Citation Nr: 1323044 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 10-31 185 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a lung disorder claimed as emphysema. 2. Entitlement to service connection for a heart disorder to include as secondary to the claimed lung disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active duty from January 1954 to December 1956. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a March 2009 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Veteran requested a Travel Board hearing on the July 2010 Form 9. However, the Veteran later submitted a February 2012 statement canceling his request for a Travel Board Hearing. In an August 2012 decision the Board disposed of other issues on appeal and remanded the issues of service connection for a lung disorder and a heart disorder to the RO for further development. Such has been completed and this matter is returned to the Board for further review. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The evidence does not demonstrate that the Veteran's currently diagnosed lung disorder, to include COPD, asthma, and obesity hypoventilation syndrome with respiratory failure is related to his active service including any incident therein, to include asbestos exposure, nor is it shown that a preexisting asthma was aggravated beyond natural progression by service. 2. The evidence does not demonstrate that the Veteran's currently diagnosed heart disorder to include acute, subacute or old myocardial infarction, coronary artery disease, congestive heart failure and cor pulmonale is related to his active service, nor was a cardiovascular-renal disorder shown to have been manifested within the first post service year, nor is it shown to have been caused or aggravated by any service connected disorder. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for a lung disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2012). 2. The criteria for a grant of service connection for a heart disorder has not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). 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); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the duty to notify was satisfied by way of a letter sent to the Veteran in November 2008 that fully addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letter informed the Veteran of what evidence was required to substantiate the claim and of the Veteran's and VA's respective duties for obtaining evidence. This letter also provided notice regarding how disability ratings and effective dates are assigned if service connection is awarded. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In a case such as this, where it appears that the Veteran's service treatment records were destroyed in the 1973 fire at the National Personnel Records Center (NPRC), the Board's obligation to explain its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule, is heightened. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992); Ussery v. Brown, 8 Vet. App. 64 (1995); Russo v. Brown, 9 Vet. App. 46 (1996). The Board must note; however, the O'Hare precedent does not raise a presumption that the missing service treatment records would, if they still existed, necessarily support the Veteran's claim. Case law does not establish a heightened 'benefit of the doubt,' only a heightened duty of the Board to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision when the appellant's medical records have been destroyed. See Ussery v. Brown, 8 Vet. App. 64 (1995). Similarly, the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant. See Russo v. Brown, 9 Vet. App. 46 (1996). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (2012) (harmless error). In view of the foregoing, the Board finds that the appellant was notified and aware of the evidence needed to substantiate his claim, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO obtained the Veteran's VA medical records, and provided him with VA medical examinations for his lung and heart disorders in February 2013, with addendum confirming claims file review in May 2012. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran 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). II. Service Connection Service connection may be granted for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1131. Certain chronic diseases, to include cardiovascular-renal disease if manifest to a compensable degree within one year after separation from service, may be presumed to have been incurred in service. See 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Service connection is available for a preexisting condition provided it was aggravated during service beyond its natural progression. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service. In order to rebut the presumption of aggravation, there must be clear and unmistakable evidence that the increase in severity was due to the natural progress of the disability. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. See 38 U.S.C.A. § 1153 (2002); 38 C.F.R. §§ 3.304, 3.306(b) (2012). A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Under VA law, every person employed in the active military, naval, or air service 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. 38 U.S.C.A. §§ 1111, 1137. In order to rebut the presumption of soundness, VA must demonstrate by clear and unmistakable evidence both that the disease or injury in question existed prior to service and that it was not aggravated by service. See VAOPGCPREC 3-2003 (July 16, 2003). Congenital or developmental defects are not diseases or injuries within the meaning of the applicable legislation and cannot be found to be service connected. See 38 C.F.R. § 3.303(c), 4.9 (2012). An exception is made is if there is evidence of additional disability due to aggravation during service of the congenital disease, but not defect, by superimposed disease or injury. VAOPGCPREC 82-90; Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90; and VAOPGCPREC 11-99. Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 38 C.F.R. § 3.310(b); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). An appellant's own conclusion, stated in support of his claim, that his present disability is secondary to his service-connected disability is not competent evidence as to the issue of medical causation. See 38 C.F.R. § 3.159 (2012); see also Grivois v. Brown, 6 Vet. App. 136 (1994). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, 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 the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. Lung Disorder and Heart Disorder The Veteran claims entitlement to service connection for disorders affecting the heart and lungs. He has alleged that his duties while in the service as a truck driver in Alaska resulted in exposure to extremely cold weather and truck fumes which he believes injured and caused his current issues with his lungs and heart. He also has alleged exposure to asbestos while recapping tires in the service at Atlanta General Depot. A secondary service connection claim has also been forwarded by his representative who in an August 2011 brief argued that a heart disorder of congestive heart failure is being caused or aggravated by his lung disorder. As noted above, the Veteran's service treatment records were not available for review. The Board notes, however, that the evidence of record contains a copy of the Veteran's DD-214 and the November 1956 separation examination. This separation examination was remarkable for findings of an abnormal examination of the lungs and chest, with a mild chest deformity documented. Otherwise the separation examination revealed normal blood pressure of 100/74, pulse of 72 sitting and pulse of 86 after exercise. His cardiovascular examination was marked as normal. Regarding his claimed exposure to cold and fumes in service, the Board observes that the Veteran is competent to state that he experienced such exposure in service. See Charles v. Principi, 16 Vet. App. 370 (2002). Moreover, his DD-214 reflects that he was a tire repairman for his military occupational specialty (MOS) and, thus, corroborates his account of in-service exposure to fumes from driving trucks. Regarding his claimed asbestos exposure from working on tires in the 1950's while performing his MOS as tire repairman, the Board notes that there is no specific statutory guidance with regard to asbestos-related claims, nor has the Secretary of VA promulgated any regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) provides guidelines for considering compensation claims based on exposure to asbestos. The DVB circular was subsumed verbatim as § 7.21 of Adjudication Procedure Manual, M21-1, Part VI. (This has now been reclassified in a revision to the Manual at M21- 1MR, Part IV, Subpart ii, Chapter 2, Section C.) See also VAOPGCPREC 4-00 (Apr. 13, 2000). The adjudication of a claim for service connection for a disability resulting from asbestos exposure should include a determination as to whether or not: (1) service records demonstrate the veteran was exposed to asbestos during service; (2) development has been accomplished sufficient to determine whether or not the veteran was exposed to asbestos either before or after service; and (3) a relationship exists between exposure to asbestos and the claimed disease in light of the latency and exposure factors. See M21-1MR, Part IV, Subpart ii, Chapter 2, Section C, Subsection (h). In this regard, the M21-1 MR provides the following non-exclusive list of asbestos-related diseases/abnormalities: asbestosis, interstitial pulmonary fibrosis, tumors, effusions and fibrosis, pleural plaques, mesotheliomas of pleura and peritoneum, lung cancer, bronchial cancer, cancer of the larynx, cancer of the pharynx, cancer of the urogenital system (except the prostate), and cancers of the gastrointestinal tract. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (b). The M21-1 MR also provides the following non-exclusive list of occupations that have higher incidents of asbestos exposure: mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and manufacture and installation of roofing and flooring materials, asbestos cement sheet and pipe products, and military equipment. See M21-1 MR, part VI, Subpart ii, Chapter 2, Section C, 9 (f). In Dyment v. West, 13 Vet. App. 141, 145 (1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of former VBA Manual M21-1, Part VI, did not create a presumption of exposure to asbestos. Medical nexus evidence is required in claims for asbestos-related disease related to alleged asbestos exposure in service. See VA O.G.C. Prec. Op. No. 04-00. Affording the Veteran the full benefit of the doubt, the Board will presume that he was exposed to asbestos during service, with likely exposure from brake linings in his MOS. However, in order to establish service connection, there still needs to be a probative nexus linking a current disability to the in-service injury. In June 1957 the Veteran was hospitalized for an acute episode of respiratory illness, when he was hospitalized for complaints of dyspnea with a history of having become ill with what he thought was a chest cold one week prior to admission. He gave a history of cough, chest tightness and mild wheezing treated with a penicillin injection that did not help. He also gave a history of having asthma at age 8 but none in the intervening years. Examination revealed mild wheezing, with examination showing increased AP diameter of the right thorax compared to the left, and coarsened breath sounds with inspiratory and expiatory wheeze. His heart was not enlarged and blood pressure was 120/68. He was treated with bedrest and medications including antibiotics and ephedrine. The diagnosis was asthma and bronchitis, acute, mild, organism unknown. Cardiovascular issues are first shown in VA records from 1989, when he was diagnosed with hypertension in August 1989 with a blood pressure of 142/90 reported. His systolic readings were 150 or higher with diastolic readings ranging from 92 to 102 between September 1989 and November 1989. He also was noted to weigh 240 1/2 pounds in October 1989. He persisted with high blood pressure in 1990. In August 1990 he reported having a blood pressure of 170/98 accompanied by bad headache the day prior to being seen by the clinic. He had a blood pressure reading of 136/92 during the visit, and an echocardiogram (EKG or ECG) also from August 1990 was normal. Chest X-ray from August 1990 was normal, with normal heart size and configuration shown, along with normal mediastinal structures. His lung fields were clear and there were no skeletal, pleural or diaphragmatic changes. An October 1990 VA examination for wrist issues revealed that he took medications for hypertension, with blood pressure of 186/102, pulse of 60 and respirations of 20 noted. Examination of the heart revealed no visible pulsation and no palpable thrills. Heart sounds were normal with no murmur. His blood pressure was noted to be 196/90 in a VA surgery clinic note from November 1990. By March 1991 he was assessed with hypertension, poorly controlled, with a new medication added to treat hypertension. His blood pressures remained elevated throughout the remainder of 1991, with the highest systolic readings above 160 and the highest diastolic readings above 100. However heart and lungs were negative for any signs of pathology on clinical examinations through 1991. He was noted to be obese in a September 1991 record. The VA records from 1992 to 1995, continued to reflect a diagnosis of hypertension in varying extents of control, but repeatedly were negative for any other significant findings regarding the heart and lungs. He was counseled about diet and exercise issues in a December 1993 record that documented his blood pressure at 172/106 and 160/96, with lungs clear and no pedal edema. By January 1994 his blood pressure was 200/112 with apparent medication issues as the Veteran complained of it tasting bad. Other blood pressure readings from January 1994 showed systolic ranges in the 160's-170's and as high as 191, with diastolics from 95 to 110. In March 1994 his hypertension was still poorly controlled despite a medication change with systolics still between 178 and 190 and diastolics between 102 and 111. However his heart was otherwise negative and lungs were clear. The issues with poorly controlled hypertension continued to be shown in a June 1994 record which again noted the Veteran to complain about the taste of his medications and indicated dietary issues persisted as he was counseled on a low cholesterol diet. In September 1995 he was described as having poorly controlled hypertension and obesity. In September 1995 his blood pressure was as high as 212/124 on small cuff reading with large cuff reading shown to be 184/24. Other readings taken showed it was 186/112 and 112/108. However his vital signs continued to be negative, with no complaints of chest pain or shortness of breath. His heart findings were normal and lungs were clear. Again he was assessed with poorly controlled hypertension and obesity. Heart and lung disorders other than hypertension and the acute episode of bronchitis/asthma (treated in 1957) are shown in April 2000, after the Veteran received inpatient treatment for an exacerbation of chronic obstructive pulmonary disease (COPD) for which a pulmonary consult was ordered. The April 2000 pulmonary consult further assessed the Veteran with acute respiratory failure on chronic, hyperoxice and hypercapneic now improving. He had chronic lung disease combined obstructive and restrictive vent disease, suspected primarily restrictive with morbid obesity and hypoventilation. He was noted to be essentially a non smoker having quit 35 years ago. He had a history of industrial exposure to dust, perhaps contributing to his loss of lung volume. He had congestive heart failure (CHF) mainly right sided, based on pulmonary hypertension, and cor pulmonale. He also had coronary artery disease (CAD) and hypertensive cardiovascular disease (HCVD). The doctor also noted that the Veteran had a non Q myocardial infarction (MI) in the past but found no evidence or history of cardiac catheterization ever done. A 2-D echo was done but its accuracy was suspect. The Veteran was said to possibly have an element of left heart failure also. Further cardiovascular workup was recommended. VA records show that in July 2003 the Veteran was prescribed home oxygen for his pulmonary condition. A September 2003 pulmonary consult noted the Veteran to have known diagnoses of COPD, obstructive sleep apnea (OSA), obesity, hyperventilation treatment on chronic CPAP. He was also noted to be continuing to gain weight. Physical examination was unremarkable and he was assessed with OSA, obesity and hyperventilation syndrome. In June 2006 the Veteran had a GI consult for diarrhea since May 2006 when he was admitted for respiratory failure, MI, renal insufficiency, morbid obesity, asthma and hypertension. VA records from 2010 and 2011 reveal continued treatment for cardiopulmonary issues, with continued home oxygen prescribed in April 2010 for history of CHF, cor pulmonale or HCT greater than 56 percent. A routine primary care follow up in August 2010 noted a problem list that included morbid obesity, hypertension NOS, asthma without status asthma, cor atherosclerosis NATV, CVSL, cor pulmonale, chronic right heart failure, CHF and impaired fasting glucose. Following physical examination which was essentially unremarkable on cardiovascular and pulmonary, aside from an elevated blood pressure reading of 163/92, the assessment was asthma without status asthma on bronchodilators, cor atherosclerosis NATV C VSL, stable on beta blockers, CHF with ejection fraction on catheterization of 45 % in 2006. Also diagnosed was ischemic heart disease CAD/CHF. Additionally morbid obesity, hypertension NOS, and acute and chronic respiratory failure were diagnosed. He persisted with routine 6 month follow-ups with essentially the same medical history on problem list, findings and diagnoses made in March 2011, September 2011, February 2012 and August 2012. He also is shown to have continued with home oxygen therapy with follow-ups recertifying such use shown in April 2011 and April 2012. He also continued to be followed up and instructed on proper diet and exercise as shown in the records up to and including August 2012. The report of a February 2013 VA cardiovascular disorders examination noted that the claims file was not available for review. The diagnoses included acute, subacute or old MI, CAD, CHF and cor pulmonale. The Veteran was noted to have a history of service from 1954 to 1956 as a truck driver in Alaska, and he gave a lay statement expressing his belief that the heart and lung conditions resulted from breathing fumes from his truck and being in cold weather. Electronic records reviewed showed the Veteran to have had a non Q wave MI in 1998 with subsequent diagnoses of CAD. He was subsequently diagnosed in 1998 or 1998 with CHF and cor pulmonale by workup in April 2000. These conditions were attributed to obesity, hypoventilation syndrome and OSA. His BMI was 48 at that time. He was noted to have had several admissions for mix of heart and lung symptoms since 1988, but none in the past year. He had no evidence of cardiac procedures or events. He currently took medications for CAD, CHD and cor pulmonale. His BMI improved to 36 the last few years. His CAD qualified as IHD. The etiology of the Veteran's known heart disabilities were as follows. First he had an old MI secondary to CAD. Secondly he had CHF and cor pulmonale secondary to obesity hypoventilation syndrome. The date of the MI was noted to have been in 1998 treated at an unknown facility. The CHF was noted to be chronic, without any episodes of acute heart failure the past couple of years. He was noted to have a number of hospitalizations between 1998 and 2006 for exacerbation of cor pulmonale, CHF, COPD and obesity hypoventilation syndrome. Examination revealed his heart rate was 74, regular rate and rhythm, normal heart sounds, obesity obscured his PMI. His lungs were clear to auscultation, he had normal peripheral pulses, no JVD. Trace peripheral edema was noted in both lower extremities. His blood pressure was 120/64. Diagnostic tests revealed evidence of cardiac dilatation on August 2012 echocardiogram, and chest X-ray showed LVEF 55%, abnormal wall motion and abnormal wall thickness. His METS was estimated from interview was 1-3 METS, this level was found to be consistent with activities such as eating, dressing, showering and slow walking. His METS limit was not solely due to his heart disorder, it was due to multiple factors including chronic respiratory failure, and it was not possible to accurately assign a percentage to his heart disorder. The medical opinion regarding etiology noted that the claims file was not available for review, but what could be determined from the evidence and exam was that the onset of the Veteran's heart condition significantly postdated service. The examiner could not find any current evidence of any asbestos related condition on which to relate a heart condition. The examiner could determine that the Veteran developed CAD and subsequently had an MI in 1998 or 1999. This was a product of atherosclerosis in the heart supported by literature to most likely be related to his lifestyle. He also developed cor pulmonale and CHF with evidence of obesity hypoventilation syndrome (Pickwickian Syndrome). This was a condition in which excessive pressure on the heart and lungs from morbid obesity will result in OSA, CHF and cor pulmonale (right sided heart failure.) Current medical literature was noted to support that causation due to obesity. The examiner could not call this a lung or heart condition as it actually was obesity causing the lung and heart conditions. Due to the distance and onset and relationship to morbid obesity, it is less likely than not that the Veteran's heart or lung conditions are due to or aggravated by any event or injury during service. The respiratory portion of this VA examination also indicated that the claims file was not available for review. His diagnoses included asthma, COPD, both diagnosed in 1998. Also diagnosed was obesity hypoventilation syndrome with chronic respiratory failure. The same history of exposure to cold and fumes as a truck driver in service was related as had been done in the cardiovascular examination. Review of the electronic records showed a history of COPD/asthma since at least 1998. He was diagnosed with obesity hypoventilation syndrome and OSA in August 1998 and confirmed by sleep study in April 2001. In the interim he was diagnosed with acute and chronic respiratory failure in April 2000 with subsequent development of CHF and cor pulmonale. The clinical picture clearly represented Pickwickian syndrome in a morbidly obese male. Again his history of his BMI having been 48 and having several admissions for combined heart and lung symptoms was noted. He was noted to use a motorized scooter for significant exertional dyspnea and BIPAP machine at night. Diagnostic tests included a chest X-ray done in February 2013 that did not show findings. He declined pulmonary function testing, despite the examiner's urging him to undergo this. The opinion regarding the etiology of Veteran's diagnosed pulmonary disorders was the same unfavorable opinion as that given in the cardiovascular examination. Again the examiner noted there was no evidence of any asbestos-related diagnosis or findings. The examiner could not make a determination as to the asthma however because of the lack of access to the claims file. It appeared the Veteran has had a worsening of asthma (interchangeably called COPD) when he developed Pickwikian syndrome. The examiner did not have any evidence that the asthma was related to any inservice event, injury or exposure. Regarding sleep apnea, diagnosed as OSA, the examiner again pointed to the unavailability of the claims file. However the history of COPD/Asthma was noted since 1998 and a diagnosis of obesity hypoventilation syndrome and OSA was confirmed by sleep study in April 2001. The opinion regarding the etiology of the OSA was the same as that given for the other respiratory disorders. In May 2013 an addendum to the February 2013 VA examination was obtained confirming claims file review. Following such review the examiner stated that the claimed condition (of the heart and lung) was less likely than not incurred in service. The rationale noted that the claims file was reviewed as well as the February 2013 VA examination in detail. There was no further evidence in the claims file to otherwise change the prior opinion that included the medical rational of the Veteran's condition. Therefore the examiner's opinion stands as previously stated in the rationale provided in the discussion of the etiology of the heart and lungs disorders. Additionally the examiner provided an opinion for aggravation of a condition which clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by inservice injury, event or illness. The rationale remained the same as that provided in the February 2013 VA examination. The nature of the condition or conditions said to preexist service was not disclosed. The Board has carefully considered the Veteran's assertions that he has disorders of the heart and lungs that are related to his active service. The Board finds that the weight of the competent evidence shows that the Veteran is not entitled to service connection for either a heart disorder or a lung disorder on a direct basis, including due to any inservice exposure to cold, fumes or asbestos. The preponderance of the existing medical evidence does not show that these conditions were manifested in service or are otherwise related to service. Additionally, the evidence does not show that a heart disability manifested within one year of separation. Thus service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309 (2012). The Board finds that the February 2013 medical opinion with May 2013 addendum after claims file review is probative based on the examiner's thorough and detailed examination of the Veteran and claims folder, as well as the adequate rationale for the opinion. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims file and the Veteran's history, and the thoroughness and detail of the opinion). In addition, there are no contrary competent medical opinions of record. Furthermore, the record does not indicate any treatment or complaints of either a heart disorder or a lung disorder for decades following his separation from service in 1956. Cardiovascular problems of hypertension were not shown until around 1989, with subsequent heart problems such as subacute or old MI, CAD, CHF and cor pulmonale not shown for several years after that, and with medical opinions of record determining at least in part that the Veteran's long time morbid obesity was a major causative factor. Regarding the pulmonary disorder, this too was not shown to be a chronic problem until April 2000, although an acute incident of treatment was shown in June 1957. The Federal Circuit has determined that a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). In this case, the medical evidence does not show the presence of either a heart or a lung disorder for decades after separation from service. This is a factor the Board has considered in deciding the claim. Additionally the medical evidence finding obesity related complications causing heart and lung symptoms has not been refuted. Regarding the question of whether a preexisting disorder was aggravated by service, the Board notes that the examiner in the May 2013 addendum to the VA examination did state that there was clear and unmistakable evidence of a preexisting disorder, but that such disorder was clearly and unmistakably not aggravated by service, citing the same rationale as to the length of time since service for chronic manifestations of symptoms and the other etiological factors particularly obesity. While the examiner did not clarify which particular disorder was found to preexist service, the Board notes that only the asthma was shown by the medical history to have preexisted service, with the Veteran described as having asthma at age 8 in the June 1957 hospital record addressing his respiratory symptoms. However the evidence clearly and unmistakably shows no aggravation of this pre-existing condition by service. The same June 1957 hospital report described the asthma as essentially being nonexistent in the intervening years between age 8 and his treatment in 1957. This would include the years in service. No other evidence refutes this finding or the May 2013 VA examiner's opinion that no aggravation of a preexisting disorder took place. Thus the evidence clearly and unmistakably shows that no aggravation of a preexisting disorder (shown to be asthma) took place in service. Regarding the issue of a heart disorder (CHF) as secondary to a lung disorder (claimed as emphysema), given that the evidence establishes that no lung disorder diagnosed was incurred or aggravated by service ,there is no need to discuss whether any lung disorder is causing or aggravating any heart disorder, including CHF. In reaching the decision above the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against entitlement to service connection for disorders of the heart and lungs, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection is denied for a lung disorder. Service connection is denied for a heart disorder. ____________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs