Citation Nr: 1509117 Decision Date: 03/03/15 Archive Date: 03/17/15 DOCKET NO. 12-17 791A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for a heart condition, status-post pacemaker/defibrillator implantation, to include as due to an undiagnosed illness. 2. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ethan F. Maron, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from July 1984 through July 2004. The Veteran was awarded a Combat Infantryman Badge, among other decorations, for this service. This matter comes to the Board of Veterans' Appeals (Board) from an April 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. This decision, in pertinent part, denied entitlement to service connection for a heart condition and hypertension. The Veteran timely filed a notice of disagreement, and the Salt Lake City, Utah, RO confirmed both denials in a May 2011 rating decision. The Veteran thereafter timely perfected his appeal to the Board. The issue of entitlement to service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran served on active duty in the Southwest Asia theatre of operations during the Persian Gulf War. 2. The Veteran's heart condition, status-post pacemaker/defibrillator implantation, is not an undiagnosed illness or medically unexplained chronic multi-symptom illness. 3. The Veteran's heart condition, status-post pacemaker/defibrillator implantation, was not incurred in service, and is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for the Veteran's heart condition, status-post pacemaker/defibrillator implantation, have not been met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1117, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.317. (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to notify and assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2014). For the reasons to be discussed, the Board finds that VA has satisfied its duties to the Veteran under the VCAA. A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) 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. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). VA has made all reasonable efforts to assist the Veteran in the development of his claim, has notified him of the information and evidence necessary to substantiate the claim, and has fully disclosed VA's duties to assist him. In February 2009, prior to the initial adjudication of this case, and again in October 2010, the Veteran was notified of the information and evidence needed to substantiate and complete the claim for direct service connection on appeal. The Board notes that the Veteran has not been afforded specific notice as to the requirements of a claim for service connection based upon a Gulf War undiagnosed illness. However, any prejudice due to such error has been overcome in this case. The Board notes that the Veteran is a Veteran Service Representative and thus has more knowledge of the claims process than the average person. Furthermore, in this case, the Veteran has been continuously represented by an experienced Veteran Service Organization, and has submitted argument in support of his claim. In statements of August 2010, October 2010, June 2011, July 201, and July 2012, the Veteran referenced the applicable law and regulations necessary to establish entitlement to service connection under 38 C.F.R. § 3.317, and repeatedly requested a Gulf War examination. The Veteran has also submitted fact sheets pertaining to exposure to environmental toxins and particulate matter in the Persian Gulf. The Board acknowledges that the Veteran has not been provided with notice of the types of evidence that could be provided to support his claim for entitlement to service connection based upon a Gulf War presumption; however, the Veteran submitted such evidence of his own volition. Thus, the Board finds that the Veteran demonstrated actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board further finds that VA has complied with the duty to assist by aiding the appellant in obtaining evidence. VA must make reasonable efforts to assist the claimant 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 (2014); see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . must be sought - only those that are relevant to the veteran's claim"). It appears that all known and available records relevant to the issue adjudicated herein have been obtained and are associated with the claims file. The RO has obtained the Veteran's service treatment records, as well as VA and non-VA medical records. The record does not indicate, and the Veteran does not assert, that pertinent treatments records are outstanding. Although the Board is remanding the claim for hypertension for records from Dr. B., the Board notes that in the July 2012 authorization for these records the Veteran specifically indicated that Dr. B. treated his back and sciatica at that facility. He has never indicated that Dr. B. treated his heart condition, or his hypertension. Unlike the claim for hypertension, the diagnosis for the heart condition is well-established and the Veteran has never asserted that his heart condition manifested within one year of his separation from service. Accordingly, the Board finds that the records for Dr. B. would not be of assistance in this matter and only result in further delay of adjudication. See 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); 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 claimant). The Board observes that the Veteran's representative, in an October 2014 brief, requested that the Veteran be afforded a VA Gulf War examination. However, the Veteran was afforded a VA Gulf War examination with regard to his heart condition and hypertension in March 2013. In fact, another representative from the same Veteran Service Organization quoted the examination report extensively in an August 2013 brief. The October 2014 brief does not argue that the March 2013 examination is deficient; rather, the representative asserted that the Veteran was entitled to evaluation of his claim that he had an undiagnosed illness. It appears that the representative who drafted the October 2014 brief was unaware the Veteran had already been provided with the requested examination. The Board notes that the March 2013 VA examiner conducted a physical examination of the Veteran, was provided the claims file for review, took down the Veteran's history, considered the lay evidence presented, laid factual foundations for the conclusions reached, and reached conclusions and offered opinions based on history and examination that are consistent with the record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met regarding the matters of service connection for a low back disorder. 38 C.F.R. § 3.159(c)(4); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). Although some time passed between the March 2013 examination and the October 2014 brief, the Veteran's representative does not assert that a material change in the Veteran's condition during the interim rendered the March 2013 examination inadequate. The passage of time alone does not render a VA examination inadequate. Palczewski v. Nicholson, 21 Vet.App. 174, 180 (2007). For the foregoing reasons, no further notice or assistance to the Veteran is necessary, and the Board may properly proceed to adjudicate the claim. II. Legal criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2014). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1131 (West 2014); see also Degmetich v. Brown, 104 F.3d 1328 (1997). This requirement "is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. . ." McLain v. Nicholson, 21 Vet. App. 319, 321 (2007). Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). As noted in the Introduction, the Veteran served in combat and the provisions of 38 U.S.C.A. § 1154 (b) apply. This statute and regulation ease the evidentiary burden of a combat veteran by permitting the use, under certain circumstances, of lay evidence. If the veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d) . That section 1154(b) establishes an event and injury during service does not end the matter. The provision does not mean that a grant of service connection is presumed for veterans who were injured in combat. Section 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disability etiologically to the current disorder. Caluza v. Brown, 7 Vet. App. 498, 507 (1995); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). Section 1154(b) does not establish entitlement to a grant of service connection for a combat veteran; rather, it aids him or her by relaxing the adjudicative evidentiary requirements for determining what happened in service. See Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996). Even when the section 1154(b) combat presumptions apply, a "veteran seeking compensation must still show the existence of a present disability and that there is a causal relationship between the present disability and the injury...incurred during active duty." Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). Cardiovascular disease is listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a disease noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as cardiovascular disease, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Service connection may be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 21, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. VA is authorized to pay compensation to any Persian Gulf veteran suffering from a "qualifying chronic disability." For purposes of 38 C.F.R. § 3.317, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (a) an undiagnosed illness; or (b) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; or (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a), (c). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317(a)(2), (3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Analysis The Veteran contends that he has had a heart disorder that is related to his active military service. The Veteran was diagnosed with non-sustained ventricular tachycardia and cardiomyopathy in October 2008, and was implanted with a pacemaker/defibrillator. In his June 2011 Notice of Disagreement and July 2012 substantive appeal to the Board, the Veteran further asserted that his heart condition was presumptively connected to his service in the Southwest Asia theater of operations, as per 38 C.F.R. § 3.317. Review of the Veteran's military personnel record confirms that he served in Operation Iraqi Freedom and his DD Form 214 reflects service in Iraq from March 2003 until December 2003. As an initial matter, the record contains competent evidence of a current heart disorder. The Veteran was seen at Holy Cross Medical Center in October 2008 with congestive heart failure and dilated non-ischemic idiopathic cardiomyopathy. Coronary angiography showed normal coronary arteries, an ejection fraction of 20 percent, and no renal artery stenosis. The Veteran was implanted with a pacemaker/defibrillator for prevention and treatment of non-sustained ventricular tachycardia. See McClain v. Nicholson, 21 Vet. App. 319 (2009) and Romanowsky v. Shinseki, 26 Vet App 289, 294 (2013)(noting that a diagnosis shortly before a claim is filed, but relevant to the disability claimed, should be considered by the Board in determining whether a current disability existed during the pendency of the claim). In his August 2013 brief, the Veteran's representative asserted that the Veteran's service medical records reflect an in-service history of non-sustained ventricular tachycardia with cardiomyopathy. The Board observes that the representative's brief of October 2014 does not assert that these symptoms occurred in service, and conceded that the Veteran's service treatment records "did not note any cardiovascular disorders or complaints." Nonetheless, the Board has carefully reviewed the Veteran's service treatment record for cardiovascular complaints. The service treatment records fail to reflect any complaints, treatment or diagnoses related to the heart. Examinations in January 1988 and March 1993 described the heart and vascular system as normal. On the March 2003 post-deployment heath assessment questionnaire the Veteran denied any chest pain or pressure. On a December 2003 post deployment medical assessment the Veteran denied palpitation, pounding heart or abnormal heartbeat and heart trouble or murmur. In a March 2004 in-service medical history report, the Veteran denied any history of shortness of breath, dizziness, fainting spells, chest pain or pressure, heart trouble or murmurs, or high or low blood pressure. The Board notes that the Veteran did list health problems that he believed he had experienced in military service: a need for glasses/contact lenses, hearing loss, and pain in his right shoulder, back, ankle, heels, knee, fingers, and toes. The Veteran was afforded a pre-discharge VA examination in March 2004, and the examination report was drafted in June 2004. At this examination, the Veteran listed his in-service medical complaints as right knee pain, right ankle pain, low back pain, and a left great toe problem. The Veteran also reported that he had broken his fingers and toes in service. On examination, the Veteran's blood pressure was 124/67, pulse was 70, and cardiovascular findings were within normal limits. EKG findings were normal. A chest x-ray found that the Veteran's heart and pulmonary vessels were within normal limits. The record does not reflect, and the Veteran has not asserted, any event or injury related to his combat service that purportedly was the onset of his heart disease. Rather, his main contention is that his heart disease is the result of an undiagnosed illness from his service in the Persian Gulf. In his July 2012 substantive appeal, the Veteran asserted that he had been referred for five days of blood pressure observation at his retirement examination, and that this had been due to elevated blood pressure findings on earlier examinations. Five days of blood pressure observations were ordered at the Veteran's March 2004 examination; however, the Veteran's blood pressure was normal at this examination. A separate note in the Veteran's service treatment record reflects that readings were taken on March 9-12 of 2004, with a final reading taken on March 15, 2004. Blood pressure findings were 127/70, 119/71, 121/73, 129/78, and 138/74, respectively. The Veteran retired from the military in July 2004, and does not assert that he was treated for a heart condition prior to October 2008. However, in his August 2010 notice of disagreement, the Veteran asserted that he had served in Iraq from March through December 2003, had sustained toxic chemical exposure in Mosul due to pollution from fires, and that a Gulf War medical examination was necessary to evaluate any link between Gulf War service and the Veteran's hypertension and heart condition. The Veteran also submitted a fact sheet explaining that the June 2003 fire at the Mishraq State Sulfur Mine (near Mosul) had produced tremendous quantities of sulfur dioxide and hydrogen sulfide, which has been associated with constrictive bronchiolitis. Another fact sheet submitted in August 2010 noted that particulate matter exposure in Southwest Asia could cause pulmonary and cardiopulmonary disease. The Board has carefully considered whether the Veteran's heart condition or hypertension constitute undiagnosed illnesses or medically unexplained chronic multisystem illnesses, as contemplated in 38 C.F.R. § 3.317. The March 2013 VA Gulf War Examination report found that the Veteran's non-sustained ventricular tachycardia, cardiomyopathy (resolved) and congestive heart failure (resolved) were all specific diagnoses. The Board notes, as did the examiner, that the Veteran's cardiomyopathy was described in October 2008 treatment notes as "idiopathic." Dorland's Medical Dictionary defines idiopathic as an illness having an "unknown cause or spontaneous origin." Dorland's Illustrated Medical Dictionary 912 (32nd ed. 2012). However, the VA examiner found that the Veteran's cardiomyopathy was not truly idiopathic, because the Veteran's treatment record indicated that the Veteran's heart condition was most likely due to a recent viral infection. The Veteran's treating cardiologist indicated in October 2008 that the Veteran's "idiopathic cardiomyopathy" was "most likely secondary to viral infection." This opinion appears to be based on the Veteran's medical history; the Veteran had first sought treatment at Henry Mayo Newhall Memorial Hospital in mid-September 2008 for an upper respiratory infection. A chest x-ray led to a diagnosis of pneumonia. The Veteran was discharged, but returned ten days later complaining of shortness of breath. Per treatment records from Holy Cross Medical Center, the Veteran was then diagnosed with congestive heart failure and cardiomyopathy, and transferred to Holy Cross. It appears that the Veteran's October 2008 treatment notes did not use "idiopathic" to refer to a truly unknown diagnosis; rather it was to indicate that the etiology of the known diagnosis of cardiomyopathy was not clear. The treating cardiologist's opinion was not merely a hypothetical discussion of possible etiologies that additional facts might reveal, but a medical conclusion based upon the history of this particular patient. See VAOPGCPREC 8-98 (August 3, 1998) (holding that the determination as to whether a veteran's disability can "be attributed to any known clinical diagnosis" must be based on "history, physical examination, and laboratory tests," not the diagnosis that could be found based upon facts not in evidence). A treatment record of October 10, 2008 indicates that the Veteran's treating nephrologist considered the etiology of the Veteran's heart condition to be "unclear." The treating nephrologist noted that the Veteran had given a history of alcohol use, but that the extent of this use was unclear, and the Veteran had denied alcoholism. The nephrologist also stated that HIV infection could explain the Veteran's cardiomyopathy, and that he wondered if the Veteran's recent respiratory infection could have caused a viral cardiomyopathy. In his view, testing for HIV, as well as coxsackie virus, would be necessary to attempt to ascertain the etiology of the Veteran's heart condition. The Board acknowledges that the Veteran's treating nephrologist did not, unlike the cardiologist, identify a specific illness as the probable cause of the Veteran's cardiomyopathy. However, the nephrologist agreed, based upon the Veteran's medical history and symptoms, that a viral infection was the likeliest cause of the Veteran's cardiomyopathy. Significantly, the Veteran's treating cardiologist, treating nephrologist, and the VA examiner agreed that the Veteran had been diagnosed with cardiomyopathy. This is a distinct clinical diagnosis. The March 2013 VA examiner specifically noted that the Veteran had nonsustained ventricular tachycardia, cardiomyopathy, resolved, and acute congestive heart failure, resolved and further explained that "these are all specific diagnoses". A Veteran may not receive service connection under 38 C.F.R. § 3.317 if the Veteran's symptomatology can be fully accounted for by a clinical diagnosis other than a medically unexplained chronic multi-system illness. Based upon the evidence discussed herein, the Board concludes that the Veteran's symptomatology is fully accounted for by a clinical diagnosis other than medically unexplained chronic multi-system illness. Accordingly, service connection under 38 C.F.R. § 3.317 is not warranted. Although the Veteran is ineligible for service connection under 38 C.F.R. § 3.317, the Veteran may still establish service connection for his heart condition on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, as discussed in reviewing the Veteran's in-service medical history, the Veteran's service treatment records contain no record of treatment for a heart condition. The Veteran's service treatment records do record some instances of elevated blood pressure, however, the VA examiner noted that these isolated findings of elevated blood pressure were not consistent with the majority of blood pressure readings through the Veteran's service, which found normal blood pressure, and that these findings did not meet the VA criteria for a diagnosis of hypertension. The Veteran has not asserter his heart condition was related to combat. No medical evidence of record establishes a causal link or relationship between the Veteran's service, including the in-service elevated blood pressure, and his current heart disability. Rather, as noted above, the evidence indicates the heart disability most likely had a viral cause. The VA examination report of March 2013 noted that the Veteran had asserted exposure to environmental toxins while in the Persian Gulf. However, the examiner emphasized that the onset of the Veteran's cardiac symptoms first occurred four years after separation from military service, which made correlation with in-service toxin exposure unlikely. Moreover, the Veteran's treating physicians in October 2008 considered viral exposure - not in-service toxin exposure - the likeliest cause of his heart condition. The examiner concluded that the evidence did not show the Veteran's heart condition had been incurred in or caused by military service. The only evidence that links the current heart disability to service is the Veteran's own statements. To the extent to which the Veteran attributes his condition to toxins in service, high blood pressure findings in service or as an undiagnosed illness, however, he is not competent to provide such an etiology and his assertions in this regard therefore have no probative value in establishing a nexus to service. See Layno v. Brown, 6 Vet. App. 465 (1994). There is no evidence that the Veteran has medical expertise. An opinion of etiology in this particular case would require knowledge of the complexities of the cardiovascular system and the various causes of heart disease and would involve objective clinical testing that the Veteran is not competent to perform or interpret. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, an opinion as to whether the current cardiovascular is related to an event in service falls outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n.4 (lay persons not competent to diagnose cancer). Additionally, the Veteran has not provided or identified any other competent evidence to support his contentions. The Board has carefully reviewed the factsheets that the Veteran submitted in August 2010, pertaining to toxin and particulate matter exposure in the Persian Gulf. Toxin and particulate matter exposure was stated to increase a Veteran's risk for pulmonary disease. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, the information submitted by the Veteran is of a general nature and does not contain any information or analysis specific to the Veteran's case. Moreover, the Veteran does not seek service connection for a pulmonary or cardiopulmonary disorder. The Board finds that these documents have no probative value in establishing a nexus between the Veteran's military service and his heart condition. The Board finds that the March 2013 VA examiner's conclusion that the medical evidence does not suggest the Veteran's heart condition was incurred in or caused by service to be highly probative. "The credibility and weight to be attached to [medical] opinions [are] within the province of the [BVA as] adjudicators." Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The examiner's conclusion was based on both a physical examination of the Veteran, and review of the claims file. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The examiner provided a detailed rationale for his opinions that cited to the Veteran's reported environmental exposures and to medical evidence pertaining to the Veteran. The examiner further noted that the Veteran did not experience symptoms of a heart disorder prior to October 2008 - four years after leaving military service. The Board also finds that the weight of the competent and credible evidence shows that the Veteran did not experience continuous symptoms of cardiovascular disease in service or since service separation. As noted above, service treatment records did not reflect any complaints or treatment for the heart. Separation examination in March 2004 described the heart as normal. A June 2004 VA examination indicated the cardiovascular system has S1 S2 within normal limits without rubs, murmurs or gallops and explained the chest x-ray showed some thoracic dextroscoloisosis obscuring with superior mediastinum but was otherwise normal and EKG was normal. The first evidence of treatment for the heart was in October 2008. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Those records reflect that he denied any prior cardiac history and indicated the history was from two weeks prior when he presented with what he thought was a respiratory infection. Further, the Veteran has never contended that he had a heart problem prior to October 2008. Thus, presumptive service connection under the provisions of 38 C.F.R. § 3.303(b) is not warranted. There can be no doubt from review of the record that the Veteran rendered honorable and faithful service for which the Board is grateful, and he is sincere in his belief that his heart condition is related to military service. While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted. The Board has weighed the evidence of record, and finds the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a heart condition, status-post pacemaker/defibrillator implantation, is denied. REMAND A preliminary review of the record discloses that further development is necessary before the Veteran's claims to service connection for hypertension can be adjudicated. Outstanding records that may pertain to the Veteran's claimed hypertension must be associated with the claims file, if available. The March 2013 VA examiner indicated that the Veteran was diagnosed with hypertension in October 2008. The examiner explained that this conclusion was based solely upon the fact that several of the medications the Veteran was prescribed for treatment of his heart condition are also used to treat hypertension. The VA examiner noted that no diagnosis of hypertension had been found in the Veteran's service treatment record, and that the Veteran's post-service medical record contains no diagnosis of hypertension. However, a March 2013 VA treatment record indicates that the Veteran was prescribed several medications for blood pressure, including Lasix, and the Veteran's primary care provider was identified as a Dr. B., of Lone Tree, Colorado. The Board notes that a prior authorization for Dr. B. was provided by the Veteran in July 2012 and the Veteran only indicated that he treated there for his back and sciatica. The RO requested these records, however a response from the facility received in May 2013 indicated that the "release is incomplete, missing signature page." Although the Veteran has not specifically identified Dr. B. as having records pertaining to his hypertension, as Dr. B. is a primary care physician and his treatment records may include pertinent blood pressure readings, they should be obtained on remand. While on remand, any other pertinent VA or non-VA records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Request the Veteran to identify all records of VA and non-VA health-care providers who have treated or examined him for hypertension, including Dr. B. of Lone Tree, Colorado. After obtaining any appropriate authorizations for release of medical information, the RO must seek to obtain any potentially relevant records that have not been previously received from each health-care provider the Veteran identifies. If any requested records are not available, that fact must clearly be documented in the claims file and proper notification under 38 C.F.R. § 3.159(e) should be provided to the Veteran. 2. Thereafter, complete any additional development warranted, and readjudicate the claim. If any benefit sought on appeal remains denied, the Veteran and his accredited representative should be provided a supplemental statement of the case (SSOC) which addresses all relevant actions taken on the Veteran's claims for benefits, to include a summary of the evidence considered, since the issuance of the last supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs