Citation Nr: 1313689 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 06-37 685 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for a cardiac disease, to include coronary artery disease, status post coronary artery bypass. REPRESENTATION Appellant represented by: Todd S. Hammond, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty with the Air Force from March to October 1971. He subsequently served with the National Guard from June 1980 to September 2000 and had numerous periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA) during that period, including a period of ACDUTRA from August 1, 1995 to August 2, 1995. This matter initially came before the Board of Veterans' Appeals (Board) from a November 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In that decision, the RO denied entitlement to service connection for coronary artery disease. In his November 2005 notice of disagreement (VA Form 21-4138), the Veteran requested a hearing before a Decision Review Officer (DRO) at the RO. Informal hearing conferences with a DRO were conducted in October and November 2006 in lieu of a formal hearing and reports of those conferences have been associated with the Veteran's claims folder. In January 2009, the Board remanded this matter to schedule the Veteran for a Board hearing before a Veterans Law Judge at the RO (Travel Board hearing). The Veteran testified before the undersigned at a March 2009 Travel Board hearing. A transcript of that hearing has been associated with his claims folder. In May 2009 and October 2011, the Board again remanded this matter for further development. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. The documents in this file have been reviewed and considered as part of this appeal. FINDING OF FACT The Veteran's current cardiac disease did not have its clinical onset in service, was not aggravated in service, and is not otherwise related to active duty. CONCLUSION OF LAW The Veteran's current cardiac disease was not incurred or aggravated in service. 38 U.S.C.A. §§ 101(2), (24), 1110, 1131, 1137, 1153, 5107(b) (West 2002); 38 C.F.R. §§ 3.6(a), 3.303, 3.304, 3.306(a), (b) (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a pre-adjudication letter dated in February 2005, the RO notified the Veteran of the evidence needed to substantiate his claim of service connection for a cardiac disease. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability rating and effective date elements of his claim, in a March 2006 letter. The timing deficiency with regard to this letter was cured by readjudication of the claim in a November 2006 statement of the case. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's March 2009 hearing, the undersigned identified the issues on appeal (including entitlement to service connection for a cardiac disease (such as coronary artery disease, status post bypass surgery) and asked the Veteran about the history of his cardiac disease. Further, the Veteran provided testimony as to the symptoms and history of his cardiac disease and the treatment provided for the disease and has submitted additional evidence throughout the claim period, thereby demonstrating actual knowledge of the ability to identify and submit additional relevant evidence. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records, pertinent service personnel records, and all of the identified relevant post-service private medical records. The Veteran has not reported, and the evidence does not otherwise reflect, any relevant post-service VA medical treatment for a cardiac disease. In addition, the Veteran was afforded VA examinations to assess the nature and etiology of his current cardiac disease and opinions have been obtained concerning the etiology of this disease. In its May 2009 and October 2011 remands, the Board instructed the agency of original jurisdiction (AOJ) to, among other things: contact all appropriate sources to verify the Veteran's periods of ACDUTRA and INACDUTRA; ask the Veteran to identify the name and location of any VA or private medical treatment provider that has provided treatment for a cardiac disease (including Dr. Stutzman); obtain any additional relevant private treatment records for which the appropriate release form was submitted; afford the Veteran a VA examination to assess the nature and etiology of his current cardiac disease; and obtain opinions as to the etiology of the current cardiac disease. All relevant evidence pertaining to the Veteran's periods of ACDUTRA and INACDUTRA has been obtained and associated with the claims file. In an October 2011 letter, the Veteran was asked to identify any treatment provider that has provided treatment for a cardiac disease and was asked to complete the appropriate release form so as to allow VA to obtain any identified private treatment records (including records from Dr. Stutzman). Copies of the release form (VA Form 21-4142) were included with the letter. The Veteran did not specifically identify any additional VA or private medical treatment for a cardiac disease and did not complete a release form so as to allow VA to obtain any additional records. However, he did submit additional private treatment records (including from Dr. Stutzman). Also, the Veteran was afforded a VA examination in July 2011 and opinions were obtained concerning the nature and etiology of his claimed cardiac disease in July 2011 and February 2012. Thus, the AOJ substantially complied with all of the Board's relevant May 2009 and October 2011 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claim being decided herein. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. The term "active military, naval, or air service" includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C.A. § 101(2), (24); 38 C.F.R. § 3.6(a). In other words, service connection is available for diseases or injuries incurred in or aggravated by ACDUTRA and injuries incurred in or aggravated by INACDUTRA (including an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element for certain chronic disabilities listed in 38 C.F.R. § 3.309(a) (2012) is through a demonstration of continuity of symptomatology. See Clyburn v. West, 12 Vet. App. 296, 302 (1999). 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. See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay 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); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. §§ 1153, 1137; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. §§ 3.304, 3.306(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Initially, the Board notes that the Veteran's April 1980 examination for entrance into the National Guard was normal other than for a scar. Generally, a veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b). The presumption of soundness under 38 U.S.C.A. § 1111 does not apply, however, when a claimant has not been examined contemporaneous to entering a period of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Moreover, the presumption of aggravation under 38 U.S.C.A. § 1153 is only applicable to the Veteran's period of active service from March to October 1971. Specifically, the Court has held that a claimant whose claim is based solely on a period of ACDUTRA or INACDUTRA can never be entitled to a "presumption of service connection." See Id. at 47. Such a presumption is not possible in such circumstances because, by definition, the presumption of service connection applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. With regard to a claimant whose claim is based solely on a period of ACDUTRA or INACDUTRA, however, there must be some evidence that the condition was incurred or aggravated during the relevant period of service. Id. The Veteran's only service during the periods other than from March to October 1971 was with the National Guard, to include periods of ACDUTRA and INACDUTRA. He did not undergo any examinations contemporaneous to entering any specific period of ACDUTRA. Hence, the presumption of soundness is inapplicable in this case to any period of service other than from March to October 1971. Furthermore, presumptive service connection for the Veteran's current cardiac disease is not warranted under any circumstance (to include under the provisions pertaining to aggravation of a pre-existing disease) during the periods of service other than from March to October 1971. Id. Rather, in order for service connection to be warranted on the basis of aggravation of a pre-existing cardiac disease during a period of ACDUTRA, the Veteran must provide direct evidence both that a worsening of the disease occurred during the period of ACDUTRA and that the worsening was caused by the period of ACDUTRA Id. at 48. In this case, medical records, including a July 2011 VA examination report, reveal that the Veteran has been diagnosed as having coronary artery disease, status post coronary artery bypass graft. Thus, a current cardiac disease has been demonstrated. The Veteran has not reported, and the evidence does not otherwise reflect, a continuity of cardiac symptomatology in the years since service. Nevertheless, even if there was evidence of a continuity of symptomatology, an award of service connection on this basis would nonetheless be precluded because the Veteran's current cardiac disease is not among the chronic conditions listed in 38 C.F.R. § 3.309(a). Service connection on the basis of a continuity of symptomatology may only be granted if a claimed disability is among this list of chronic conditions. See Walker, 708 F.3d at 1338. The evidence does not reflect, and the Veteran has not reported, that his current cardiac disease is related to his period of active service from March to October 1971. Specifically, there is no evidence of any complaints of or treatment for a cardiac disease or any symptoms of a cardiac disease in his service treatment records dated during this period of service and his August 1971 separation examination was normal other than for defective vision, a left varicocele, and right knee problems. Furthermore, the first post-service clinical evidence of possible cardiac problems following his period of active service from March to October 1971 is a service treatment record dated in May 1991 which reflects that the Veteran was placed on a physical profile due to a cardiovascular risk screening. During the March 2009 hearing, the Veteran reported that he was diagnosed as having high cholesterol in 1990. There is no clinical or lay evidence of any earlier cardiovascular symptoms or abnormalities following the Veteran's 1971 service. The Veteran contends that his current cardiac disease was incurred during his period of ACDUTRA from August 1, 1995 to August 2, 1995. In the alternative, he claims that the current cardiac disease was aggravated by a period of ACDUTRA. Service treatment records include an undated report of Phase I and Phase II failure during a cardiovascular medical screen. In May 1991, the Veteran was placed on a physical profile due to a cardiovascular risk screening. Following a cardiovascular risk screening and medical screening survey conducted in June 1991, he was not cleared to participate in the Army Physical Fitness Training Program. In May 1995, there was a Phase II failure during a cardiovascular medical screen. Therefore, the Veteran underwent a myocardial perfusion exercise test on August 2, 1995 (during a verified period of ACDUTRA). This test revealed evidence of anterolateral and inferior wall ischemia. He was again placed on a physical profile in June 1995 and was not cleared to participate in the Army Physical Fitness Training Program. He underwent cardiac bypass surgery in September 1995. The medical opinions of record indicate that the Veteran's current cardiac disease was not incurred in or aggravated during any period of active service. The physician who conducted an October 2005 VA examination opined that it was not likely ("not as likely as not") that the Veteran's service directly contributed to his coronary artery disease. Also, his service in the National Guard did not aggravate his cardiovascular problems. The examiner reasoned that it was likely that the Veteran's significant family history, hypertension, dyslipidemia, and male gender were his most significant risk factors to cause his coronary artery disease. Although stress associated with activity (including military stress and possibly exercise) could elevate his blood pressure transiently, this in itself was not a significant risk factor for heart disease. Further, his cardiovascular problems were likely due to a natural progression of the condition, especially with his risk factors of high cholesterol, hypertension, and significant family history. Therefore, it was not likely ("less than 50 percent probability") that his military activities contributed to his coronary artery disease/heart condition. The physician who conducted the July 2011 VA examination expressed confusion as to whether the Veteran's service was from March to October 1971 or from March 1971 to September 2000. Nevertheless, she opined that his current coronary artery disease was not related to the period of active duty from March to October 1971. Also, if the Veteran was considered to be on active duty through September 2000, his current coronary artery disease was a continuation of what he had in service. This opinion was based on the fact that he was diagnosed as having heart disease in 1995. In February 2012, the examiner who conducted the July 2011 VA examination re-reviewed the Veteran's claims file and acknowledged that the Veteran had been on active duty in 1971, followed by National Guard service until 2000 (which included periods of ACDUTRA). She opined that it was not likely ("less likely than not") that his coronary artery disease was due to or caused by his active service in 1971 or any subsequent periods of active service with the National Guard. She reasoned that there was no evidence of any coronary artery disease in the Veteran's service treatment records. In the absence of an actual cardiac event occurring during active reserve duty (of which the examiner could not find any evidence), it was unlikely that brief periods of active reserve duty would cause the development of either hyperlipidemia (which relates to diet and heredity) or coronary disease. The finding of an abnormal stress test would not indicate that the heart disease was due to or caused by the Veteran's brief periods of military service during his years of reserve duty. In September 2012, the Board sought to obtain an expert medical opinion through the Veterans Health Administration (VHA opinion) in accordance with the provisions of 38 C.F.R. § 20.901(a) (2012). In October 2012, a VA physician reviewed the Veteran's claims file and initially stated that he concurred with the gist of the July 2011 and February 2012 opinions in that the Veteran's current coronary artery disease was a continuation of the coronary artery disease that was discovered during a stress test during a period of ACDUTRA. The presence of coronary artery disease was subsequently confirmed by a cardiac catherization performed in the private sector. Secondly, there was no evidence of a specific cardiac event, such as a heart attack, episode of congestive heart failure, or episode of unstable angina that occurred during a period of active duty. Finally, the abnormal stress test in 1995 was merely an indication that significant coronary artery disease existed at that time, and it did not relate to the cause or the time of onset of the disease process. The physician then specifically opined that the Veteran's coronary artery disease was not caused by a period of ACDUTRA and did have its onset during any such period. He reasoned that there was no known cause for coronary artery disease, but that there are multiple known risk factors. Many such factors are genetically determined, such as family history, male gender, and disorders of lipid metabolism. Environmental factors such as diet, smoking, and lack of exercise contribute to the process. There are also risk factors that may be a mixture of environmental and hereditary issues, such as hypertension, diabetes, and obesity. The physician further reasoned that autopsy studies had shown that coronary atherosclerosis (or coronary artery disease) begins as fatty streaks in arteries many years before it becomes clinically detectable. Thus, the Veteran's coronary atherosclerosis undoubtedly began long before it was detected by the stress test in 1995. Also, the Veteran had a mixed lipid disorder involving a high LDL, high triglycerides, and a low HDL. All of these were risk factors for the development and progression of coronary artery disease. The severe derangement in lipid metabolism and family history of coronary artery disease were strong predictors of more rapid progression of coronary artery disease and an earlier onset of symptoms. Therefore, while the Veteran's coronary artery disease became clinically apparent on a stress study obtained while on ACDUTRA, the coronary artery disease undoubtedly started many years earlier and was related to multiple risk factors, some of which were inherited. It was quite possible that early atherosclerosis was present in a subclinical form even before his period of active duty in 1971. The physician then opined that it could not be determined whether the Veteran's coronary artery disease was permanently worsened beyond its natural progression during periods of ACDUTRA because it would require both serial angiograms to assess the progression of the disease and a reliable benchmark for the rate of disease progression with the Veteran's constellation of risk factors. However, neither of these types of evidence existed. Nevertheless, the physician opined that it was highly unlikely that permanent worsening of the Veteran's coronary artery disease was caused by a period of ACDUTRA. He explained that regular exercise was shown to be helpful in raising HDL, preventing obesity, and helping to control hypertension and diabetes. Each of these would have a beneficial effect to help slow the progression of coronary artery disease. Thus, the physical training during the Veteran's periods of active duty were more likely to have helped slow the progression of his coronary artery disease than to have exacerbated its progression. The evidence also reflected that he had experienced significant weight gain after his separation from service. Lack of exercise after separation from service may have contributed to this risk factor. The physician additionally explained that while treatment of hypertension, high LDL cholesterol, and high triglycerides will help to slow the progression of coronary artery disease over time, the Veteran's treatment for these conditions was obtained and regulated by medical care outside of the military. His brief and intermittent periods of service were highly unlikely to have affected his overall treatment program, even if medications were possibly interrupted for a few days during periods of ACDUTRA, because control of the above listed risk factors exerted its influence on disease progression over a period of months or years (rather than days), with two possible exceptions. There was some debate as to whether a period of very intense physical activity might contribute to the occurrence of atherosclerotic plaque rupture. Rupture of a plaque can cause a rapid change in the open area (lumen) of a coronary artery and thus cause an acute exacerbation in the symptoms related to coronary disease. However, there was no evidence that this type of event occurred during a period of ACDUTRA. Rather, the event that prompted the Veteran's bypass surgery was related to an elective cardiac catherization and an attempt to perform percutaneous intervention (i.e. balloon angioplasty). This event occurred outside of the Veteran's periods of ACDUTRA and in a private hospital. Moreover, the other potential mechanism that may worsen coronary artery disease beyond its natural progression is exposure to Agent Orange. However, there was no evidence that the Veteran had experienced such exposure. The October 2012 opinions were based upon a review of the Veteran's medical records and reported history and are accompanied by detailed rationales that are not inconsistent with the evidence of record. Thus, these opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The October 2005, July 2011, and February 2012 opinions are of limited probative value because they either do not reflect consideration of the abnormal cardiac testing conducted during a period of ACDUTRA on August 2, 1995 or are based upon an inaccurate history of the Veteran's service and cardiac problems. See Boggs v. West, 11 Vet. App. 334, 345 (1998); Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Nevertheless, these opinions at least support a conclusion that the Veteran's current cardiac disease was not caused or aggravated by service. The Veteran has expressed his belief that his current cardiac disease had its onset during his period of ACDUTRA in August 1995, as evidenced by the abnormal exercise test conducted on August 2, 1995. However, as a lay person, he can only comment as to symptoms and immediately-observable relationships. He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his current cardiac disease had onset in or was aggravated by active service. Rather, it would require medical expertise to evaluate the disease, consider all the potential causes, and determine that one was a more likely cause than another. Hence, the Veteran's opinion on this question is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2) (2012). Although the Veteran has received treatment from medical professionals for his cardiac disease, none have attributed this disease to any disease or injury in service or claimed that the disease was aggravated by service. Rather, the only medical opinions of record reflect that no such relationship exists between the current cardiac disease and service. There is no other evidence of a relationship between the Veteran's current cardiac disease and service, and neither the Veteran nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's current cardiac disease is related to his period of active service from March to October 1971 or any subsequent periods of ACDUTRA, manifested during any period of active service, or was aggravated by any period of active service. Also, there is no evidence of any myocardial infarction, cardiac arrest, or cerebrovascular accident during a period of INACDUTRA. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt doctrine is therefore not for application in this case and the claim of service connection for a cardiac disease must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. ORDER Entitlement to service connection for a cardiac disease is denied. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs