, he has shortness of breath and chest tightness. He reported he sought treatment in 1989 and had a triple bypass at that time. He also reported that he did well until a few years ago when he had more chest pains on exertion and shortness of breath. He saw a cardiologist who did a treadmill with echo in 2011 that showed 11 METS. Present medications included Topolol XL 50 mg per day, Lipitor 40 mg at bedtime, and aspirin 81 mg. The examiner noted that he went through the questionnaire with the Veteran concerning his heart. The Veteran denied syncope. As far as angina is concerned, any exertion will cause chest pain. He said he can do six minutes on a flat treadmill at three miles per hour, and he will get angina. He gets shortness of breath easily and has fatigue. He denied dizziness. He denied having a myocardial infarction. Physical examination revealed a well-developed, well-nourished white male in no distress. He was mentally alert. His blood pressure sitting was 163/84 and pulse was 59. Blood pressure standing was 170/84 and pulse was 56. His blood pressure lying down was 154/77 and pulse was 54. Diagnostic laboratory results were all normal. Chest X-ray showed the heart to be normal size, no inflammatory disease or any other problems noted. It did show that the Veteran had cardiac surgery in the past. The diagnosis of was status post heart bypass procedure X3 with scars. As far as providing a medical nexus opinion, the examiner stated that the Veteran required no medical attention while he was on active duty in the military concerning his heart. Separation physical examination was normal. EKG was normal. Thus, it would be pure speculation to say that any problems while in the military caused or aggravated the problems he has now. The Veteran submitted additional private medical records showing that in January 2006 he underwent cardiac catheterization again because of worsening angina. He reported he develops chest pain with exertional activity that usually resolves with rest but he occasionally takes a nitroglycerin tablet which helps. He denied significant shortness of breath, palpitations, orthopnea, paroxysmal nocturnal dyspnea and extremity edema. His symptoms of angina had been more noticeable over the prior four months. The discharge summary indicates he was found to have normal left ventricular function. He had complex coronary anatomy. Following arteriography, a stent was placed in the bifurcation lesion in the distal right. Just prior to placing the stent, he developed fairly significant chest pain requiring a single nitroglycerin for relief. This was associated with ST depression in lead II. Over all, he tolerated the procedure well. The final diagnoses were low-level exertional angina, dyslipidemia, and mild hypertension. On April 5, 2006, the Veteran was again hospitalized. It was noted that he had undergone cardiac catheterization the day before as well as in January having underwent coronary arteriography and stenting of his distal right coronary artery in a heavily diseased and calcified segment. Shortly after this procedure, he developed hematuria and work up revealed an invasive bladder tumor for which he underwent cystoprostatectomy with lymph node dissection in early March. He was readmitted on March 17 with urosepsis and treated. It was noted that, at the time of the cystectomy, he developed severe angina and had positive cardiac enzymes. His chest pain was also associated with marked electrocardiographic change. He has continued to have low level angina. His catheterization demonstrated severe restenosis in the distal right coronary artery. He had extensive collaterals. The left internal mammary artery to the left anterior descending was closed. His left anterior descending filled by right ventricular marginal collaterals. His posterolateral branch was filled primarily by collaterals from the circumflex system. Because of the severe restenosis, it was recommended that he undergo coronary artery bypass grafting. The night before admission, he developed angina, which was not unusual for him; however, he then developed fever with a temperature of 102 with chills. He came to the emergency room where he developed severe unstable angina with marked electrocardiographic changes of 5 mm of anterolateral ST depression. His pain could not be relieved, and he was taken to the cardiac catheterization lab where he underwent acute intervention with an intra-aortic balloon pump and balloon dilatation of his diffusely stenotic right coronary artery. On April 17th, he underwent a redo coronary artery bypass grafting x3 with saphenous vein graft to the distal left anterior descending artery, the posterior descending and the posterolateral branches of the right. On postoperative day 2, the Veteran developed a right hemothorax that was treated with placement of a chest tube, which was removed on postoperative day 7. The Veteran's discharge diagnoses included coronary artery disease, status post redo coronary artery bypass grafting. The Veteran testified at a Board hearing held in November 2009 that, while in the Air Force, he would walk to the hospital about a half to three-quarters of a mile away, and he would develop premature ventricular contractions in bigeminy with associated chest pain. He would have to stop and rest for about five minutes and the PVCs and chest pain would go away. Then he could finish walking to the hospital. He admitted that he did not check this out with anybody nor did he have any tests done. He stated that, although the separation EKG was normal, people can have a normal EKG and an abnormal EKG with exercise so he personally discounts this. He further testified that, after service, if he would do any exertion such as planting a tree, he would have to stop and lie down because of shortness of breath, and that continued until he had the beginning of chest pain probably in 1988. In addition, upon question about his medical background, the Veteran stated that he went to medical school, residency for four years in internal medicine, two years in the military, and then spent about 30 years in private practice. His specialty was internal medicine. In April 2010, the Board requested a VHA medical expert opinion from a cardiologist, which was received in July 2010 from the Chief of the Cardiology Section at the McGuire VA Medical Center in Richmond, Virginia. After reviewing the claims file, the VHA cardiologist noted the Veteran's military service as a medical officer and his report in March 1969 of chest pressure with accompanying premature beats while walking. He also noted that the Veteran sought medical attention in 1989 and was noted to have significant coronary artery disease resulting in three vessel coronary artery bypass grafting. Notably, an exercise stress test in October 2001 noted the Veteran's ability to achieve 11 METS. Unfortunately, he redeveloped angina that was progressive and resulted in the need for repeat coronary artery bypass grafting in 2006. In rendering an opinion, the VHA cardiologist opined that it is unlikely that the episodes of symptomatic premature beats that occurred during active duty represented significant coronary artery disease. In providing a rationale, the VHA cardiologist stated that, in young and middle aged adults, premature beats have no particular prognostic significance. Had there been symptomatic angina in 1969 supporting the very unusual presence of symptomatic coronary artery disease in a man of young age, it is extremely unlikely that the Veteran would have been able to remain compensated for the next 20 years on apparently minimal medical therapy. Subsequent cardiac evaluations have excluded any congenital coronary artery anomalies or other structural heart disease that are far more likely causes of cardiac chest pain in a healthy young military officer than atherosclerotic heart disease. The medical journal references in the claims file regarding the finding of early, asymptomatic atherosclerosis in young soldiers killed in the Korean conflict have been interpreted by the medical community to reflect the initiation of the atherosclerotic processes earlier than previously suspected in the American population as a whole, not a selective risk in a military population. Such findings are unfortunately generally present in both the military and civilian population. The VHA cardiologist concludes by saying that there is not adequate information provided in the records available in the claims file regarding typical coronary artery disease risk factors that may have been present in the Veteran subsequent to military discharge that may have been significant contributors to the coronary artery disease that became evident in 1989. Thus, it remains unlikely that the Veteran had the onset of symptomatic atherosclerotic coronary artery disease during active duty between 1967 and 1969. In response to this medical opinion, the Veteran submitted a statement in which he disagreed with the VHA cardiologist's opinion. He stated that the VHA cardiologist noted an incident of chest pressure when in fact there were multiple episodes of central chest pain not pressure brought on by exertion. Also, people with coronary artery disease can have normal EKGs at rest that become abnormal with exertion. The Veteran opined that it is at least as likely as not that he had significant coronary artery disease when he was on active duty. In May 2012, the Veteran was afforded a new hearing before the undersigned Veterans Law Judge at the RO. At the hearing, the Veteran presented the same arguments against the VHA cardiologist's opinion that he did in the prior statement. He also related similar testimony as at the prior hearing that, after service, he would get extreme shortness of breath and feel faint upon exertion like digging a hole to plant a tree and he would have to lie down in order for it to go away. He acknowledged that paroxysmal ventricular contractions (PVCs) in and of themselves do not indicate coronary artery disease but that, when they come on with exertion and atypical anginal pain, they deserve evaluation, which he did not have (although unlike previously when he reported he did not seek treatment, he stated that a stress EKG was not done probably because the small hospital he was at did not have a treadmill indicating he did seek treatment for his complaints in service). The remainder of his testimony did not add anything new to what had previously been provided. In September 2012, the Board requested another VHA medical expert opinion from another cardiologist. In making the opinion request, the Board specifically asked that the VHA medical expert consider the following: ? Service treatment records which show that on separation examination in March 1969, the examiner indicated that the Veteran had pain or pressure in his chest in July 1967 associated with runs of premature ventricular beats, no treatment was required and the EKG was normal. On the medical history dated that same month, the Veteran indicated he had pain or pressure in his chest. A chest x-ray in March 1969 was normal. ? The Veteran's assertions that during service he had multiple episodes of central chest pain brought on by exertion and has had a continuity of heart symptoms since service. ? The Veteran's opinion as a medical doctor that the fact that his EKG was normal at the time of separation is not dispositive as people with coronary artery disease can have normal EKGs when they are at rest. ? The fact that other than the Veteran's statements, the medical evidence of record first shows a heart condition in September 1989, which is 20 years after the Veteran was separated from service, when he underwent a triple coronary bypass. Records dated in 1989 noted a history of chest pain for the past several weeks. ? The VHA examiner's opinion that if the Veteran had symptomatic angina during service it is extremely unlikely that the Veteran would have remained compensated for the next 20 years on minimal therapy. ? Medical literature which shows the initiation of atherosclerotic processes among younger people and the fact that the Veteran was approximately 30 years old during service. An opinion was received in December 2012 from a cardiologist at the VA Medical Center in Cincinnati, Ohio. In her opinion, this cardiologist acknowledged that it is well documented that the histologic precursors of coronary artery disease may be present in arteries of children and young adults, especially those with a positive family history of coronary artery disease or coronary artery disease risk factors. Some of this data comes from autopsy studies of military personnel killed in combat but there is no data that military service per se is a risk factor for development of premature coronary artery disease. She also acknowledged that it is true that neither a chest X-ray nor a normal resting EKG at the time of the Veteran's discharge from the service excludes the possibility that he had significant obstructive coronary artery disease at that time. Both studies may be normal in a patient with chronic stable angina. She goes on to state, however, that the key question is whether it is possible that a patient with symptomatic coronary artery disease at age 30 would continue to have symptoms continuously for the next 20 years without any manifestation of morbidity (acute coronary syndrome or acute myocardial infarction) or mortality in the absence of aggressive medical therapy. The Framingham Study reported that the probability of a "coronary attack" within eight years after the onset of angina was 30 percent in men presenting between the ages of 29 and 44 years. Angina was relatively rare before age 50 and the events were too few to definitely ascertain whether there is an increased risk of death associated with angina pectoris in persons who develop it before age 50, compared with men presenting in middle age. Angina in men over the age of 50 was associated with about 4 percent per year mortality. In men over the age of 50 presenting with either uncomplicated angina, or angina following a myocardial infarction, 40 percent had died after 11 years. (Am J Cardiol 1972; 29:154). Other long term natural history studies also indicate an adverse prognosis associated with angina. In White's longitudinal study of 500 patients with angina published in 1943 (JAMA 123:801), most patients had died at the 25 year follow up; the average survival was 9.7 years. Richards reported a mortality rate of 41 percent at 10 years (J Chronic Dis 1956; 4:423). In a long term follow up study reported in 1952 (Block et al. JAMA 150:259), average annual mortality was 9 percent; 5 year mortality was 58.4 percent. However, a study in military personnel published in 1969 (Zukel WJ, et al. AM Heart J 78:159) found a somewhat lower overall annual mortality rate of 3 percent per year; but even in the subgroup of men age 30 to 39, survival was still significantly reduced (71 percent at 15 years). Thus, this cardiologist stated that, if the Veteran's chest pain syndrome during his military service was indeed due to obstructive coronary artery disease, it seems very unlikely, but not impossible, that it would remain stable, unchanged, and without further manifestation of progression to acute coronary syndrome, acute myocardial infarction, or sudden death for the next 20 years. Furthermore, if the Veteran did indeed have symptomatic coronary artery disease at age 30, this characterizes him as having "premature coronary artery disease" which is usually associated with strong family history (which he did not report). The clinical presentation of coronary artery disease in younger patients is different from that in older patients, in that a higher proportion of young patients do not experience angina, and, in the majority of cases, an acute coronary syndrome that progresses rapidly to myocardial infarction (most often an ST elevation myocardial infarction) if left untreated is the first manifestation of coronary heart disease. The association of the Veteran's chest pain at age 30 with ventricular extopy is not helpful in determining if the chest pain was due to significant coronary artery disease, as random extopy is common in healthy young adults and carries significant prognostic weight only if associated with overt ischemia, which was not apparent in this case. In summary, the cardiologist stated that this Veteran's chest pain at age 30 may have been a manifestation of premature coronary artery disease, but, if so, it was distinctly unusual in its presentation and course. While there is no way to definitively exclude the possibility that this Veteran's chest pain at age 30 was a manifestation of significant coronary artery disease that remained quiescent for the next 20 years, it is highly unlikely. The Board must evaluate this evidence in rendering a decision, including an analysis of the credibility and probative value of the evidence, accounting for evidence which 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); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, 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 or adequate quotation from recognized medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, the Board must account for evidence that 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. Nevertheless, when, after considering all the evidence, a reasonable doubt arises regarding a determinative issue, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. While the Board may not reject a favorable medical opinion based on its own unsubstantiated medical conclusions, Obert v. Brown, 5 Vet. App. 30, 33 (1993), the Board does have the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence," Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the Court has stated, in pertinent part: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator . . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another, provided that it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). A physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion. Prejean v. West, 13 Vet. App. 444, 448-99 (2000). The Board is not bound to accept an opinion based on history provided by the appellant and on unsupported clinical evidence. See Black v. Brown, 5 Vet. App. 177, 180 (1993). An opinion based upon an erroneous factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A medical opinion based on speculation, without supporting data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 5 Vet. App. 104, 145 (1999). After considering all the evidence of record, the Board finds that service connection is not warranted under 38 C.F.R. § 3.303(a). The evidence demonstrates the Veteran has a current disability diagnosed as coronary artery disease, status post three vessel coronary artery bypass grafts in 1989 and 2006. The service treatment records are silent for any treatment for or diagnosis of coronary artery disease during service. The Veteran reported on his March 1969 separation examination that he had pain or pressure in the chest in July 1967 associated with runs of premature ventricular beats but no heart abnormality was noted. However, the Veteran has related that he had multiple episodes of shortness of breath and chest pain while walking from the barracks to the hospital he worked at while in the Air Force. Consequently, the evidence demonstrates a current disability and in-service symptoms. The question remains, however, whether the in-service symptoms reported by the Veteran were signs or symptoms of his current coronary artery disease. The Board notes that the Veteran is a physician with over 30 years of practice in internal medicine. Consequently, the Board finds that he is competent to provide statements medical in nature. The Board acknowledges that the Veteran has opined that it is at least as likely as not that he had significant coronary artery disease when he was on active duty and that this opinion is based upon his symptoms in service, his diagnosis now and medical literature that he has submitted in support of his claim. Contrary to his opinion are the two VHA medical expert opinions obtained from VA cardiologists in July 2010 and December 2012. As for the November 2005 VA examiner's statement, the Board finds that this statement is not adequate for rating purposes because the examiner did not render a conclusive opinion. Rather he only stated that it would be pure speculation for him to say any problems in the military caused or aggravated the problems the Veteran has now. He did not offer significant further rationale for this conclusion. Consequently, the Board assigns no probative value to the November 2005 VA examiner's statements. As to the VHA medical opinions, the Board agrees with the Veteran that it appears that the July 2010 cardiologist did not take into consideration the Veteran's current statements that he had multiple episodes of PVCs with shortness of breath and chest pain but rather only considered that he had one episode as that is how it is noted on the Veteran's separation examination. Thus, the Board finds that the probative value of this medical opinion is diminished. However, in so far as it agrees with the December 2012 VHA medical opinion, the Board finds that it has probative and persuasive value. The Board finds that the December 2012 VHA medical opinion is highly probative and persuasive as it is clearly based upon the entire record, including the Veteran's statements and arguments, as well as supportive medical literature given that the VA cardiologist cites multiple sources to support her opinion. Furthermore, this cardiologist's medical opinion is corroborated by the July 2010 cardiologist's opinion with regard to the likelihood the Veteran would have gone 20 years without any acute coronary event if his symptoms reported to have occurred in service were the result of coronary artery disease. The Board acknowledges that the cardiologist who rendered the December 2012 medical opinion was not able to completely rule out the possibility that the Veteran's symptoms in service were evidence of "premature coronary artery disease;" however, she clearly believed that it was "highly unlikely" that this was the case given that, for 20 years after service, his symptoms were quiescent and did not require aggressive medical therapy. The Board notes that a medical professional does not have to provide an opinion that is 100 percent certain but, rather, only has to meet the "likelihood" measure. Meaning, it is the probability of a relationship that is asked for in obtaining a medical opinion, not a beyond doubt measure. Consequently, even if there is a possibility of a nexus, so long as the probability is less likely than not, the preponderance of the evidence is against the claim. After weighing the July 2010 and December 2012 VHA medical opinions against the Veteran's medical opinion, the Board finds the VHA medical opinions, especially the December 2012 opinion, to be more probative and persuasive as to whether there is a relationship between the Veteran's current coronary artery disease and his reported in-service symptoms. Although the Veteran submitted treatise evidence regarding studies done on young adults killed during the Korean conflict, the July 2010 cardiologist stated that these studies were generally interpreted by the medical community to apply to the American population as a whole. In her December 2012 opinion, the cardiologist acknowledged that the histologic precursors of coronary artery disease may be present in arteries of children and young adults and that some of this data comes from autopsy studies of military personnel killed in combat, presumably referring to the studies submitted by the Veteran. She, however, found that the key question in the Veteran's case is whether it is possible for a patient with symptomatic coronary artery disease at age 30 would continue to have symptoms continuously for the next 20 years without any manifestation of morbidity (acute coronary syndrome or acute myocardial infarction) or mortality in the absence of aggressive medical therapy. As did the July 2010 VHA medical opinion, she found this to be highly unlikely based upon medical studies regarding morbidity rates of men who had angina, which studies clearly demonstrate that the morbidity rate is much less than 20 years. Consequently, the Board finds that the more probative and persuasive medical evidence of record is against finding that there is a nexus between the Veteran's current coronary artery disease, status post coronary artery bypass grafts, and his complaints during service. Thus, under 38 C.F.R. § 3.303(a), the preponderance of the evidence is against the Veteran's claim for service connection for his coronary artery disease, status post coronary artery bypass grafts. The Board must also consider whether service connection for a chronic disease based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) is warranted as coronary artery disease, also known as arteriosclerosis, is a chronic disease listed in 38 C.F.R. § 3.309(a). In the present case, the Board finds that the evidence fails to demonstrate either a chronicity of coronary artery disease in service or for many years after service. The service treatment records are silent for a diagnosis of coronary artery disease. Although the Veteran reported having pain or pressure in his chest in July 1967 associated with runs of premature ventricular beats at his separation examination in March 1969, no abnormality was found on examination. Consequently, the Board finds that chronicity of coronary artery disease in service is not established. Furthermore, the Board finds that a continuity of symptoms since service is not shown. Specifically the Board notes that the Veteran has testified that, after service, he would have shortness of breath on exertion when doing something like digging a hole to plant a tree, and he would feel faint and have to lay down until this passed. He did not report continuing to have PVCs or having chest pain after service. In fact, at the November 2009 Board hearing, the Veteran testified that he did not have the beginning of chest pain until probably in 1988. (See transcript p. 4.) Also, at the September 2012 Board hearing, the Veteran testified he did not receive treatment until 1989 and that he had been having symptoms, chest pains, again for about a year. (See transcript p. 5.) The Board notes there are no medical records demonstrating the Veteran received treatment for coronary artery disease prior to 1989. Based upon the foregoing, the Board concludes that the preponderance of the evidence is against finding that there was chronicity of coronary artery disease in service or that there was a continuity of symptomatology after service. Consequently, service connection pursuant to 38 C.F.R. § 3.303(b) is also not warranted. Finally, the Board notes that 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. §§ 1112, 1133 and 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307 and 3.309(a). As previously noted, arteriosclerosis is a chronic disease listed in § 3.309(a). The Board finds, however, that the evidence fails to demonstrate that the Veteran's coronary artery disease had manifest to a compensable degree within one year of his discharge from active duty. Rather the evidence shows the Veteran was essentially non-symptomatic until shortly before September 1989 when he underwent his first coronary artery bypass graft, which was more than 20 years after his discharge from service. Consequently, the preponderance of the evidence is against finding that presumptive service connection for the Veteran's coronary artery disease is warranted based upon the presence of a chronic disease. In conclusion, the Board finds that the preponderance of the evidence is against finding that service connection for the Veteran's coronary artery disease, status post coronary artery bypass grafts, is warranted. The preponderance of the evidence being against the Veteran's claim for service connection, the benefit of the doubt doctrine is not applicable. Consequently, the Veteran's claim must be denied. ORDER Entitlement to service connection for cardiac disorder, status post cardiac bypass with residual scarring is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs