Citation Nr: 1751275 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 07-25 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for arteriosclerotic heart disease with residuals of an aortic dissection, valve replacement and coronary artery bypass, to include as secondary to hypertension. 3. Entitlement to service connection for acute tubular necrosis renal failure, to include as secondary to hypertension. REPRESENTATION Appellant represented by: Patty Shewmaker, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G.C., Associate Counsel INTRODUCTION The Veteran served on active duty from November 1963 to November 1965. This matter is on appeal from a February 2006 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The Veteran testified before the undersigned Veterans Law Judge in December 2009. A transcript of the hearing is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. Hypertension was not diagnosed in service or until many years thereafter; and, the preponderance of evidence fails to establish that the Veteran's hypertension is etiologically related to his active service. 2. Cardiovascular disease was not manifested during the Veteran's active duty or for many years thereafter, nor is any cardiovascular disease otherwise related to such service or aggravated by service or a service-connected disability. 3. Kidney disability is not shown in service nor within the initial post separation year; post service findings for kidney disease are not attributable to disease or injury incurred in or aggravated by service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 1111, 1153, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2017). 2. Cardiovascular disease was not incurred in or aggravated during the Veteran's active duty service, nor has any such disease been caused or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103A, 5103, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310(a) (2017). 3. The criteria for service connection for a kidney disability are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In October 2010, the Board remanded this matter for further development, to include gathering of outstanding records and for a VA examination. The requested development was completed. Records from USAMRIID regarding experimental programs related to Q fever and Tularemia were obtained. The Veteran underwent both a VA examination in December 2010 with accompanying addenda in February 2011, as well as an additional VA opinion with greater detail and rationale, which the Board finds competent. Under the circumstances, the Board finds that there has been substantial compliance with its remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). Neither the Veteran nor his attorney has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection - Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In this regard, the evidence must demonstrate (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; (3) and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167-67 (Fed. Cir. 2004). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303 (d). With chronic disease shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). 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. Id. When the disease identity is established, there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309 (a), to include hypertension, heart disease and kidney calculi. See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013) (holding that the term "chronic disease in 38 C.F.R. § 3.303 (b) is limited to a chronic disease listed at 38 C.F.R. § 3.309 (a)). A grant of service connection under 38 C.F.R. § 3.303 (b) does not require proof of the nexus element; it is presumed. Id. Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and hypertension, heart disease and/or kidney disease becomes manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112(a), 1113; 38 C.F.R. §§ 3.307, 3.309. Although the Veteran served during the Vietnam era, there is no evidence of service in the Republic of Vietnam, Korea, or Thailand or that he was otherwise exposed to herbicide agents. He makes not allegation to the contrary. Application of 38 38 U.S.C.A. § 1116 (f) is thereby not warranted. See 38 C.F.R. §§ 3.307 and 3.309(e). Analysis - Entitlement to Service Connection for Hypertension The Veteran contends that his hypertension is either related to service or was caused or aggravated by service, and specifically, by his participation in "Operation Whitecoat". In his December 2009 hearing, the Veteran noted that during the time he was "on the experiment or the project", he became very sick with body and head pains [...]. He also noted having had a high pulse rate, and although his vitals were taken twice a day, hid blood pressure readings were either not recorded or were recorded in a separate file. A review of the Veteran's service treatment records does not reflect any diagnosis or treatment for hypertension. Hypertension is present when the diastolic blood pressure is predominantly 90mm. or greater. Isolated systolic hypertension is present when systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104 (2016) DC 7101, Note (1). The blood pressure readings which are of record reflect a normal range: 130/70 (1963); 106/64 (1964); 120/70 (January 14, 1965); 120/70 (January 15, 1965); 130/70 (1965). The Veteran's available in-service blood pressure readings never exceeded 130/70. Furthermore, on his October 1965 separation examination, the Veteran himself indicated that he had experienced no high or low blood pressure issues. See October 1965 Separation examination. The Veteran testified through his representative at his December 2009 hearing that the Veteran went to a private doctor for his hypertension in 1966, and received treatment which included being put on medication. The Veteran's representative indicated that those treatment records were unavailable due to the doctor's passing. The Veteran's representative also indicated at the hearing that the next time the Veteran received treatment and has a record of said treatment was in 1993, when he underwent an emergency operation of his aorta. The record contains an April 1993 operative report indicating that the Veteran underwent surgery for a Type II Aortic Dissection with right leg ischemia. The surgeon, Dr. J.G. noted that the Veteran developed ischemia in the right extremity as well as acute renal failure following initial medical treatment. The Veteran reported being told that it was his hypertension that caused the issues with his aorta. Pertinently, the surgical record contains the first indication of a hypertension diagnosis post service, approximately 28 years after separation from service. The next medical evidence of record is an April 2005 letter from the Veteran's kidney doctor, Dr. S. K., who writes that the Veteran "volunteered in 1965 for Operation Whitecoat and received live vaccine for P. tularensis [...] He developed fever; myalgia and headaches afterwards, and eventually developed hypertension." The doctor further states that the Veteran now has major organ damage from long standing hypertension, and that while he is not familiar with any studies looking at the long term effects of diseases like Tularemia, he indeed developed hypertension in the 1960's. Next, the record contains an August 2005 statement by the Veteran's ex-wife, who states she is a registered nurse and health educator. She states that she was involved with the Veteran since 1964, during the time the Veteran was stationed at Ft. Detrick, undergoing testing as a participant in Operation White Coat. Pertinently, she states that the Veteran was very ill when she would visit him, having high fevers and high blood pressure, where these were non-existent before. She further states that from the time the Veteran was in service until the present, "he has sustained many illnesses that have been complicated by high blood pressure and aneurisms." Also of record is a letter from the Veteran's cardiologist, Dr. A. K., dated in April 2006. Dr. A. K. states she has known the Veteran since he was under her care during his 2004 surgery. The doctor stated that the Veteran had "longstanding hypertension which he states began soon after being a study subject in Operation Whitecoat." Pertinently, Dr. A.K. indicated that she certainly could not state with reasonable confidence that the Veteran's hypertension and subsequent multiple other medical problems were the direct result of participating in Operation White Coat. Another April 2006 cardiology note of record is from Dr. S. T. R., who writes that the Veteran has been a patient as of January 2003, and that his medical history is significant for Hypertension, among other conditions. The doctor reviewed the Veteran's service records, and noted that while there was a record of high fever in January 1965, blood pressure records were unavailable. However, the doctor opined that the Veteran's hypertension could have been a contributory factor in the development of his type III aortic dissection with right leg ischemia and atherosclerotic heart disease. The Veteran was afforded a VA examination in December 2010. The examiner indicated that he reviewed the Veteran's claims file. He indicated that the Veteran's in-service blood pressure readings were as follows: 106/64 (1964), 130/70 (1963), 130/70 (1965). In an addendum opinion dated in February 2011, the examiner opined that since there is no evidence of hypertension while in service, it does not seem likely that the Veteran's hypertension or coronary artery disease are related to service. The examiner further stated that he knows of no connection between tularemia or c. bruneti and hypertension or coronary artery disease. In June 2011, the Veteran submitted a medical treatise, which contains a description of Tularemia and Q fever, along with a history of how these diseases were discovered, a history of the military testing for treatment and vaccines, and an overview of the symptomatology and prognosis associated with these diseases. There is no evidence of a causal connection between Tularemia, Q fever, the bacteria that cause these diseases and hypertension in this treatise. In an attempt to gather additional medical information and a more detailed etiological opinion, the RO sought an additional medical opinion from Dr. E.B. from the VA medical center in Atlanta. Dr. E. B. noted that she had reviewed the Veteran's claims file, and further restated the questions the Board directed be addressed in its October 2010 remand of the Veteran's claim. The examiner indicated that the Veteran's service treatment records (STRs) did not reveal treatment or symptoms for hypertension in service. To the contrary, the examiner noted all the blood pressure readings reflected in the STRs, and indicated that the highest recorded blood pressure readings recorded during the Veteran's military service did not exceed 130/70. Furthermore, the examiner noted that the Veteran does not have medical records for the year following his discharge from the military, nor was the date of diagnosis of hypertension available in the claims file. The examiner noted the Veteran's statements in his December 2009 letter, which reflect that he participated in Operation Whitecoat human testing from 1963 to 1965, was discharged in 1965, began treatment for hypertension in 1966, and has continued said treatment since. The examiner explained that Operation Whitecoat was a program that exposed volunteer servicemen to various viruses and bacteria in order to develop an improved response in the event of a biological attack. In reviewing records from USAMRIID in Ft. Detrick, MD, the examiner noted that the Veteran was exposed to the F. tularensis bacterium, though the Veteran also asserted being exposed to C. brunetii. See October 2010 USAMRIID record search letter. The examiner stated the record did not reflect any evidence of exposure to C. Brunetii during Operation Whitecoat. Also addressed was the Veteran's contention that his blood pressure was elevated during his participation in the study. The examiner stated that she reviewed the Veteran's vitals sheet during his period of acute infection in January 1965, but that no blood pressure readings were noted. Significantly, however, the examiner stated that even if the Veteran's blood pressure had been elevated during his illness, and that was conceded as a fact, the Veteran's recovery would have brought it back down to normal levels. In fact, the examiner notes, the Veteran's blood pressures on admission in January 1965 were normal, and the Veteran's separation examination in October 1965 indicated that he had no history of high or low blood pressure. The examiner took note of the Veteran's ex-wife's August 2005 statements that she is a registered nurse and visited the Veteran while he was at Fort Detrick when he had "high fevers and high blood pressure." Furthermore, the examiner conducted research regarding the bacteria the Veteran was exposed to as well as C. Brunetii. She concluded, based on said research, that F. tularensis, which causes Tularemia, can be cured by treatments with antibiotics, and that the Veteran was in fact treated and recovered. As far as his exposure to C. Brunetii, the examiner states that it is impossible to say the Veteran was exposed to Q fever, which C. Brunetii causes, as the record is silent. After reviewing the Veteran's entire medical record in detail, the examiner opined that it is less likely than not that the Veteran's hypertension had its onset in service or within a year of service discharge based on the evidence in the claims file. She states that a review of the medical literature does not suggest that the Veteran's hypertension or subsequent cardiovascular problems and acute tubular necrosis are secondary to the Operation Whitecoat exposures. While the Veteran's claims file contains evidence of exposure to tularemia, it does not contain evidence of exposure to Q fever, and while there is evidence that C. Brunetii causes infected thoracoabdominal aneurysms, a culture of the Veteran's aorta at the time of surgery would have been necessary to confirm exposure. The Board finds that the most probative medical opinion to address the relationship between the Veteran's current hypertension and his periods of service, that of the Dr. E.B., found that the Veteran's hypertension was not related to service. The VA examiner's opinion is based on a review of the claims file, to include a review of both the Veteran's service and post-service medical records. The opinion includes a detailed analysis and review of all the lay statements of record as well as medical research in support of her opinion. Consideration has been given to the Veteran's report that he initially development hypertension in service. There is no competent evidence to support this history. Contemporaneous service treatment records are negative blood pressure readings that would support a hypertension diagnosis. Dr. E.B. made such a finding. The medical opinion of Dr. E.B. outweighs the Veteran's opinion. Indeed, to the extent that the Veteran had a period of elevated blood pressure in service, which may have met the criteria for a hypertension diagnosis, Dr. E.B. explained that the Veteran's blood pressure was within normal limits by the time of his service discharge. It is also noteworthy that there is no documentation of a hypertension diagnosis until several decades after service discharge. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). The Board has taken note of the Veteran's ex-wife's August 2005 statement, wherein she states she remembers the Veteran having high blood pressure and illness, which was contemporaneous to his participation in Operation White Coat. She also indicated that he had not had problems with his blood pressure prior to active service, and that his later development of "illnesses" were complicated by high blood pressure. She did not actually state that the Veteran was diagnosed as having hypertension in service or until many years thereafter. She also provides evidence that a relationship exists between the Veteran participation in Operation White Coat and his later development of hypertension. Rather, in very vague terms, she states that the Veteran has had "illnesses" that were complicated by his high blood pressure. The August 2005 statement thereby holds no probative value. The Board has considered the positive opinions of record. Dr. S.K.'s opinion suggests that the Veteran's hypertension had its onset in service or that his development of hypertension could be the result of illnesses he had in service. The opinion is not supported by any rationale. See Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations include the qualifications of the person opining). Dr. S.K. fails point to a review of medical records or any blood pressure readings to support his opinion. By contrast, the opinion from Dr. E.B. cites to blood pressure readings in the service treatment records and provides detailed rationale for her negative opinion. In his April 2006 opinion, Dr. A. K. indicated that the Veteran had longstanding hypertension which he [the Veteran] states began soon after his participation in Operation White Coat. The opinion from Dr. A.K. is also not supported by any rationale. Moreover, Dr. A.K.'s statement that the Veteran had longstanding hypertension which the Veteran states began soon after being a study subject in Operation White Coat is merely a history offered by the Veteran alone. This negates the probative value because a bare transcription of a lay history is not transformed into competent medical evidence merely because the transcriber happens to be a medical professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). In light thereof, this opinion is also outweighed by the negative VA opinion of record that, as stated, includes a detailed review of record and analysis for the conclusions provided.. Consideration has also been given to the medical treatise the Veteran has submitted. Although it was helpful in understanding the origins and nature of Tularemia and Q fever, the evidence did not contain any evidence of a causal connection between those diseases and the development of the Veteran's hypertension. Also, such generic evidence, without a supplemental opinion from a medical professional, lacks the degree of certainty that would heighten its probative value. Cf. Mattern v. West, 12 Vet. App. 222 (1999); Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998) (noting that medical literature or treatises can provide important support when combined with an opinion of a medical professional if the article or treatise evidence 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). The Board finds the VA examiner's opinion to be persuasive and probative of the matter under consideration. It is based on consideration of both lay and medical evidence, and contains not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). In this case, the VA examiner reviewed the Veteran's STRs and did not find evidence or symptoms of hypertension. She also reviewed the post-service medical evidence which included the Veteran's family history of hypertension (which she identified as a significant risk factor). Therefore, while consideration has been given to the Veteran's lay history and contentions, the Board assigns greater probative weight to the VA examiner's opinion in light of her expertise and competency in the field of medicine and the explanation she provided in her opinion. It is clear from the record that the VA examiner reviewed the pertinent medical evidence in reaching her conclusion, as well as the Veteran's history. Furthermore, there is no evidence that the Veteran's hypertension manifested within the first post-service year. While lay persons, such as the Veteran, 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-whether the Veteran's hypertension is related to his periods of service or within the first post-service year falls outside the realm of common knowledge or expertise of the Veteran. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a)(1) (2016). Under the circumstances-given the lack of competent medical evidence relating the Veteran's hypertension to his active military service or within the first post-service year-the Board concludes that service connection for hypertension is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence weighs against the claim, that doctrine is not helpful to the Veteran. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Analysis - Entitlement to service connection for arteriosclerotic heart disease with residuals of an aortic dissection, valve replacement and coronary artery bypass, to include as secondary to hypertension. The Veteran's STRs are negative for any evidence of heart disease. During his separation examination in October 1965, clinical evaluation of the heart was normal. The Veteran himself reported having had no shortness of breath, no pain or pressure in his chest and no palpitation or pounding heart symptoms, though he did note a family history of heart trouble. Also, a chest x-ray in June 1964 was normal, and an Echocardiogram in that same year showed "probable juvenile pattern." The first post-service medical evidence in the record diagnosing the Veteran with heart disease was not until 1991, when the Veteran is first noted to have experienced congestive heart failure, more than 26 years after service discharge. See December 2009 note from Dr. S. K. with May 2009 record. In sum, the record tends to show a remote, post-service onset of the Veteran's heart disease. Indeed, the Veteran is noted to have undergone an emergency aortic aneurysm repair in 1993, and had another complicated hospital admission in February 2004 for an aortic valve resuspension with replacement of his ascending aorta. None of the operative or treatment reports of record contain any mention of an etiological link between the Veteran's participation in Operation Whitecoat in service or any other service-related event or injury and his current heart disease. In fact, the Veteran's treating physicians have related the Veteran's heart disease to his hypertension. See Statements from Dr. A.K., dated April 2006, Dr. S.K., dated April 2005 and December 2009, Dr. S.T.R., dated April 2006, and Dr. J.G., dated November 2010. In December 2010, the Veteran was afforded a VA examination. The examiner stated that he reviewed the Veteran's claims folder, and that there is no evidence of hypertension while in service. Based on his review, the examiner opined that it does not seem likely that the Veteran's hypertension or coronary artery disease are related to his service, and that further, he knows of no connection between tularemia or c. brunetii and hypertension or coronary artery disease. Indeed, in a February 2011 addendum, the examiner stated that his review of the Veteran's records revealed no specific symptoms of coronary artery disease. As the aforementioned VA examiner's opinion was deemed by the RO to require clarification, Dr. E. B. provided an opinion as to the nature and etiology of the Veteran's disabilities. The doctor indicated that she reviewed the Veteran's entire claims file. Pertinently, she indicated that she conducted research as to whether there was any relation between tularemia, which the Veteran contracted in service and hypertension and cardiovascular disease, and no associations were found. She concluded that there doesn't appear to be an association with hypertension, coronary artery disease or acute tubular necrosis. As the Veteran also contends he was exposed to C. Brunetii while in service, the doctor indicated pursuant to research that said bacterium causes Q fever, with endocarditis being the major form of resulting disease. However, the doctor indicated that the Veteran's claims file reflects no evidence of exposure to C. Brunetii in service. Pertinently, the doctor opined that it is less likely than not that the Veteran's arteriosclerotic heart disease or any other identified cardiovascular disease had their onset in service or were otherwise aggravated by service. The rationale given was that a review of the medical literature does not suggest that his cardiovascular problems are secondary to his Operation Whitecoat exposures, and that the claims file contains no evidence of Q fever. Furthermore, the doctor opined that it is at least as likely as not that the Veteran's cardiovascular disorders are secondary to the Veteran's diagnosed hypertension. The doctor explained that hypertension is the Veteran's greatest risk factor for his cardiovascular diseases, as is his family history. The doctor also explained that it is unlikely the Veteran was exposed to C. Brunetii while in service because the Veteran does not report two separate episodes of acute illness. A grant of service connection requires competent evidence establishing a diagnosis of current disability and evidence relating the diagnosis to the Veteran's military service. While the record demonstrates current diagnosis of heart disease, it does not contain competent evidence which relates this disorder to any injury or disease in service. There is no competent opinion of record which attributes the Veteran's heart disorders to his service, and in fact, both the Veteran as well as his doctors claim they are secondary to his hypertension. See March 2006 statement. With respect to the Veteran's claim for service connection for heart disease as secondary to hypertension, the Board notes that secondary service connection presupposes the existence of an established service-connected disability. In this case, as analyzed above, the Veteran is not service-connected for hypertension. Thus, there can be no secondary service connection for any condition due to hypertension. Where application of the law to the facts is dispositive, the appeal must be terminated because there is no entitlement under the law to the benefit sought. Sabonis v. Brown, 6 Vet. App. 426 (1994). As there is no legal basis for an award of secondary service connection for heart disease, the claim for secondary-service connection must be denied as a matter of law. While the Veteran contends that his heart disease is related to service, the Board finds that as a lay person the Veteran is not competent to offer such an etiology opinion. The etiology of heart disease is a complex medical question not capable of lay observation and is not the type of medical issue for which a lay opinion may be accepted as competent evidence. As a lay person, the Veteran does not have the education, training and experience to offer an etiology opinion as to the onset or etiology of this condition. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); 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). Accordingly, the Veteran's lay statements in this regard are not competent or probative evidence supporting his claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. Based on a review of the record evidence, the Board concludes that service connection for arteriosclerotic heart disease with residuals of an aortic dissection, valve replacement and coronary artery bypass, to include as secondary to hypertension is not warranted. Although the record evidence shows that the Veteran currently has cardiovascular disease, it does not indicate that the Veteran's heart disease has a causal connection to or is associated with his active military service. In light of the foregoing, the Board must conclude that the preponderance of the evidence is against the claim. In reaching this conclusion, the Board considered the applicability of the benefit of the doubt doctrine. However, that doctrine is not applicable in the instant appeal as the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102 (2016). Analysis - Entitlement to service connection for acute tubular necrosis renal failure, to include as secondary to hypertension. STRs have been reviewed and reflect no complaints or injuries as regards the Veteran's kidneys. In fact, in his October 1965 separation examination, the Veteran reported he was in good health, and that he had no kidney stone or blood urine issues. The first medical treatment note of record regarding the Veteran's acute tubular necrosis kidney failure is over 39 years after separation from service in February 2004, after the Veteran suffered from complications from a hospitalization. See March 2004 Discharge Summary. The hospital record indicates that the Veteran was diagnosed with Ischemic Acute Tubular Necrosis after coronary artery bypass grafting, requiring hemodialysis afterward. It is further explained that the Veteran was referred to cardiac surgery during his hospitalization, which included coronary artery bypass graft to three vessels, mitral valve resuspension, atrial fibrillation ablation, aortic dissection repair and ligation of the left atrial appendage. Pertinently, it is noted that the Veteran developed severe hypotension after his cardiac surgery, requiring pressors for almost seven days, and he became anuric and was found to be in acute tubular necrosis which required hemodialysis for the remainder of his hospitalization. Indeed, a follow-up note from Dr. A. K. dated in April 2004 indicates that the Veteran was suffering from acute tubular necrosis renal failure post a prolonged postoperative course after his bypass, and was requiring hemodialysis three times a week. The next medical note of record is an April 2006 letter from Dr. A. K., the Veteran's attending cardiologist, who reiterates that the Veteran had a complex hospitalization in 2004, and had chronic renal insufficiency prior to his surgical procedure, but developed post-operative acute tubular necrosis post-operatively. Another note in April 2006 from Dr. S. T. R. indicates that the Veteran was operated in 2004 for heart bypass surgery, and that he developed kidney failure and has been on dialysis since then. The following note of record is a December 2009 letter from the Veteran's attending nephrologist, Dr. S. K. He writes that the Veteran has been under his care for end stage renal disease, and that it is his opinion that the Veteran's longstanding history of hypertension most likely contributed to his end stage renal disease and cardiovascular problems. The aforementioned opinion from VA doctor E.B. is of record. The report indicates that the Veteran's entire claims file was reviewed. The doctor stated based on medical research that there does not appear to be an association between tularemia and acute tubular necrosis. The doctor explained that acute tubular necrosis refers to damage or death of the tubules in the kidney that carry urine to the ureters. She further explained that the damage can occur suddenly from toxins (like contrast dye) or ischemia (due to poor blood flow), and that it is unclear to her what exactly caused the Veteran's acute tubular necrosis. However, she opined that contrast dye and a complicated hospital course with a decreased flow of blood to the kidneys during aortic dissection may have both contributed. Further, the doctor stated that the record suggests the Veteran may have had underlying chronic kidney disease secondary to hypertension that put him at higher risk for acute tubular necrosis, and hypertension is not a direct cause of acute tubular necrosis. Finally, Dr. E. B. opined that it is less likely than not that the Veteran's acute tubular necrosis requiring dialysis after a complicated hospitalization in 2004 had its onset in service or was otherwise aggravated by service. The examiner's rationale was that a review of the medical literature does not suggest that the Veteran's acute tubular necrosis was secondary to the Veteran's Operation Whitecoat exposures. Further, the doctor stated the Veteran's acute tubular necrosis is less likely than not related to his hypertension, and is more likely related to the hypotension and ischemia he experienced during his aortic dissection or toxic injury from contrast studies during his complicated hospital admission in 2004. The STRs and VA medical opinions weigh against the claim for service connection for kidney disease. The Board accepts that the Veteran is competent to report any injuries, symptoms, and treatment he may have received. Layno, supra. However, the Board finds the Veteran is not competent to etiologically link his current renal disabilities and acute tubular necrosis to service, since this is not susceptible to lay observation and he lacks any medical expertise. See Jandreau supra. at 1377; see also, Buchanan supra. Therefore, the Veteran's opinion that his current disability is etiologically related to service or a service-related disease has no probative value. Moreover, the private medical evidence submitted in the appeal suggests strongly that kidney disease is related to hypertension, which is a nonservice-connected disability and his acute tubular necrosis was more likely related to complications from surgery. None of the kidney disorders shown during this appeal are etiologically linked to disease or injury incurred in service. Because hypertension is not a service-connected disability, service connection may not be granted based on secondary service connection under 38 C.F.R. § 3.310 (a). The Board assigns significant probative value in this matter to the STRs that show no kidney disease, to the private medical evidence relating the kidney disease shown during this appeal to hypertension, and to Dr. E. B.'s VA medical opinion indicating that the Veteran's complaints and symptoms show that it is less likely than not that the Veteran's acute tubular necrosis neither had its onset in service nor was aggravated by service, and that further, it was more likely related to hypotension and ischemia during his 2004 aortic dissection or toxic injury from contrast studies. This medical evidence is more probative than the Veteran's unsubstantiated opinion because it was prepared by skilled, trained and medical professionals. Also, Dr. E. B.'s medical opinion includes a complete rationale for the conclusions reached. On balance, the weight of the evidence is against the claim. As the evidence of record is not roughly in equipoise, there is no doubt to resolve. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Accordingly, the claim is denied ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for arteriosclerotic heart disease with residuals of an aortic dissection, valve replacement and coronary artery bypass, to include as secondary to hypertension is denied. Entitlement to service connection for acute tubular necrosis renal failure, to include as secondary to hypertension is denied ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs