Citation Nr: 1312328 Decision Date: 04/15/13 Archive Date: 05/02/13 DOCKET NO. 10-26 923 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for sinus bradycardia, with postoperative residuals of permanent pacemaker implantation. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active service from September 1952 to September 1973. This matter comes before the Board of Veterans' Appeals (Board) from a November 2009 decision of the VA RO in Waco, Texas. 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) (West 2002). FINDINGS OF FACT 1. The Veteran acute episodes of bradycardia during a brief during active service that were physiologic, but not pathologic, in nature. 2. Chronic pathologic sinus bradycardia is first demonstrated decades after active service in 2003, when the Veteran related a history of syncope of only 5 or 6 years duration, and it is unrelated to the Veteran's military service and any incidence therein, including acute episodes of sinus bradycardia in the 1960s; and it is not shown or contended that sinus bradycardia is caused or aggravated by service-connected prostatitis, hypercholesterolemia, or inguinal hernia repair. CONCLUSION OF LAW The criteria for service connection for sinus bradycardia, with postoperative residuals of permanent pacemaker implantation, are not met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107(b) (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) imposes on VA a obligation to notify claimants what information or evidence is needed for claim substantiation prior to an initial unfavorable decision but, if not, any such error may be cured by providing notice followed by readjudication Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); Mayfield v. Nicholson, 20 Vet. App. 537 (2006) (Mayfield III), citing Mayfield II, 444 F.3d at 1333-34. In service connection claims, the VCAA imposes a duty to inform a claimant of all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Also, the VCAA imposes a duty to assist claimants by making reasonable efforts to get needed evidence. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Here, the RO provided the Veteran with notice of the elements required for service connection and of the respective evidence gathering duties by letter in October 2008, prior to the initial November 2009 adjudication of the claim for service connection for sinus bradycardia, with postoperative residuals of permanent pacemaker implantation. It also provided notice of how disability ratings and effective dates are assigned. Dingess, Id. Accordingly, the Board finds that VA satisfied its duties to notify the Veteran in this case. As required by 38 U.S.C.A. § 5103A, VA has made reasonable efforts to identify and obtain relevant records for claim substantiation. The Veteran's declined to testify in support of his claim. In correspondence in September 2009 the Veteran reported that he desired to have his case decided based on the information that VA had on file. However, he also stated that if the claim could not be allowed, he "would request an opportunity to meet your Board." In this regard, VA may not make a pre-determination decision in order to facilitate a request for a hearing. Moreover, in his subsequent VA Form 9, Appeal to the Board, in June 2010 he reported that he did not want a Board hearing. The Veteran's private treatment records have been obtained. The Veteran has been given a VA examination as to the service-connection claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). An addendum was obtained in August 2009 to the July 2009 examination. The adequacy of the examination and medical opinion, as well as the addendum, obtained have not been challenged. The Board is entitled to assume the competence of a VA examiner and the adequacy of a VA medical examiner's opinion unless either is challenged. See Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011); Bastien v. Shinseki, 599 F.3d 1301, 1307 (Fed.Cir. 2010); Rizzo v. Shinseki, 580 F.3d 1288, 1290-91 (Fed. Cir. 2009); and Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); and Hilkert v. West, 12 Vet. App. 145, 151 (1999). The Veteran's available service treatment records (STRs) have been obtained. As to this, repeated efforts were made to obtain records from Wilford Hall and from the U.S. Air Force Academy. In June 2009 the RO made a formal finding of the unavailability of records from Wilford Hall Medical Center for the period from October 1, 1973, to December 31, 1981. It was stated that all procedures to obtain the records were documented in the file and all efforts had been exhausted and based on this it was concluded that that the records were not available. In a September 2009 letter the Veteran reported that he had personally contacted Wilford Hall Medical Center on three occasions and the National Personnel Records Center (NPRC) twice and on each occasion was told that the records did not exist or were not available. He stated that in 2009 he had submitted "original copies" of his medical records which clearly defined his medical condition from the time he entered military service until 1981 when he left San Antonio and he had received no subsequent treatment at Wilford Hall. Thus, all information pertaining to his medical treatment that VA had requested was contained in the records he had submitted to the RO in February 2009. In a September 2009 RO letter the Veteran was informed of the steps taken by the RO to obtain records from Wilford Hall Medical Center, including three requests prior to receiving information that there were no records available. In an October 2009 RO letter the Veteran was informed that a response had not been received for the Veteran's records at the U.S. Air Force Academy. It was noted that the Veteran, by letter earlier that month, had requested that the RO make a decision based on the evidence already on file. Thus, the RO was proceeding to adjudicate his claim without those records. There was no subsequent request to obtain those records. As there is neither indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board finds these actions have satisfied VA's duty to assist and that no additional assistance is required. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Background Examination for enlistment in September 1952 revealed no pertinent abnormality. In September 1960 the Veteran complained of chest pain. An examination was essentially negative and his blood pressure was 128/60. It was indicated that chest X-rays revealed an enlarged 4th rib. An EKG in August 1968 revealed sinus bradycardia. The Veteran's June 1973 examination for service retirement found no pertinent abnormality and an EKG was normal. The Veteran was hospitalized in July and August 1973 for repair of a right inguinal hernia. On physical examination his pulse was 60. A cardiac examination revealed sinus bradycardia without murmurs, rubs or gallops or evidence of cardiomegaly. His serum cholesterol and triglyceride levels were noted to be moderately elevate. The Veteran was hospitalized at the Mayo Clinic in August 2003 for implantation of a pacemaker. It was noted that he had a history of presyncopal episodes over the last five to six years, especially when standing up. These were associated with lightheadedness that resolved after walking. Recently, the episodes had become more severe and severe. An August 2003 Holter monitor revealed profound sinus bradycardia, with a heart rate of 35 beats per minute, an average heart rate during the day of 41 beats per minute, and a maximum heart rate of 51 beats per minute. His average heart rate when sleeping varied from 33 to 39 beats per minute. An August 2003 EKG revealed a structurally normal heart with mild left ventricular hypertrophy, and a normal ejection fractions but mild bi-atrial enlargement with some tricuspid bowing. During an echocardiogram he had profound bradycardia with periods of second degree atrioventricular block, Mobitz type II. The Veteran was hospitalized at the Heart Hospital of Austin in May 2008 because of a pacemaker malfunction. It was noted that his syncope was likely related to his significant sinus node dysfunction and failure of his atrial lead to function properly. On VA examination in July 2009 the Veteran's claim file was reviewed. It was observed that a 1960 progress noted indicated that the Veteran had chest pain but a cardiac examination was essentially negative with blood pressure of 128/60 and not mention as to the pulse rate. An August 1968 EKG revealed normal sinus rhythm and a ventricular rate of 45 with a summary of evaluation of a normal record with sinus bradycardia. His service discharge physical in June 1973 noted that an EKG was normal and related no history of any symptoms of arrhythmia. Further evaluation of the progress notes shows no other episodes of chest pain or bradycardia. It was noted that the Veteran reported having had bradycardia during service with a history of three (3) episodes of near syncope and having been seen on sick call with a diagnosis of heat casualty. He was found to have a bradycardic heart rate but was told that was because of his good physical shape. He did well until about 2003 when he started having sickly episodes, with a fall at home. A subsequent evaluation found he had symptomatic bradycardia and an EKG showed sinus bradycardia at a rate of 35 beats per minute. He had a Holter monitor in August 2003 when his average heart rate during the active hours of the day varied from 41 to 51 beats per minute. The average heart rate during sleep varied from 33 to 39 peats per minute. He had a stress test that was normal. He had an echocardiogram in August 2003 that showed a structurally normal heart other than mild left ventricular hypertrophy, and a normal ejection fraction. He had an incidental finding during the echocardiogram of profound sinus bradycardia with periods of second degree atrioventricular block, type Mobitz II. He subsequently had a pacemaker implant inserted at that time with significant improvement and resolution of his syncopal episodes. He had a pacemaker malfunction and a second implant in 2005 and had been doing well since then. The examiner noted that the Veteran had been able to engage in his usual daily activities from the time of his military discharge in 1973 until 2003. The diagnosis was bradycardia associated with second degree heart block, Mobitz type II. The examiner noted that an opinion would be requested from a cardiologist as to cause and effect of whether a bradycardia on EKG in 1968 could result in need for a pacemaker implant in 2003. An August 2009 addendum to the July 2009 examination stated that during service the Veteran underwent pre-operative evaluation for elective herniorrhaphy in 1969 and upon examination the medical note stated "heart rate 45, sinus bradycardia, normal reading." There were no cardiovascular complaints through service or afterwards until 1997, at age 62. In 2003, the Veteran gave a history of fainting spells "for 6 years," i.e., beginning at age 62. A 2003 work-up revealed "profound" sinus bradycardia of 35 beats per minute. During an echocardiogram in 2003, second degree atrioventicular block, type Mobitz II, was noted. The Veteran was diagnosed with sick sinus syndrome, along with intermittent second degree atrioventricular block, Mobitz II. He also had dyslipidemia, impaired fasting blood sugar, and later on a diagnosis of diabetes mellitus type II in 2005. The opinion was that the Veteran's sinus asymptomatic bradycardia noted during service was not pathologic but physiologic, reflecting a healthy, conditioned soldier. At age 62, he developed episodes of syncope caused by 2nd degree atrioventricular block causing pathologic bradycardia incidentally noted while undergoing an echocardiogram in 2003. Atrioventricular block "as a result diseased his bundle along with sick sinus syndrome." There was no relation between the asymptomatic, physiologic sinus bradycardia in service to the pathologic (aging heart related) bradycardia with syncope caused by atrioventricular block, type Mobitz II, and sick sinus syndrome. In a January 2009 statement the Veteran reported that in the mid-sixties, during service at Lackland Air Force Base in San Antonio, Texas, he started having periods of dizziness which lasted from mere moments to several minutes and would require him to pause long enough to regain equilibrium. He had not placed too much importance to these episodes, which he had thought were weather related or some kind of condition that would clear up. However, the episodes became more frequent and on several occasions he went on sick call to determine if an underlying condition existed. He felt it should be noted that the clinics for the sick calls were satellite locations away from Wilford Hall Hospital and the physicians were often completing medical training. In each case, no obvious cause for his symptoms was found but in each case the physician mentioned that he had a very low pulse rate. They indicated that this was not uncommon for athletes and those in very good physician condition. The Veteran further reported that due to being in Training Command, diet and fitness were required, but he was not an athlete by any stretch and even had difficulty running the mile each year in the allotted time. He recalled several instances when his resting heart rate was under 50 which "they" did not seem concerned about. General information now available indicated that his heart was not beating at a rate sufficient to provide him with adequate oxygen and this was certainly the cause of his periods of dizziness. Dr. F. K. of the Mayo Clinic had told the Veteran that even world class athletes did not have heart rates that low. The Veteran felt that at some point medical personnel should have referred him to cardiology to ascertain whether or not there was an underlying reason for his problem. Due to the transitory nature of the physicians in training during service no one ever saw the same doctor on subsequent visits, and continuity of treatment was almost impossible. If physicians during service had placed him on a heart monitor it would have been found that he had a definite problem. Treatments were available but none were ever recommended. He believed that his episodes of dizziness during service were a precursor to his present condition and worsened over the next several years until it reached the point of becoming fainting spells and finally resulted in the implantation of a cardiac pacemaker in 2003 at the Mayo Clinic. He attached information obtained from Internet sites of the Mayo Clinic. The information from the Mayo Clinic website indicates, in pertinent part, that symptoms of bradycardia included dizziness, near-fainting or fainting (syncope), fatigue, and shortness of breath. A resting heart rate of less than 60 beats per minute could be normal for some people, particularly healthy, young adults and trained athletes and in such cases it was not considered a health problem. A number of conditions could cause signs and symptoms of bradycardia. A physician could order tests to help establish a link between bradycardia and symptom, and identify the condition that might be causing bradycardia. A Holter monitor, a portable EKG, was recommended. The Veteran's hand-written note next to this entry was that "I think this would have solved the problem!" Principles of Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain conditions, arteriosclerosis and cardiovascular-renal disease, including hypertension, will be presumed to have been incurred in service if manifested to a compensable degree within 1 year after service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309(a). Previously, caselaw allowed for continuity of symptomatology to be used as a basis to grant service connection for diseases not contained in the list of chronic diseases at 38 C.F.R. § 3.309(a). See Savage v. Gober, 10 Vet. App. 448, 495-96(1997). Recently the United States Court of Appeals for the Federal Circuit in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) explicitly overruled this principle, holding that continuity of symptomatology could establish service connection only for the disorders specifically listed as chronic at 38 C.F.R. § 3.309(a) but not for other disorders which might be chronic in a medical sense, much less for non-chronic disorders. In Walker, 708 F.3d 1331 (Fed. Cir. 2013) the Court interpreted the interplay between 38 C.F.R. §§ 3.303(b), 3.307(a), and 3.309(a) as permitting service connection for chronic diseases listed at 38 C.F.R. § 3.309(a) in two circumstances. First, when a listed chronic disease is shown inservice or within a presumptive period under 38 C.F.R. § 3.307 which requires that it be "well diagnosed beyond question" or "beyond legitimate question." The second circumstance is when a condition is noted during service or a presumptive period but is not shown to be chronic or when a diagnosis of chronicity may be legitimately questioned such that a chronic disease is not shown. In such a case, proven continuity of symptomatology then establishes the nexus with the current existence of the listed chronic disease and also confirms the existence of listed chronic disease during service. Walker, Id. On the other hand, for diseases not listed as a chronic disease at 38 C.F.R. § 3.309(a), service connection must be established under 38 C.F.R. § 3.303(a) (and not § 3.303(b)) which requires that the "nexus" requirement be satisfied (whereas, § 3.303(b) provides for presumptive service connection or service connection by use of continuity of symptomatology. See Walker, Id. Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Reasonable doubt will be favorably resolved and it exists when there is an approximate balance of positive and negative evidence. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Analysis "[T]here is no categorical requirement of 'competent medical evidence ... [when] the determinative issue involves either medical etiology or a medical diagnosis'." Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir. 2009) and Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007)); see also 38 U.S.C.A. § 1154(a) and 38 C.F.R. §§ 3.159 (defining competent and lay evidence) and 3.307(b) (addressing lay evidence as to chronicity and continuity of symptoms). Lay evidence may, in some circumstances, establish a medical diagnosis, causation or etiology, i.e., when a layperson (1) is competent to identify the medical condition, (2) is reporting a contemporaneous medical diagnosis, or (3) describes symptoms at the time which supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313 (Fed.Cir. 2009) (overruling broad holdings in Buchanan v. Nicholson, 451 F.3d 1331 (Fed.Cir. 2006) and Jandreau, Id., that competent medical evidence is required when the determinative issue is either medical etiology or medical diagnosis. See also King v. Shinseki, 700 F.3d 1399 Fed.Cir. 2012); 2012 WL 6029502 (C.A.Fed.) (confirming that Davidson, Id., overruled the broad holdings in Buchanan, Id., and Jandreau, Id.). The credibility of lay evidence may not be refuted solely by the absence of corroborating medical evidence, but it is a factor. Davidson, 581 F.3d at 1316 (Fed.Cir. 2009). Other credibility factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). Mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Once lay evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994). Initially, the Board notes that the evidence does not establish that the Veteran now has arteriosclerosis or cardiovascular-renal disease, including hypertension. Further, it is not shown or contended that sinus bradycardia is caused or aggravated by his only service-connected disabilities of prostatitis, hypercholesterolemia, or inguinal hernia repair. Although there is an isolated notation of sinus bradycardia in 1968 and again about five years later in 1973, there is a lapse of any contemporaneous evidence of sinus bradycardia until 2003, almost 30 years after the Veteran's active service. The STRs fail to demonstrate the combination of manifestations sufficient to identify chronic sinus bradycardia of pathologic origin, as opposed to being physiologic, during active service. In this regard, 38 C.F.R. § 3.307(b) provides that unless the clinical picture is clear otherwise, consideration will be given as to whether an acute condition is an exacerbation of a chronic disease. On the other hand, 38 C.F.R. § 3.303(b) states that to establish the existence of chronic disease inservice there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic and when the disease identity is established there is no requirement of evidentiary showing of continuity. Here, however, bradycardia is not a chronic disease listed at 38 C.F.R. § 3.309(a) and the STRs, as well as the evidence as a whole, does not establish the existence of any chronicity of pathologic bradycardia inservice. As noted by the recent VA examiner, there were no further complaints or treatment for sinus bradycardia for many years after service. Moreover, when first seen after service for sinus bradycardia the Veteran reported during his initial hospitalization at the Mayo Clinic in 2003 that he had had the onset of syncope, which has been the predominate symptom of his bradycardia, for only the last five or six years. "[T]he more contemporaneous the evidence, the greater [the] probative value and credibility than can be attached to that evidence, especially when later-dated testimony [] and statements were generated for pecuniary purposes ... 'memory hinges on recency', earlier statements are generally more trustworthy than later ones." Curry v. Brown, 7 Vet. App. 59, 64 (1994). With respect to the Veteran's lay evidence of what inservice clinical evaluations might have been revealed had they been conducted during service, even when considered with the information gleaned from the Internet, this is no more the speculation. In this regard, the Veteran is competent to describe visible or personally observable symptoms. While continuity of symptomatology is not a means of establishing service connection for a disease which is not listed, at 38 C.F.R. § 3.309(a) as chronic, such nexus evidence is still a factor for consideration. See 38 C.F.R. § 3.303(d) (service connection is warranted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service). The clinical history which he has recently related is that he has had syncope since the episode of syncope in the 1960s. However, this is in stark contrast to the clinical history he initially reported after service when he was first evaluated for sinus bradycardia in 2003. At that time, in 2003, he reported only the recent onset of syncope, i.e., having had syncope for only five or six years. This latter history would only antedate that symptom to a point in time which is still more than 20 years after his discharge from active service. Because the clinical history he related in 2003, of the recent onset of chronic syncope was in conjunction with his initial in-depth evaluation for sinus bradycardia, the Board accords that clinical history greater weight than the more recent statements of continuously having had syncope that had an initial onset during military service. Curry, 7 Vet. App. 59, 64 (1994). Moreover, this is consistent with the August 2009 opinion that the sinus bradycardia during service was only physiologic and not pathologic and that it was not until he was of about age 62 that he developed pathologic bradycardia, described as being aged related. Since consistency is the hallmark of credibility, and because the Veteran's history has varied greatly over time, the Board finds that the Veteran's more recent statements of continuous syncope since the 1960s are not credible. Moreover, while the Veteran has reported that private physicians have informed him that his bradycardia during service could not have been physiologic, he has not submitted a corroborating private medical opinion which would refute the only medical opinion on file that addresses this matter. The Veteran himself does not have the medical training, experience or education to make a determination that any episode or occurrence of bradycardia is physiologic as opposed to pathologic, and such a determination is a complex question requiring these factors. Also, he has not reported having had a contemporaneous medical diagnosis of pathologic bradycardia during military service and he has not described symptoms supported by a later diagnosis by a medical professional of pathologic bradycardia during service. See generally Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Furthermore, when the underlying medical nature of evidence has been significantly diluted, as in the connection between a lay account of past medical information, and filtered through layman's sensibilities, such evidence is too attenuated and inherently unreliable to constitute competent or medical evidence and does not rise to the level of establishing that that a private physician rendered a favorable medical opinion. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995). While posited as lay evidence, the Veteran's belief that the inservice bradycardia was pathologic, and not physiologic, and was a precursor of his current chronic sinus bradycardia, is actually a medical opinion in the guise of lay evidence and, as such, is not competent. Based on a review of the record the recent VA opinion was that the current chronic sinus bradycardia is age-related and is no associated with the physiologic bradycardia during service and, as such, the current sinus bradycardia is not caused by or of service onset. The VA examiner supported this conclusion with citation to relevant facts following a review of evidence. There is no persuasive contrary evidence, including medical opinion evidence, of record. Posited against this is the Veteran's interpretation of the medical evidence which is not supported by the actual medical evidence on file. The Board is not required to accept the Veteran's lay interpretation of medical evidence because the Veteran lacks the education, experience, and training to make such interpretations. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). While competent medical evidence is not always required in a claim for service connection, and competent lay evidence may suffice in appropriate circumstance, competent evidence of some kind, either medical or lay evidence, is required. Here, there is neither competent medical evidence nor lay evidence which is both competent and credible that establishes that the current pathologic sinus bradycardia is the same as the physiologic bradycardia during service or that the current pathologic sinus bradycardia is otherwise of service onset. Thus, the Board finds that the recent VA medical opinion outweighs, for the reasons explained, the credibility of the Veteran's statements of putative continuity of episodes of syncope beginning during service. As to this, the Board must consider only independent medical evidence to support a conclusion rather than use noncompetent lay evidence in the guise of competent evidence, including a medical opinion. See Colvin v. Derwinski, 1 Vet. App. 171, 172 (1991). Here, there is no other persuasive medical opinion addressing the question of etiology or onset of pathologic sinus bradycardia. In sum, the Board does not question that the Veteran sustained some type of bradycardia during service. He contends that his inservice bradycardia was the same as the bradycardia he now has, i.e., that the bradycardia during service was of pathologic origin and not physiologic. However, there is no credible manner by which it can now be found that his current pathologic bradycardia is the same as the physiologic bradycardia he had during service or that the current pathologic bradycardia is of service origin, as opposed to being due to some other possible etiology, e.g., from cause(s) of postservice origin such as the aging process. So, the Board is without a basis upon which to predicate entitlement to service connection for sinus bradycardia, with postoperative residuals of permanent pacemaker implantation. Accordingly, service connection for sinus bradycardia, with postoperative residuals of permanent pacemaker implantation, is not warranted. Since, for these reasons, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for sinus bradycardia, with postoperative residuals of permanent pacemaker implantation, is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs