Citation Nr: 1322687 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 09-15 744 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for cardiovascular disability with cardiac residuals of rheumatic fever. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from November 1955 to August 1959. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in San Diego, California. In January 2013, the Board remanded the claims of service connection for hypertension, a cardiovascular disorder, and hearing loss for further evidentiary development. By an April 2013 rating decision, the Appeals Management Center (AMC) granted service connection for bilateral hearing loss and assigned a noncompensable disability rating, effective June 26, 2007. In April 2013 correspondence, the Veteran indicated that he was satisfied with the grant of service connection for hearing loss. Consequently, this matter is no longer on appeal. (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's cardiac pathology associated with rheumatic fever clearly and unmistakably existed prior to his entrance into service and was clearly and unmistakably not aggravated by service. 2. The Veteran's hypertension is not related to his military service; it was not manifested within one year following separation from service, and it was not caused or made worse by service-connected disability. 3. The Veteran's cardiovascular disability is not related to his military service, was not manifested within one year following separation from service, and was not caused or made worse by service-connected disability. CONCLUSIONS OF LAW 1. The Veteran does not have hypertension that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The Veteran does not have cardiovascular disability or cardiac residual of rheumatic fever that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1101, 1111, 1112, 1113, 1131, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify & Assist The Veterans Claims Assistance Act (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, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the appellant 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). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, a failure to provide notice before initial adjudication may be cured by re-adjudication. In a November 2007 letter, issued prior to the rating decision on appeal, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate claims of service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. The letter also advised the Veteran of how VA determines a disability rating and assigns an effective date, and the type of evidence that impacts such. The case was readjudicated in April 2013. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claims. 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). In this case, VA obtained all of the service treatment records and available post-service VA and private treatment records. In August 2007, VA attempted to obtain treatment records for Douglas Community Hospital and Dr. R.A.V. In November 2007, the request for treatment records to Dr. R.A.V. was returned as not deliverable as addressed and unable to forward. In a May 2008 Report of Contact, the Veteran indicated that VA would probably not get any records from Dr. R.A.V. or Douglas Community Hospital and to decide the claims without those records. In September 2009 another request for records from Dr. R.A.V. was returned as undeliverable. In October 2009 correspondence, the Veteran advised VA that he was in the process of trying to find out where records from Dr. R.A.V. were stored. In May 2010, VA attempted to obtain the Veteran's Social Security Administration (SSA) disability benefit records. In June 2010, VA received a response that such records were destroyed. In June 2010, VA advised the Veteran of the trouble obtaining SSA records and asked him to provide VA with any alternative sources as to where to obtain the records. In September 2010, VA issued a formal finding on the unavailability of federal records. In October 2010, the Veteran was advised of the unavailability of SSA records. In March 2011, another formal finding on the unavailability of federal records was issued and a letter was sent to the Veteran advising him that his SSA records were destroyed. In a March 2011 Report of General Information, the Veteran was asked if he had any copies of his SSA disability records and he indicated that he would submit any that he found. In March 2011, the Veteran submitted the notice of award to SSA disability benefits. Thus, VA has made every reasonable effort to obtain all records relevant to the appellant's claim. In June2011, the Board remanded the claim, in part, to obtain a VA opinion addressing whether any cardiac pathology pre-existed service, was attributable to military service or the first post-service year, was aggravated by service or was caused or aggravated by the Veteran's service-connected disabilities. The November 2011 and 2012 opinions provide enough adequate evidence to decide the claims are in compliance with the prior remand instructions. See Barr v. Nicholson, 21 Vet. App. 303 (2007); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). VA treatment records were electronically available through the Compensation and Pension Records Interchange (CAPRI) and were uploaded to the Virtual VA eFolder. The Veteran's claim was subsequently readjudicated in December 2012 and April 2013. The Veteran has not identified any additional outstanding evidence and review of the paper claims file as well as Virtual VA does not reveal any additional documents pertinent to the claim decided herein. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is 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 include statements conveying sound medical principles found in medical treatises. It also includes 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 is 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). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Claimants are presumed 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 evidence demonstrates that the injury or disease in question existed prior to service and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1137. Only such conditions as are recorded in entrance examination reports are to be considered as "noted." Crowe v. Brown, 7 Vet. App. 238, 245 (1994). VA's General Counsel has held that to rebut the presumption of sound condition under 38 C.F.R. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The appellant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. See VAOPGCPREC 3-2003, 69 Fed. Reg. 25,178 (2004); see also Cotant v. Principi, 17 Vet. App. 116 (2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by 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 (West 2002); 38 C.F.R. § 3.306 (2012). In addition, certain chronic diseases, such as cardio-vascular renal disease, including hypertension, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. See 38 U.S.C.A. §§ 1101, 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Pursuant to 38 C.F.R. § 4.104 , Diagnostic Code 7101 (2012), the term "hypertension" means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. A 10 percent rating is defined as diastolic pressure predominately 100 or more, or; systolic pressure predominately 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominately 100 or more who requires continuous medication for control. Under section 3.310(a) of VA regulations, service connection may be established on a secondary basis for a disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsens. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990) The Veteran is seeking service connection for various cardiovascular disorders and hypertension, to include as secondary to his service-connected cold injuries of the extremities. He indicates that his service-connected cold injury residuals affected his cardiovascular system. See February 2010 Form 9. He also contends that his hypertension is due to or has been aggravated by his cold weather injuries of the upper and lower extremities, to Raynaud's phenomenon of the upper and lower extremities, and to peripheral neuropathy with loss of Achilles reflex of the lower extremities. See February 2010 Form 9, and May 2010 VA examination report. Post-service medical records reflect that the Veteran has been diagnosed as having various cardiac disabilities some of which are related to a bout of rheumatic fever. Beginning in June 1980, treatment records from Sacred Heart Medical Center show that the Veteran was admitted with a diagnosis of arteriosclerotic heart disease with recent myocardial infarction. A coronary angiogram demonstrated occlusion of the circumflex coronary artery and a significant stenosis of the intermediate coronary artery. In August 1993 correspondence, Dr. R.A.V. reported that he began to treat the Veteran in 1980 for a subendocardial myocardial infarction. The Veteran had his first angiography at that time, which demonstrated a totally occluded circumflex and a significant stenosis of the intermediate coronary artery. Dr. R.A.V. noted that increasing angina and reversible ischemia was shown in May 1990. Treatment records from Drs. J.S. (dated from 1999 to 2005), S.T (dated from February 2000 through July 2007), and A.P.F (dated in February 2000) as well as Providence St. Vincent Medical Center (dated in February 2000 and November 2003) showed that the Veteran underwent a coronary artery bypass times 2 in February 2000 with diagnoses of CAD and mitral regurgitation. A February 2000 treatment record from Dr. S.T. noted that the Veteran had Raynaud's phenomenon and underwent a retinal artery occlusion in October 1998. He was diagnosed with angina pectoris, atherosclerotic cardiovascular disease with past inferior myocardial infarction and past right artery angioplasties, hypercholesterolemia, and Raynaud's phenomenon. A June 2006 treatment record reported that an electrocardiogram showed sinus rhythm with an inferior myocardial infarction. The treatment record also included a diagnosis of hypertension. VA treatment records noted that the Veteran had multiple heart attacks, status post open heart surgery. A December 2009 record noted a review of the September 2009 echocardiogram and found mild mitral regurgitation (MR) and aortic insufficiency (AI), mild aortic stenosis (AS), moderate left atrial enlargement (LAE), and endocardial calcification. A history of rheumatic heart disease was noted. A February 2011 record noted a history of rheumatic fever as youth and a September 2009 echocardiogram was consistent with rheumatic heart disease with mild MR, mild AS/AI. June 2011 through April 2012 VA treatment records included a past medical history of valvular heart disease (including rheumatic heart disease) with systolic murmur, status post rheumatic fever in childhood. A past medical history of coronary artery disease, hypertension, and post-surgical aortocoronary bypass status was also noted. November 2011 and 2012 VA examination reports include such diagnoses as hypertension, coronary artery disease (CAD), ischemic heart disease, and rheumatic mitral valve regurgitation. See November 2011 and 2012 VA examination reports. Thus, current disabilities have been demonstrated. Turning to the Veteran's service treatment records, a November 1955 enlistment examination revealed that the Veteran's lungs and chest, heart, and vascular system were normal and that he had no defects. His blood pressure was 130/70 (diastolic and systolic readings well below the criteria established by Diagnostic Code 7101). On November 1955 Report of Medical History, the Veteran specifically denied ever having rheumatic fever, shortness of breath, pain or pressure in chest, palpitation or pounding heart, and high/low blood pressure. On entrance into service, there was no mention of any pre-existing cardiac problems, including as due to rheumatic fever. Given the foregoing, the Veteran is entitled to a presumption of soundness at service entrance as to his heart. Therefore, the Board must determine whether the presumption of soundness is rebutted by clear and unmistakable evidence. See 38 U.S.C.A. § 1111; Cotant; VAOPGCPREC 3-2003. The Veteran's remaining service treatment records are negative for any complaints, treatment, or diagnoses related to his heart until he reported a history of having rheumatic fever on his July 1959 separation Report of Medical History. However, at that time, he still denied having shortness of breath, pain or pressure in chest, palpation or pounding heart, or high/low blood pressure. The physician's summary section clarified that the Veteran had rheumatic fever in 1949 for which he was hospitalized for two weeks, was home bound for three months, and had questionable cardiac involvement. On July 1959 Report of Medical Examination, a clinical evaluation of the lungs and chest, heart, and vascular system were normal. His blood pressure was 114/70. The physician again noted the Veteran's prior history of rheumatic fever in 1949. As the evidence shows that the Veteran has at least one current cardiac disability related to his history of rheumatic fever, the Board will address whether or not the Veteran had a pre-existing disability. Post service treatment records include VA records and a February 2000 treatment record from Providence St. Vincent Medical Center that reported a history of the Veteran of having rheumatic fever in his childhood. On November 2011 VA examination, the examiner noted a medical history of the Veteran having rheumatic fever either in 1943 or 1949. The Board finds that the evidence shows that the Veteran's rheumatic fever clearly and unmistakably existed prior to service. The Veteran's reports of a history of symptoms, treatment, and representations made to him, prior to service are probative. In this case, the Veteran has repeatedly stated the he had rheumatic fever in the 1940s. Furthermore, the November 2011 VA examiner referred to the Veteran's rheumatic fever as pre-existing cardiac pathology based on the Veteran's reported history and review of his C-file. See Miller v. West, 11 Vet. App. 345, 348 (1998); Harris v. West, 203 F.3d. 1347 (Fed. Cir. 2000) (the determination of the existence of a pre-existing condition may be supported by contemporaneous evidence, or recorded history in the record, which provides a sufficient factual predicate to support a medical opinion). The opinion is highly probative, as it is shown to have been based on a review of the Veteran's C-file. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Moreover, there is no suggestion that he had such a disease in service until he mentioned it at separation. The Board therefore finds that there is clear and unmistakable evidence that Veteran's rheumatic fever existed prior to service. The next question is whether there is clear and unmistakable evidence that the Veteran's rheumatic fever or any cardiac residual thereof was not aggravated by service. See Wagner, 370 F.3d at 1089. The Veteran's service treatment reports have been discussed. Complicating matters is a September 1961 letter from Dr. A.H.N. led to the medical disqualification of the Veteran for general military service. The private doctor stated that the appellant had had rheumatoid spondylitis for nine years (or approximately 1952, prior to the Veteran's active military service). As there was a question as to whether or not the diagnosis of rheumatoid spondylitis was a residual of rheumatic fever, the Board sought a VA opinion on the matter in A June 2011 remand. At the same time, the Board requested an opinion as to whether or not the Veteran had any pre-existing cardiac pathology that was aggravated by service. In November 2011, a VA examiner clarified that "rheumatic" and "rheumatoid" did not have the same meaning. She explained that rheumatoid spondylitis was a manifestation of rheumatoid arthritis, which had no relationship to rheumatic fever. The examiner added that fewer than 5% of patients with rheumatic fever had symptoms that persisted for 6 months or more and sequelae of rheumatic fever were limited to the heart and were dependent upon the severity of the carditis during the acute attack. The VA examiner noted that the statement that the Veteran had rheumatoid spondylitis for 9 years (as per the 1962 letter) did not show any relationship to the rheumatic fever. The examiner reported that rheumatoid arthritis was associated with ischemic heart disease, and the risk of myocardial infarction was increased in patients with rheumatoid arthritis. The examiner cited "[TI High risk of clinical cardiovascular events in rheumatoid arthritis AU C. Meune, etal SO Arch Cariovasc Dis 2010 Apr: 103(4): 253-261]". Additionally, the examiner noted that heart disease secondary to rheumatic fever usually involved the mitral valve, especially mitral valve stenosis, but mitral valve prolapse (regurgitation), could also be a sequelae of rheumatic fever. It was not known when the Veteran's mitral valve prolapse was first diagnosed. The first documentation in the available records was in February 2000, when an echocardiogram revealed mild mitral regurgitation. The examiner reported that there apparently was no increase in the severity of the mitral valve regurgitation between 2000 and 2009, as the September 2009 echocardiogram also reported it as mild. The examiner noted that the cardiologist that interpreted that echocardiogram noted that the mitral valve "appeared rheumatic." The examiner determined that the Veteran had mitral valve prolapse, which was most likely caused by or a result of his rheumatic fever. The examiner stated that rheumatic heart disease did not usually manifest until 10-20 years after the original illness. She reported that if rheumatic fever occurred in 1949, the Veteran was approximately 13 years old and any rheumatic heart disease would have expected to manifest by 1959-1969. The examiner stated that the most likely presentation would have been a heart murmur, which was not evident at the time of his separation examination in July 1959 (or any other time during military service). Therefore, the examiner opined that it was less likely than not that said pre-existing cardiovascular pathology was aggravated (increased in severity beyond the normal progression) by any incident of service. In November 2012, a VA examiner reported that there was no evidence that the Veteran had high blood pressure before or during his time in service, thus it could not have been aggravated by service. The examiner reported that atherosclerosis was well known to begin relatively early in life and as such the Veteran may have had a sub-clinical atherosclerosis before he left the service in 1959. However, the examiner found that there was no evidence whatsoever that the Veteran had obstructive CAD that led to symptomatic heart muscle under-perfusion with blood or heart muscle damage as this did not manifest until 11 years after he left service. The examiner added that the Veteran smoked while in service, but beyond that it would be hard to say that military service itself aggravated his condition. The VA examiner reported that the Veteran's mitral valve regurgitation was first clinically noted in February 2000. The examiner indicated that this was compatible with rheumatic valvular disease. The examiner reported that since there was substantial documentation that the Veteran had rheumatic fever as a child, his mitral valve disease was very likely sequela of the rheumatic fever. The examiner found that there was no evidence that his pre-existing problem was aggravated by his military service. The Veteran's regurgitation remained mild through 2009. The examiner stated that the 1961 private statement the Veteran had "rheumatoid spondylitis of the lumbosacral spine" implied that the doctor thought the spine had the appearance of someone with rheumatoid arthritis. As noted by the prior VA examiner, this had nothing to do with rheumatic fever. The Board finds that there is clear and unmistakable evidence that the Veteran's rheumatic fever and any cardiac residual thereof was not aggravated by service. The Veteran is shown to have had rheumatic fever prior to service. Both VA examiners indicated that their opinions were based on a review of the Veteran's records and were accompanied by a thorough explanation, and were therefore considered highly probative evidence against the claim. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000), (holding that among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The Board points out the first documentation of any complaints of cardiac problems is in a June 1980 treatment record from Sacred Heart Medical Center, approximately 21years after the Veteran's discharge from service. The Board notes that on November 2012 VA examination, the examiner indicated that CAD did not become evident until 11 years after service. Finally, there is no competent and probative countervailing etiological opinion of record. Given the foregoing, the Board finds that the claims files contain clear and unmistakable evidence that the Veteran's preexisting rheumatic fever or cardiac residual thereof was not aggravated by his service. See 38 U.S.C.A. § 1111; Cotant. In regards to any other cardiac disability or hypertension, there is no evidence of any relationship to military service. The Board notes that it has neither been alleged nor shown that the Veteran's cardiac disability or hypertension began in service. Service treatment records are completely negative for any complaints, treatment, or diagnoses related to any present cardiovascular problems or hypertension, and the first documentation of any complaints of cardiac problems is in a June 1980 treatment record from Sacred Heart Medical Center, approximately 21years after his discharge from service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability that still exists currently). The Board notes that on November 2011 VA examination, the examiner reported a history of the Veteran having hypertension since approximately 1970, which was still 11 years after service. On November 2011 VA examination, the examiner noted that there was no evidence of signs or symptoms of cardiac pathology in the available records dated through April 1959, including the STRs. The examiner pointed out that the Veteran did not have any documented hypertension, exercise intolerance, angina, dizziness, dyspnea, or a heart murmur. The examiner reported that there was no evidence in the available records that the Veteran's military service caused any cardiac pathology. The examiner stated that there was evidence of long-term dyslipidemia for which the Veteran continued to require treatment, a history of tobacco smoking until 1992, and years of treatment for hypertension, all of which were known factors in the development of ischemic heart disease. The examiner cited to and referred to excerpts from Dr. Robert J. Bryg, writing online for WebMD at "[TI Causes of High Blood Pressure AU Robert J Bryg, MD http://www.webmd.com/hypertension-high-blood-pressure/guide/blood-pressure-causes]". Therefore, the examiner opined that the Veteran's current cardiac pathology, including ischemic heart disease, hypertension, and mitral valve prolapse were less likely caused by or a result of military service. In November 2012, a VA examiner reported that hypertension was first noted in approximately 1970. The examiner stated that CAD was first noted in approximately 1980 when the Veteran had chest pains, ruled in for a myocardial infarction. The examiner indicated that there were no signs or symptoms of any cardiac pathology noted in service or within one year of service and there was no evidence that the nature of his service played any causative role in his current cardiac medical problems. There is no competent or probative evidence to the contrary. Thus, the Board finds that the preponderance of the evidence is against the claim of service connection for hypertension and any cardiovascular disabilities on a direct basis and a presumptive basis. In regards to whether the Veteran's cardiac disabilities, including hypertension were caused or aggravated by his service-connected cold weather injuries of the upper and lower extremities, to Raynaud's phenomenon of the upper and lower extremities, and to peripheral neuropathy with loss of Achilles reflex of the bilateral lower extremities, the Board turns to the evidence of record. On May 2010 VA examination for hypertension, the examiner reviewed the claims file. The examiner stated that there was no medical evidence that cold injuries, up to and including frostbite, caused changes in long-term blood pressure and/or hypertension. The examiner cited to and quoted excerpts from an online and up-to-date article regarding the short-term and long-term effects of frostbite, which did not include changes in blood pressure or hypertension. The examiner stated that the vasospasm associated with Raynaud's phenomenon is acute/short term and related only to situations in which the affected extremities are exposed to the triggers of cold and/or emotional distress. There was no evidence that having primary Raynaud's phenomenon (as this Veteran does), even at a severe level, was associated with the development of hypertension or other vascular problems. The examiner cited, "UpToDate Online article entitled "Pharmacologic and surgical treatment of the Raynaud phenomenon": "The Raynaud phenomenon (RP) is an exaggerated vascular response to cold temperature or emotional stress. (See "Pathogenesis of the Raynaud phenomenon".)" The examiner found that there was no medical evidence that mild to moderate peripheral neuropathy (including meralgia paresthetica) caused hypertension, as this was a disorder of the peripheral nervous system and did not affect the autonomic nervous system that, in part, controlled blood pressure. The examiner opined that there was no evidence that previous cold injuries were a risk factor for the development of atherosclerosis, myocardial infarction, or cardiac valvular disease. The examiner opined that as per the medical rations above, it was unlikely that the Veteran's hypertension was caused by his cold injuries or any complication of his cold injuries. On November 2011 VA examination, the examiner opined that there was no medical evidence that cold injuries, including the known residuals of peripheral neuropathy and Raynaud's phenomenon, caused long-term changes in blood pressure and lead to the development of hypertension, ischemic heart disease, and valvular heart disease. The examiner stated that the major cause of mitral valve disease (both stenosis and prolapsed) was valvular heart disease. The examiner stated that cardiac involvement was the major cause of long-term morbidity from rheumatic fever. The examiner cited [TI Rheumatic Fever in Emergency Medicine AU Steven Parrillo, DO http://emedicine.medscape.com/article/808945-overview]. The examiner stated that there was no evidence in the medical literature that cold injury, including the known residuals of peripheral neuropathy and Raynaud phenomenon, aggravated, contributed to, or accelerated cardiac or cardiovascular pathology. Therefore, the Veteran's current cardiac pathology, including ischemia heart disease, hypertension, and mitral valve prolapse was less likely as not caused by or a result of his service-connected cold injury residuals of all extremities, peripheral neuropathy, or Raynaud phenomenon. When asked if the Veteran's cold injury residuals of the extremities, peripheral neuropathy or Raynaud's phenomenon aggravated, contributed to, or accelerated any cardiac or cardiovascular pathology including hypertensive vascular disease, she responded that this was not applicable and referred to her above findings. In November 2012, a VA examiner reviewed the claims file. The examiner indicated that none of the Veteran's service-connected conditions caused or worsened hypertension, CAD, or mitral valve regurgitation. The examiner opined that it was not at all likely that the Veteran's time in service, including the cold injury, neuropathy or Raynaud's he experienced then, had anything to do with the cardiac problems he subsequently developed over a decade later. The VA examiners in May 2010, November 2011, and November 2012 reviewed the Veteran's claims file, including post-service diagnostic studies, considered his intentions, and provided explanations for their opinions. See Prejean, Supra; Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As to the Veteran's assertions that his cardiac problems, including hypertension are related to his service or service-connected disabilities, the Board notes that generally etiology of dysfunctions and disorders is a medical determination. See Jandreau v. Nicholson, 492 F.3d 1372, 1374-75 (Fed. Cir 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the appellant, as a lay person without the appropriate medical training and expertise, is not competent to make such an etiological conclusion with regard to his cardiac problems, including hypertension and his service-connected disabilities, especially in light of the fact that the probative evidence fails to demonstrate that his cardiac problems, including hypertension were related to his service or his service-connected disabilities or permanently increased in severity as a result of his service or service-connected disabilities. See Jandreau, supra. Based on the foregoing, the preponderance of the evidence is against the claims. ORDER Entitlement to service connection for hypertension, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for a cardiovascular disability or any cardiac residual of rheumatic fever, to include as secondary to a service-connected disability, is denied. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs