Citation Nr: 1334616 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 08-37 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for a pulmonary disability, to include as due to exposure to asbestos. 2. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus. 3. Entitlement to service connection for a cardiovascular disability, to include as secondary to diabetes mellitus. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1968 to June 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran provided testimony at a March 2009 Decision Review Officer (DRO) hearing at the RO. The Veteran also testified at a May 2010 hearing before the undersigned Veterans Law Judge of the Board held at the RO. Transcripts of those hearings are associated with the claims file. This case was previously before the Board in December 2010 and was remanded for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with its December 2010 remand with regard to the issues decided herein. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. There has been no demonstration by the most probative competent clinical, or competent and credible lay, evidence that the Veteran's pulmonary disability is related to his military service, to include exposure to asbestos. 2. The Veteran's pre-hypertension was noted at entrance into active service. 3. The most probative and competent evidence of record fails to establish that the Veteran's preexisting pre-hypertension underwent increase in severity during or as a result of active service. 4. The Veteran's cardiovascular disability, diagnosed as coronary atherosclerosis, was initially demonstrated many years after service, and has not been shown by the most probative competent clinical, or competent and credible lay, evidence to be causally related to the Veteran's active service. CONCLUSIONS OF LAW 1. A pulmonary disability was not incurred in, or aggravated by, active service. 38 U.S.C.A. § 1110, (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Hypertension was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1111, 1153, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.102, 3.303, 3.306 (2012). 3. A cardiovascular disability, diagnosed as coronary atherosclerosis, was not incurred in or aggravated by active military service, nor may it be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307. 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS VCAA VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). VA correspondence dated in December 2006 and August 2009 advised the Veteran of the necessary elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Specifically, the Veteran was informed of what evidence was required to substantiate the claims for service connection, of his and VA's respective duties for obtaining evidence. It also notified him that a disability rating and effective date would be assigned, in the event of award of the benefit sought, as required by the Court in Dingess/Hartman. The December 2006 VA notice was provided prior to the November 2007 initial adjudication, in compliance with Pelegrini. Although the August 2009 notice was not provided to the Veteran prior to the initial adjudication of the claims, the Board finds that providing him with adequate notice in the August 2009 letter followed by a readjudication of the claims in the February 2010 and February 2012 supplemental statements of the case (SSOCs), "cures" any timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 20 Vet. App. 537 (2006). The purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, including the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The Board concludes that VA's duty to assist has also been satisfied. The Veteran's service treatment records and post service medical records are in the file. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In compliance with the Board's December 2010 remand, in correspondence dated in February and November 2011, the RO solicited from the Veteran any treatment records or information in support of his claims; however, no response has been received. The RO also provided the Veteran appropriate a VA examination in April 2011 and a supplemental opinion was obtained in October 2011. Green v. Derwinski, 1 Vet. App. 121 (1991) (holding that the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran). The Board finds that, the VA examination and opinions are adequate, as the opinions are predicated on an examination of the Veteran and a review of his claims file. The opinions consider the pertinent evidence of record, to include the Veteran's lay statements, and a rationale was provided for the opinions proffered. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Based on the foregoing, the Board finds the RO substantially complied with the Board's December 2010 remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The provisions of 38 C.F.R. § 3.103(c)(2) (2012) require that the Decision Review Officer (DRO) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. § 3.103(c)(2) (2012) also requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill the same duties to comply with the above the regulation. Here, during the DRO hearing, the Veteran was assisted at the hearing by an accredited representative from the Veterans of Foreign Wars of the United States. The representative and the DRO asked questions to ascertain to ascertain the onset of symptoms, duration of symptoms, any nexus between current disabilities and service, and the existence of any pertinent outstanding evidence. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. Therefore, the Board finds that the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). During the Board Travel Board hearing, the VLJ identified the issues and noted the elements of the claims that were lacking to substantiate the claims for service connection. The VLJ solicited information as to any pertinent potentially available outstanding evidence. The VLJ asked questions to ascertain the onset of symptoms, duration of symptoms, and any nexus between current disabilities and service. The Veteran was assisted at the hearing by an accredited representative from the Veterans of Foreign Wars of the United States. On remand, a VA examination was conducted and an addendum to the examination report was obtained; otherwise, no pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative that has yet to be obtained. Thus, the submission of overlooked evidence was not only suggested, but obtained. The hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for service connection. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Law and Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Generally, in order to establish service connection for the claimed disorders, there must be (1) 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) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In certain circumstances, lay evidence may also be competent to establish a medical diagnosis or medical etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Board is to consider all lay and medical evidence as it pertains to the issues. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence."). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify."). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Pulmonary Disability The Veteran asserts that service connection is warranted for a pulmonary disability. Specifically, he contends that such pulmonary disability is due to exposure to asbestos on the ship on which he served in service. At his March 2009 DRO hearing, the Veteran testified that he served on a naval ship and slept right next to walls that were made of asbestos. However, he stated that he was not treated for any pulmonary condition in service. He stated that his military occupational specialty (MOS) was Boatswain's Mate, which involved various duties including loading ammunition onto the ship, steering the ship, swabbing the deck, watch duties, and painting the ship. During his May 2010 hearing before the Board, he testified that asbestos was all around his ship, including in the walls, in the overhead pipes, and in the gun room. He further testified that he was first diagnosed with chronic obstructive pulmonary disease (COPD) approximately 4 years previously at the Porter Memorial Hospital. Service personnel records reflect that the Veteran served in the Navy aboard USS Goldsborough. His MOS was Boatswain's Mate (BM-0100). A November 1968 service treatment report noted a history of asthma and bronchitis. Physical examination revealed the lungs were clear on percussion and auscultation, except for areas of scattered wheezes. The impression was no significant illness. An October 1969 service treatment report noted complaints of chronic cough and past history of bronchitis. It was noted that he smoked three packs of cigarettes a day. Physical examination of the chest revealed wheezes on forced expiration. Separation examination report dated in May 1970 noted that on clinical evaluation, the Veteran's lungs and chest were normal. It was noted a chest X-ray in March 1970 had been normal. After separation from service, private treatment records dated from January 2006 to the present reflect diagnoses of COPD. The Veteran was afforded a VA examination in April 2011. The VA examiner indicated that the claims file was reviewed. It was noted that the Veteran had a history of COPD, which began approximately ten years ago per the medical records. He had shortness of breath with mild exertion, such as walking up a flight of stairs or walking a couple of blocks. He had a history of smoking cigarettes, for approximately 40 years. He had flare-ups of COPD, approximately three times a year, which were usually associated with upper respiratory infections as the precipitating cause. The examiner noted that the Veteran was exposed to asbestos while serving in the Navy. In reviewing the medical records, there was a chest X-ray showing a linear density in the right mid lung field. It was also noted that the Veteran had never been diagnosed with asbestosis or mesothelioma, or cancer associated with asbestos. Following physical examination of the Veteran and diagnostic and clinical tests, the final diagnosis was moderate obstructive lung disease having a moderate impact on activities of daily living and occupational functioning. There was no evidence on plain chest X-ray of asbestosis. The examiner opined that "[i]t is less likely as not, less than a 50% probability that [the Veteran's] current obstructive lung disease is related to exposure to asbestos in the service." In support of this opinion, the examiner provided the following rationale: ...after reviewing the medical records, [the Veteran's] x-rays, pulmonary function tests and clinical examination, including the claims file, I have concluded that in a gentleman who is a smoker for almost his entire adult life, although he was highly likely exposed to asbestos on a Naval ship [in the 1968-70 time frame, there is no evidence on x-ray of asbestosis. He does have a long history of smoking, the most common cause of obstructive lung disease and therefore although there is evidence in the literature about the combination of asbestosis as a contributing factor in the development of COPD, in this individual, who has a heavy history of smoking and no radiographic changes associated with this, I think that it is less than a 50% probability that the asbestos is related to his COPD in part or its entirety. After considering the totality of the evidence of record, the Board concludes that service connection is not warranted for a pulmonary disability. As an initial matter, the Veteran has a current diagnosis of COPD, or obstructive lung disease, as documented by his VA examination report and private treatment records. See Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). To that effect, private treatment records dated from January 2006 through January 2007 show diagnoses of COPD. X-rays of the chest in February 2006 showed accentuation of the right perihilar lung markings with minor adjacent air space opacity, which was compatible with right-sided perihilar pneumonitis. The April 2011 VA examination report confirms a diagnosis of obstructive lung disease. However, the Veteran's pulmonary disability has not been shown to be etiologically related to service. Although the Veteran's service treatment records reflect a reported history of asthma and bronchitis, no pulmonary abnormalities were found on clinical examination in service, except for scattered wheezes, nor on his separation medical examination. The first medical evidence of COPD was in January 2006 when the Veteran was admitted to the Porter Memorial Hospital for a COPD exacerbation. In this regard, the Veteran stated that he was not treated for any pulmonary condition in service and testified during the May 2010 Board hearing that he was first diagnosed with COPD approximately 4 years previously at the Porter Memorial Hospital. Therefore, a chronic pulmonary disability was not demonstrated in service. Further, the COPD demonstrated subsequent to service has not been shown to be related to service. The VA examiner in April 2011 concluded that the Veteran's current pulmonary disability was not related to military service, to include exposure to asbestos. In support of this opinion, the examiner stated that despite the high probability that the Veteran was exposed to asbestos in service, based on the lack of evidence of asbestosis on X-ray and the Veteran's history of heavy smoking for his entire adult life, asbestos is not related to the Veteran's obstructive lung disease. There is no other clinical opinion otherwise relating the Veteran's pulmonary disability to service. The Board finds the VA opinion to be competent, highly probative medical evidence as to whether the Veteran's current pulmonary disability was caused by his service. It was based on a thorough review of the Veteran's records, including the personal interview with the Veteran, and was supported by an adequate rationale consistent with the other medical evidence of record. With respect to the Veteran's contentions that his pulmonary disability is related to his exposure to asbestos while serving aboard a naval ship, the Veteran has not demonstrated that he has expertise in medical matters. While there is no bright line exclusionary rule that a lay person cannot provide opinion evidence as to a nexus between an in-service event and a current condition, not all medical questions lend themselves to lay opinion evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) referred to Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) for guidance. In footnote 4 of Jandreau, the Federal Circuit indicated that the complexity of the claimed disability is to be considered in determining whether lay evidence is competent. As to a nexus opinion relating his current pulmonary disability to his service, the Board finds that the etiology of the Veteran's obstructive lung disease is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. The Veteran has not been shown to have had the requisite medical training. Thus, the Veteran is not competent to render a medical opinion as to etiology of pulmonary disease in this case. Based on the evidence of record, the Board finds that the preponderance of the evidence is against the claim for service connection for a pulmonary disability. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Hypertension and Cardiovascular Disability The Veteran seeks service connection for a cardiovascular disability and hypertension as secondary to his diabetes mellitus. However, as service connection for diabetes mellitus is not established in this case, the Board's discussion of these issues will be on a direct-incurrence/aggravation service connection basis only. The Veteran's April 1967 pre-induction examination report noted a blood pressure reading of 132/88 mm/Hg. Physical examination of the heart was normal. In a report of medical history completed by the Veteran at that time, he denied a history of high or low blood pressure. In a November 1968 service treatment report, the Veteran complained of left-sided and sternal chest pain, radiating to the left side of the neck. Physical examination of the heart was unremarkable. His May 1970 separation examination report noted a blood pressure reading of 128/82 mm/Hg. Private treatment records from the Porter Memorial Hospital dated from January to September 2003 reflect that the Veteran was admitted for chest pain and underwent a coronary arteriography which showed severe stenosis in the obtuse marginal artery, circumflex and the right coronary arteries. The diagnosis was coronary atherosclerosis. He underwent multiple percutaneous coronary angioplasties and was stented. Private treatment records covering the period from January to September 2006 reflect diagnoses of hypertension. In August 2006, the Veteran had a recurrence of his chest pain, and underwent an exercise stress test, which was abnormal, and a repeat coronary angiogram which showed high grade stenosis in the right coronary artery. He had a stent placed in the right coronary artery. Following a treadmill stress evaluation in September 2006, the impressions were myocardial ischemia involving a small segment of the apical portion of the inferior wall of the left ventricle and a previous small myocardial infarction that involved the mid segment of the inferior wall of the left ventricle. Cardiolite stress test in August 2007 additionally showed possible ischemic changes along the basal and mid segments of the anterior wall of the left ventricle. The Veteran was provided a VA examination in April 2011 in conjunction with his claims regarding cardiovascular disabilities. The VA examiner noted diagnoses of moderately severe coronary artery disease and moderately severe hypertension, which was of greater than 20 years duration and under fair control on medications. The April 2011 VA examiner stated that the Veteran's blood pressure readings on his service entrance and separation examinations both represented pre-hypertension in a person who was between 18 and 20 years old when these two measurements were taken. The examiner added that these were abnormal blood pressures for a teenager or a person in his early 20s and that "as such, it is at least as likely as not, at least 50% probability, that the veteran's hypertension diagnosed today is related to these abnormal blood pressure readings taken while the veteran was a young man in the military service." The examiner further noted that the overwhelming majority of people with pre-hypertension go on to get hypertension, as the Veteran did, and that there is a clear continuum in the progression of the condition over time. With regard to the coronary artery disease, the examiner stated that hypertension is one of the leading causes of coronary artery disease and that although the Veteran had one isolated episode of chest pain in 1968 in service, it is less likely as not, less than 50 percent probability, that that specific episode of chest pain was related to the Veteran's current coronary artery disease. The examiner provided the following rationale: ...the development of coronary artery disease takes many years to occur. It is highly unlikely that a 19-year-old man, who has chest pain, has coronary artery disease as its origin. There was no recurrence of this until the [V]eteran was in his early 50s; however, the relationship between the hypertension and the subsequent development of the coronary artery disease exists... In October 2011, after reviewing the Veteran's claims file, a VA physician's assistant stated that "I am unable to determine if pre hypertension existed prior to induction into service with information available. There is only one bp [(blood pressure)] reading 132/88 on 4/1967 exam and no other bp documentation until time of exit from service 5/1970 when bp was 128/82.. There is no documented history of border line- hypertension in the c file. To be classified as having hypertension-pre hypertension by todays standards, he would need 3 day of bp checks with 2 or 3 reading/visit." As to whether the pre-hypertension aggravated beyond the natural progression of the disability by the Veteran's military service, the October 2011 VA examiner answered in the negative explaining that the Veteran's second bp reading was lower than the first one. The law provides that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1110, 1111 (West 2002). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (2012). When no pre-existing condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both pre-existing and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the pre-existing condition." 38 U.S.C. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under 38 U.S.C.A. § 1111, the veteran's claim is one for service connection. Conversely, if a pre-existing disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. See Wagner, 370 F. 3d at 1094-1096. In that case, 38 U.S.C.A. § 1153 applies and the question becomes whether the disability worsened in service. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C.A. § 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306 (2006); Jensen, 19 F.3d at 1417; Wagner, 370 F. 3d at 1096 (Fed. Cir. 2004). 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. 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition itself, as contrasted with mere symptoms, has worsened. See Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Green v. Derwinski, 1 Vet. App. 320, 323 (1991); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The presumption of sound condition on service entrance does not apply in this case because there is evidence prior to service entrance that the Veteran had pre-hypertension on his April 1967 pre-induction examination. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b). In this regard, while the October 2011 VA examiner's opinion remains inconclusive as to whether the Veteran had a pre-existing condition of pre-hypertension, the April 2011 VA examiner provided a clear opinion that the Veteran's blood pressure readings in service represented pre-hypertension because the blood pressure readings were abnormal for a person who was between 18 and 20 years old. The Board finds that the April 2011 VA examiner's opinion is sufficient because such opinion was rendered by a medical professional who is competent to offer a medical diagnosis and was supported by an adequate rationale. For this reason, the Board finds that the Veteran had pre-hypertension prior to service entrance. The issue thus becomes whether the Veteran's pre-existing disorder was aggravated during or due to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. While no other blood pressure readings are available in service treatment records other than that taken at the time of service separation, neither the April 2011 nor the October 2011 VA examiner's opinion indicates worsening of pre-hypertension in service. The April 2011 VA examiner simply noted that the overwhelming majority of people with pre-hypertension go on to get hypertension, as the Veteran did, and there is a clear continuum in the progression of this over time. This statement appears to suggest that the Veteran's current hypertension is a result of a natural progression of his pre-hypertension shown prior to and during service. The October 2011 VA examiner opined that the pre-hypertension was not aggravated beyond the natural progression of the disability by the Veteran's military service, because the Veteran's blood pressure reading at service separation was in fact lower than the blood pressure reading taken on service entrance. This opinion was based on a thorough review of the Veteran's records, including his reported history, and was supported by a rationale consistent in finding that there was no aggravation. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (holding that 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). As such, the Board finds that there was no evidence of aggravation of the Veteran's preexisting pre-hypertension in service. With respect to the Veteran's claim for cardiovascular disability, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as cardiovascular-renal disease, including arteriosclerosis, are presumed to have been incurred in, or aggravated by, service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this case, the Veteran's cardiovascular disability was first manifested many years after service and has not been shown to be etiologically related to service. Service treatment records are negative for any cardiovascular condition other than a single episode of chest pain of unknown etiology, and the Veteran has reported that he had no symptoms in service and that he was not diagnosed with a cardiovascular condition in service, or within one year after separation from service. To that effect, during his March 2009 DRO hearing, the Veteran testified that he was not diagnosed with a cardiovascular disability in service, or within one year after separation from service. During his May 2010 hearing before the Board, the Veteran testified that he had no symptoms in service. He stated that he had two heart attacks, with the first one having occurred 5 years previously, and four stents placed in his arteries. As such, the Board finds that the Veteran's current cardiovascular disability did not manifest in service, or within one year of separation from service. Therefore, service connection for a cardiovascular disability, diagnosed as coronary atherosclerosis or coronary artery disease in this case, is not warranted on a presumptive direct incurrence basis. See 38 C.F.R. §§ 3.307, 3.309. Further, the Veteran does not contend, and the record does not demonstrate, continuity of symptomatology since service. 38 C.F.R. § 3.303(b); also see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a)). Additionally, the probative and competent evidence of record does not relate the Veteran's current cardiovascular disability to his military service. The April 2011 VA examiner opined that it was less likely as not, less than 50 percent probability, that the episode of chest pain in service was related to the Veteran's current coronary artery disease. In support of the opinion, the examiner noted that although the Veteran had one isolated episode of chest pain in 1968 in service, development of coronary artery disease takes many years to occur and it is highly unlikely that a 19-year-old man, who has chest pain, has coronary artery disease as its origin given that there was no recurrence of chest pain until the Veteran was in his early 50s. There is no contrary medical opinion of record. The Veteran is certainly competent to testify as to symptoms, such as observable symptoms relating to his claimed disabilities. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (certain disabilities are not conditions capable of lay diagnosis). However, to the extent that the Veteran contends that his pre-hypertension that existed prior to service was permanently aggravated by service or that his cardiovascular disability was incurred in service, he has not demonstrated that he is qualified through specialized education, training or experience to offer an opinion on such complex medical matters. See Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1377. The Board finds that the etiology of the Veteran's cardiovascular disabilities, including hypertension, is too complex an issue, one typically determined by persons with medical training, to lend itself to lay opinion evidence. Thus, the Veteran is not competent to render a medical etiology of diseases involving the cardiovascular system as such is not observable but concerns the pathological process within the body. The question of etiology in this case requires medical evidence. Such evidence is against the claims in this case. Further, any probative value in the Veteran's lay opinion regarding the etiology of his cardiovascular disability and hypertension is outweighed by the opinion of the April and October 2011 VA examiners who are medical professionals. Accordingly, the Board concludes that the Veteran's pre-hypertension that preexisted service entrance was not aggravated during or due to service. The Board also concludes that the Veteran's cardiovascular disability was not incurred during or due to his service. As the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a pulmonary disability is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a cardiovascular disability is denied. ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs