Citation Nr: 1336853 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 07-35 934 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for a cardiac disorder, to include as secondary to the service-connected psychiatric disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION The Veteran/appellant served on active duty in the United States Navy from October 1972 to March 1975. This case originally came before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in St. Paul, Minnesota that denied his claim of entitlement to service connection for heart disease, status post myocardial infarction and coronary artery stenting. The Board remanded the case for additional development in September 2011. The case has now been returned to the Board for appellate review. The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability which may reasonably be encompassed by the claimant's description of the claim, the reported symptoms, and any other pertinent information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (per curiam). That holding was expanded to encompass other conditions in Brokowski v. Shinseki, 23 Vet. App. 79, 85 (2009) (claimant's identification of the benefit sought does not require technical precision). Review of the medical evidence of record reveals that the appellant has been diagnosed with atherosclerotic cardiovascular disease and hypertension, status post myocardial infarction and coronary artery stenting. The Board has therefore recharacterized the issue on appeal as listed on the first page. In addition to the paper claims files, there is an electronic file (Virtual VA) associated with the claim. Virtual VA does not currently contain evidence pertinent to the claim that is not included in the paper claims file. FINDINGS OF FACT 1. Neither hypertension nor any atherosclerotic cardiovascular disease or other heart disease was noted in service; the appellant's blood pressure reading, physical examination and chest x-ray were normal at the time of his service separation examination. 2. Neither hypertension nor atherosclerotic cardiovascular disease or any other cardiac disorder was diagnosed or clinically identified within one year after the Veteran's separation from service in March 1975. 3. A diagnosis of hypertension was rendered in August 1997, and the appellant experienced a myocardial infarction due to atherosclerotic cardiovascular disease in March 2006, and again in May 2007. 4. There is no competent medical evidence of any nexus between the appellant's current hypertension, atherosclerotic cardiovascular disease or any other cardiac disorder and his active service or a service-connected disability. 5. The competent and probative medical evidence preponderates against a finding that the appellant has any cardiac disorder that is due to any incident or event in military service, to include as proximately due to, the result of, or aggravated by, any service-connected disability, or that hypertension or atherosclerotic cardiovascular disease or any other cardiac disorder was manifested to a degree of ten percent or more within one year after service separation. CONCLUSION OF LAW The criteria for the establishment of service connection for hypertension or atherosclerotic cardiovascular disease or any other cardiac disorder, on theories of entitlement including direct, presumptive, secondary and aggravation, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1154, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran contends that he is entitled to service connection for a cardiac disorder, to include hypertension and atherosclerotic cardiovascular disease with myocardial infarction, because his heart disease was caused or aggravated by his service-connected psychiatric disorder. He has submitted medical literature to support the contention that the cardiac conditions are caused by or aggravated by the service-connected psychiatric disorder. He maintains that his service-connected psychiatric disorder and his claimed cardiac pathology are causally interconnected. I. Duty to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The 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). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The duty to notify was satisfied by a letter sent in November 2006 (sent prior to the initial unfavorable decision in January 2007). That letter addressed all of the notice elements. Thus, the appellant has been provided adequate notice with regard to the service connection claim. With respect to the Dingess requirements, the appellant was provided with the relevant information in the November 2006 VA letter. Moreover, the record shows that the appellant was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claim. See Overton v. Nicholson, 20 Vet. App. 427 (2006). Thus, based on the record as a whole, the Board finds that a reasonable person would have understood from the information that VA provided to the appellant what was necessary to substantiate his service connection claim, and as such, that he had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication was not affected. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Here, relevant service medical treatment records, VA outpatient treatment records and private treatment records have been obtained and associated with the claims file. In June 2008, the RO obtained a medical opinion on the question of the etiology of the appellant's current cardiac disorders; this opinion was supplemented by a September 2011 addendum. A Court or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). In this case, the RO obtained VA medical treatment records. The RO also obtained an etiologic opinion from the physician would conducted the June 2008 VA examination as directed by the September 2011 Board remand. Therefore, substantial compliance has been achieved. A medical opinion is adequate for claims purposes when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The June 2008 medical opinion, with an addendum dated in September 2011, was rendered by a medical professional, and the associated report with addendum reflects review of the appellant's prior medical records. The opinion included descriptions of the history and symptoms for the claimed heart disease and demonstrated objective evaluations. The VA physician was able to assess the nature, risk factors, and etiology of the appellant's claimed cardiac disorders, including hypertension and atherosclerotic cardiovascular disease with myocardial infarction. The Board finds that the June 2008 medical opinion report, including the September 2011 addendum, is sufficiently detailed with recorded history and clinical findings. In addition, it is not shown the report was in any way incorrectly prepared or that the VA physician failed to address the clinical significance of the appellant's claimed condition. As a result, the Board finds that additional development by way of another opinion or by way of an examination would be redundant and unnecessary. See 38 C.F.R. § 3.326 and 38 C.F.R. § 3.327 and Green v. Derwinski, supra. Therefore, the Board concludes that the appellant was afforded an adequate medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that the information provided to the appellant complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify and assist. In addition, the rating decision, along with the June 2007 Statement of the Case (SOC) and the July 2008, October 2008 and June 2012 Supplemental Statements of the Case (SSOCs) explained the basis for the RO's actions, and provided him with opportunities to submit more evidence. It appears that all obtainable evidence identified by the appellant relative to his cardiac disorder claim has been obtained and associated with the claims file, and that he has not identified any other available pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. It is therefore the Board's conclusion that the appellant has been provided with every opportunity to submit evidence and argument in support of his service connection claim, and to respond to VA notices. The appellant was provided with notice as to the medical evidence needed for service connection, as well as the assistance VA would provide and he was supplied with the text of 38 C.F.R. § 3.159. Therefore, there is no duty to assist that was unmet and the Board finds no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (where the Board addresses a question that has not been addressed by the agency of original jurisdiction, the Board must consider whether the veteran has been prejudiced thereby). Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). All relevant facts with respect to the service connection claim addressed in the decision below have been properly developed. Under the circumstances of this case, a remand would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). II. Merits of the Claim The appellant contends that he is entitled to service connection for a cardiac disorder, including hypertension and atherosclerotic cardiovascular disease with myocardial infarction, because he is service-connected for a psychiatric disorder and this condition has caused him to develop cardiac disease or in, the alternative, that his disability make his cardiac disease worse. In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim. The appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In order to establish service connection for a claimed disability, the facts, as shown by evidence, must demonstrate that a particular disease or injury resulting in a current disability was incurred during active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Furthermore, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability resulting from a disease or injury incurred in service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a chronic disease under 38 C.F.R. § 3.309(a) is "shown as such in service" ("meaning clearly diagnosed beyond legitimate question" Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)), or in the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is "shown as such in service", the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service connected disability compensation is sought." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Instead, service connection may be granted for subsequent manifestations of the same chronic disease without any evidence of link or connection between the chronic disease shown in service and manifestations of the same disease at a later time. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. § 3.303(b). A veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). See also Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). For VA purposes, 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. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Certain chronic disabilities, such as cardiovascular disease (including hypertension), may be presumed to have been incurred in service if they become manifest to a degree of 10 percent or more within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. When a veteran is found not to be entitled to a legal presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a another basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Under 38 C.F.R. § 3.310(a), service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 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) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a non-service-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. Aggravation will be established by determining the baseline level of severity of the non-service-connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310(b). During the pendency of this claim and appeal, an amendment was made to the provisions of 38 C.F.R. § 3.310. 71 Fed. Reg. 52,744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, supra, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of secondary service connection may be made. This had not been VA's practice, which suggests that the recent change amounts to a substantive change. The present case predates the regulatory change (July 2006). Given what appear to be substantive changes, the Board's analysis of secondary service connection in the present appeal considers the version of 38 C.F.R. § 3.310 in effect before the change, which version is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. Review of the appellant's service medical treatment records reveals that the appellant underwent a service entrance examination in September 1972. His clinical evaluation was normal and his chest x-ray was negative. His blood pressure reading was recorded as 134/86. The service medical records do not reflect any diagnosis of, complaint of, or treatment for, any cardiac disorder. The appellant underwent a service separation examination in February 1975. His clinical evaluation was normal and his chest x-ray was within normal limits. His blood pressure reading was recorded as 120/80. The first post-service medical treatment records are dated in 1997, and relate to the appellant's inpatient treatment at two private facilities for a psychiatric disorder and ethanol abuse. A County Health Center progress note dated August 5, 1997, indicates that the appellant described problems with drugs and alcohol since the age of fifteen. He also stated that he had had behavior problems as a youngster. A week later, another progress note indicated that it had been noticed that the appellant's blood pressure had been elevated and that EKG testing had led to an impression of probable anxiety/panic symptomatology. Medical for hypertension was prescribed. The discharge report states that high blood pressure that was known to the appellant since 1990 was treated during the hospitalization. The appellant was also diagnosed with major depression and an anxiety disorder. The appellant underwent a VA general medical examination in November 2005. Blood pressure readings of 140/94, 138/100, and 140/100 were recorded. The appellant stated that he had started on blood pressure medication approximately a month-and-a-half earlier. The examiner noted that the appellant continued to use alcohol and that he had active tobacco use disorder. The appellant denied chest pain and he also said that his shortness of breath was "normal with smoking." The examiner rendered a diagnosis of hypertension under treatment. No other cardiac disorder was diagnosed. Review of the appellant's VA treatment records, dated between March 2005 and August 2011, reflect that the appellant experienced a myocardial infarction in March 2006. He underwent coronary artery stenting in a VA facility that same month. The appellant was also treated for non-cardiac chest pain due to a panic attack in April 2006. A May 2006 cardiac consultation note indicates that the appellant was doing well in relation to his arteriosclerotic cardiovascular disease (ASCVD) and that his blood pressure was controlled on his current medication. The appellant's lipids had inadequate control, but no medications could be used due to the elevated liver enzymes due to ethanol use by the appellant. A September 2006 mental health provider note stated that the appellant was taking multiple medications, including for hypertension, cholesterol, depression and anxiety. In May 2007, the appellant experienced another myocardial infarction and underwent a three-vessel coronary artery bypass procedure. An October 2010 urgent care note indicates that the appellant complained of chest pressure. An EKG showed a normal sinus rhythm without any acute changes; comparison was made to an April 2009 EKG. The appellant was noted to have a known history of coronary artery disease and there was concern for unstable angina. A November 2010 nursing note indicates that the appellant was seeking a cardiology consultation because he was concerned about his blood pressure. A physician subsequently stated that the appellant's blood pressure readings were acceptable. A February 2011 primary care note indicates that the appellant was being followed up after a medication change; he reported that his blood pressure was significantly better and that he was tolerating the medication without side effects. The appellant's blood pressure reading was 125/82. The clinical assessment was hypertension, control improved. The appellant was afforded a cardiology consultation in July 2011; it was noted that the appellant had not had symptoms of late. The physician stated that a 2009 stress cardiogram had revealed a normal ejection fraction and normal wall motion with a normal response to dobutamine infusion. The doctor also noted that the appellant was sedentary and that he had hypertension and hyperlipidemia both of which were reasonably controlled. The appellant's blood pressure reading was 114/80. The physician stated that lifestyle modification (diet and exercise) remained the single most important intervention the appellant could pursue towards further reducing his ongoing cardiovascular risk. However, the cardiologist concluded there were no pressing matters for further adjustment other than the indication for some physical exercise. The appellant underwent a VA medical examination in June 2008; the examining physician reviewed the claims file. The examiner noted that the appellant had quit smoking after his second myocardial infarction in May 2007; the appellant had started smoking at age ten, and drinking at age fifteen. The examiner noted that the appellant was on multiple medications, including for hypertension, cholesterol, heart, psychiatric and stomach. The appellant denied chest pain and shortness of breath at rest, but he did report having dyspnea with exertion. Blood pressure readings of 129/72, 129/95 and 128/97 were recorded. The appellant underwent an electrocardiogram which was negative. A chest x-ray indicated that the cardiac size was normal. No acute cardiopulmonary process was evident. The examiner concluded that the appellant's heart condition was multi-factorial due to hypercholesterolemia, hyperlipidemia, hypertension, obesity, elevated blood glucose and cigarette smoking. The physician opined that the appellant's heart condition was not due to, or secondary to, his chronic adjustment disorder with mixed anxiety, depression or mood. In a September 2011 addendum report, the examining physician indicated that she had reviewed the claims file. She opined that it was less likely than not that the appellant's claimed condition was incurred in or related to service or an in-service event. The examiner stated that while stress can have a transient effect on hypertension, it does not change the underlying pathology. The doctor said that the appellant would have had coronary artery disease and hypertension regardless of his mental health issues. In relation to the articles submitted by the appellant about the relationship between depression and cardiovascular health, the doctor stated that there are no controlled prospective double-blinded studies with statistically significant numbers to establish a cause and effect relationship between hypertension, ischemic heart disease and mental health conditions. In addition, the examiner stated that the appellant's February 1975 separation examination documented a normal blood pressure and that the appellant was not treated for hypertension or coronary artery disease in service. As previously noted, to establish service connection for a disability, symptoms during service, or within a reasonable time thereafter, must be identifiable as manifestations of a chronic disease or permanent effects of an injury. Further, a present disability must exist at some point during the claim process, and it must be shown that the present disability is the same disease or injury, or the result of disease or injury incurred in or made worse by the appellant's military service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); 38 C.F.R. § 3.303(a); McClain v. Nicholson, 21 Vet. App. 319 (2007). "[I]n order to establish service connection or service-connected aggravation for a present disability the veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Board finds that the preponderance of the competent evidence is against a finding of a nexus between the appellant's cardiac pathology, to include hypertension and atherosclerotic cardiovascular disease with myocardial infarction, and his active service. The appellant has never contended that he had hypertension or other cardiac disorder in service and the evidence of record does not demonstrate that the appellant was ever diagnosed with hypertension or other cardiac disorder while he was in service. In addition, the record reflects, and the appellant himself has reported, that the appellant never served in the Republic of Vietnam (or the Southwest Asia Theater) and there is no alleged herbicide exposure. Therefore, the presumptive service connection provisions of 38 C.F.R. § 3.309(e) relating to certain cardiovascular diseases due to herbicide exposure are not for application. Furthermore, with respect to presumptive service connection, the evidence does not show that hypertension or any other cardiac disorder was manifested to a compensable degree within a year of the appellant's discharge from service in 1975. The first clinical evidence in the record of a diagnosis of hypertension is in 1997, although the appellant indicated at that time he had known of it since 1990. Accordingly, service connection is not warranted on a direct basis or a presumptive basis for the appellant's active duty. The appellant's primary assertion is that his cardiac pathology is caused by, or made worse by, his service-connected psychiatric disability. As to secondary service connection, the record indicates that he has been in receipt of service connection for a psychiatric disability since October 2004. Review of the Veteran's VA medical records, i.e., those involving treatment for the service-connected psychiatric disorder and the nonservice-connected hypertension and cardiovascular disease, reveals no causal linkage expressed in the medical evidence of record. In addition, the June 2008 VA medical opinion (with September 2011 addendum) states that the appellant's cardiac pathology was not caused by, or related in any way to the service-connected psychiatric disability. Furthermore, the evidence of record reflects that the appellant's blood pressure has been adequately controlled with medication. A March 2005 rating decision indicates that nonservice-connected pension benefits were granted, effective from October 2004, and that a 10 percent evaluation for pension purposes had been assigned for hypertension under Diagnostic Code 7101. The evidence of record does not show that the appellant's blood pressure has ever been manifested by diastolic pressure at predominantly 110 or more or by systolic pressure at predominantly 200 or more, as required by the next higher rating under Diagnostic Code 7101. Therefore, the Board finds that the preponderance of the competent evidence is against a finding that hypertension had ever approximated the requirements for more than the 10 percent disability evaluation that was assigned for pension purposes as of October 2004. Rather, if the Veteran's hypertension had been service-connected as of October 2004, a 10 percent evaluation would have been assigned at that time and currently. Thus, there is no clinical evidence of record to indicate that his hypertension has increased in severity at any point up since October 2004 to the present time. The same hold true for the appellant's coronary artery disease. While he has been in continuous medical treatment for his atherosclerotic cardiovascular disease since his March 2006 myocardial infarction and May 2007 bypass surgery, there is no clinical evidence of record demonstrating the existence of cardiac hypertrophy or dilatation or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. See 38 C.F.R. § 4.104, Diagnostic Code 7005 (CAD). As reflected by the July 2011 VA cardiology consultation report, the appellant had not had symptoms, his hyperlipidemia and hypertension were controlled and there were no pressing matters for adjustment. The Veteran has also contended that his psychiatric disability caused him to develop risk factors that are etiologically related to the development of heart disease. Namely, he relates his smoking to his psychiatric disability. However, as discussed above, the record reflects that the appellant he had started smoking at the age of 10 years and that he had quit smoking after his bypass surgery. Thus, despite his psychiatric disability, the appellant was able to stop smoking in May 2007, and the record reflects that he has been compliant with medical follow-up and taking medications for his heart problem and hyperlipidemia/hypercholesterolemia. In addition, the June 2008 VA opinion (with September 2011 addendum) addressed these points; the examining physician indicated that the psychiatric disability did not cause the Veteran's cardiac pathology nor was it an underlying cause. Thus, the preponderance of the probative evidence is against the Veteran's secondary service connection claim - the weight of the evidence does not demonstrate, or approximate, findings supportive of linkage between the psychiatric disability and any cardiac disorder, including atherosclerotic cardiovascular disease, myocardial infarction and hypertension. There is no probative opinion of record that provides an etiologic link, whether by causation or by aggravation, between the Veteran's current cardiac pathology (including hypertension and atherosclerotic cardiovascular disease) and his service-connected psychiatric disability. The Board has considered the Veteran's statements submitted in support of his claim that his current cardiac pathology is etiologically related to his psychiatric disability. To the extent that such statements represent evidence of continuity of symptomatology, without more, they are not competent evidence of a diagnosis, nor do they establish a nexus between any acquired pathology and his psychiatric disability. Although claimants may be competent to provide the diagnoses of simple conditions, such as a broken leg, they are not competent to provide evidence on more complex medical questions beyond simple observations. See 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); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia aggravated his diabetes and hypertension was not of sufficient weight to trigger the Secretary's duty to seek a medical opinion on the issue). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. 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"). The Board recognizes that a veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). While the appellant is competent to say that he has been treated for psychiatric problems and for cardiac conditions, he does not have the expertise to state that there is an etiologic relationship between any incident of service or service-connected disability and any current cardiac disorder; a medical opinion would be required. See Davidson v. Shinseki, 581 F.3d 1313 (Fed Cir. 2009). The same holds true for the appellant's representative. The resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, requires professional evidence. Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). A veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau; Buchanan; both supra (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Although lay evidence is acceptable to prove the occurrence of an injury during active duty or symptomatology over a period of time when such symptomatology is within the purview of or may be readily recognized by lay persons, lay testimony is not competent to prove a matter requiring medical expertise. Cardiac pathology requires specialized training for a determination as to diagnosis and causation and is not susceptible of lay opinions on etiology. Therefore, the Board cannot give decisive probative weight to the opinions of the Veteran about the origins of his hypertension or atherosclerotic cardiovascular disease with myocardial infarction because he is not qualified to offer such opinions. In addition, the matter of aggravation of a disorder is within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As the Veteran is not shown to be other than a layperson without the appropriate medical training and expertise, he is not competent to render a probative (persuasive) opinion on a medical matter. Hence, the lay assertions in this regard have no probative value. The evidence of record also includes articles and extracts of articles relating to hypertension, atherosclerotic cardiovascular disease, cardiac disease and psychiatric disorders such as depression. The Veteran obtained this information from the internet or other sources and submitted it without any reference to it by any health care professional. In addition, it has not been explained how these articles relate to the claim. The Court has held that generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish the nexus element. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Medical treatise information may be regarded as competent evidence where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 513 (1998). Furthermore, these articles reflect hypotheses and suggestive findings but not any delineation of exact mechanisms and the underlying associations are described as still uncertain. As noted in the September 2011 addendum report from the VA physician who examined the appellant in June 2008, there are no controlled prospective double-blinded studies with statistically significant numbers to establish a cause and effect relationship between hypertension, ischemic heart disease and mental health conditions. None of the material submitted in this case appears to meet the standard set forth in Wallin, because none of it delves into an association between the Veteran's service or his service-connected psychiatric disability and his currently demonstrated atherosclerotic cardiovascular disease, hypertension, or any other cardiac condition. These articles and excerpts proffered are not regarded as germane, as not one of them applies the specific facts to this specific case. Sacks v. West, 11 Vet. App. 314, 317 (1998). Service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The Board finds that the preponderance of the competent evidence is against a finding of a nexus between the Veteran's hypertension, atherosclerotic cardiovascular disease or any other cardiac disorder and his active service, including his service-connected psychiatric disability, despite his contentions to the contrary. In that regard the Board finds substantially probative the June 2008 VA medical opinion with September 2011 addendum undertaken specifically to address the matter on appeal. The opinion was rendered after review of the Veteran's claims file, including his service medical records; the opinions are clearly based on an accurate history. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (finding that a physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion). The only evidence of record to support the Veteran's contentions comes from the medical articles discussed above and his statements; however, the Board finds that these pieces of evidence are of minimal probative value, because they are generic in nature and do not provide a probative medical rationale which is specific to the Veteran's medical history. Instead the articles refer to a general or possible relationship between psychiatric disorders and cardiac disorders. The Board notes that the award of benefits may not be predicated on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; see Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (physician's comment couched in terms of "may or may not" was held to be speculative); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the veteran "may" have had pertinent symptoms also implied "may or may not", and was deemed speculative). Any medical opinion to the effect that it is possible that there is some connection between the Veteran's psychiatric disability and his hypertension or other cardiac disorder is therefore not probative. Further, as noted above, neither the Veteran nor his representative is competent to render a probative (persuasive) opinion on a medical matter. The language of 38 C.F.R. § 3.310 requires consideration of whether service-connected disability has made the claimed disability chronically worse, even if the service-connected disability did not cause the claimed disability. However, in this case, there is no competent evidence of record to suggest that the Veteran's psychiatric disability has either caused or aggravated any cardiac disorder, including hypertension and atherosclerotic cardiovascular disease with myocardial infarction. After consideration of the entire record and the relevant law and cases, the Board finds that the appellant's claimed cardiac pathology, including atherosclerotic cardiovascular disease and hypertension is not related to his active service. While it is apparent that the appellant does suffer from hypertension and atherosclerotic cardiovascular disease, the medical evidence of record as a whole supports the proposition that there is no etiological relationship between the origin and/or severity of any such condition and service. The Board has scrutinized the record with a view towards ascertaining whether there is any basis (e.g., direct, presumptive or secondary) to indicate that the claimed cardiac pathology, including hypertension and atherosclerotic cardiovascular disease, was incurred by any incident of military service, but it has gleaned no such supporting evidence or suggestion thereof. Schroeder v. West, 212 F.3d 1265 (Fed. Cir 2000); Combee, 34 F.3d at 1043 (Both for the general proposition that in claims involving presumptive service connection, the Board must also examine the evidence of record to ascertain if there is any other basis upon which to develop or grant the claim, including direct service connection). See Bingham v. Principi, 421 F.3d 1346 (Fed. Cir. 2005); Roebuck v. Nicholson, 20 Vet. App. 307, 312-313 (2006). Therefore, the Board finds that the preponderance of the evidence is against the appellant's claim of service connection for a cardiac disorder, to include hypertension and atherosclerotic cardiovascular disease with myocardial infarction, to include as secondary to service-connection disability and by way of aggravation. As a result, the evidence is insufficient to support a grant of service connection for any cardiac disorder. For the above reasons, the Board finds that the preponderance of the evidence is against the appellant's claim of entitlement to service connection for a cardiac disorder, to include hypertension and atherosclerotic cardiovascular disease. Because the preponderance of the evidence is against the cardiac disorder service connection claim, the benefit of the doubt doctrine does not apply. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). ORDER Entitlement to service connection for a cardiac disorder, to include hypertension and atherosclerotic cardiovascular disease with myocardial infarction, and claimed as secondary to the service-connected psychiatric disability, is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs