Citation Nr: 1758022 Decision Date: 12/14/17 Archive Date: 12/28/17 DOCKET NO. 11-31 760A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUE Entitlement to service connection for a heart disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1972 to November 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In April 2015, the Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing. A transcript of the proceeding has been associated with the claims file. An August 2015 Board decision denied the Veteran's claim. An April 2016 Order of the Court of Appeals for Veterans Claims (Court) granted a joint motion by the parties to vacate the Board decision and remanded the matter to the Board. In August 2016 and May 2017, the Board remanded the claim for further development. This matter is now returned to the Board for further review. FINDINGS OF FACT Coronary artery disease, myocardial infarction, ventricular arrhythmia, valvular heart disease, and hypertensive heart disease were not manifest in service or to a compensable degree within one year of service and are unrelated to service. CONCLUSION OF LAW Coronary artery disease, myocardial infarction, ventricular arrhythmia, valvular heart disease, and hypertensive heart disease were not incurred in or aggravated by service, and cannot be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duty to Notify and Assist Neither the Veteran nor his representative has raised any 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 duty to assist argument). II. Service Connection Veterans are entitled to compensation if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C.A. § 1110 (wartime service), 1131 (peacetime service). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service -the so-called 'nexus' requirement." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Cardiovascular diseases are identified as "chronic" diseases under 38 U.S.C.A §1101 and 38 C.F.R. § 3.309(a). "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, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim." 38 CFR 3.303 (b). The Veteran has been diagnosed with various cardiovascular diseases throughout the course of this appeal. These diagnoses include coronary artery disease, ventricular arrhythmia, valvular heart disease, hypertensive heart disease, and myocardial infarction. These diagnoses follow an incident in 2009, when the Veteran experienced an episode of syncope while driving. After the experience, he was diagnosed with coronary artery disease (CAD) and treated with a stent and the insertion of a pacemaker. The Veteran asserts that his cardiovascular disorders began in service. He reports that he did not experience chest pains or shortness of breath during service. Rather, he contends that he had various risk factors during service and that laboratory test results of cholesterol and triglycerides are evidence that he had signs of CAD in service or within one year of service. He also highlights increasing coronary artery risk assessment results for February 1989, March 1990, and January 1993, as evidence of CAD manifestations. He further asserts that after one of his laboratory test results, he was prescribed medications, and in approximately one week his cholesterol and triglyceride levels were reduced. He claims the medication he was given was probably a pre-cursor to Lipitor or Crestor. Service treatment records show an April 1982 coronary artery risk evaluation of 1.3. A note said "no intervention required." In January 1987, cholesterol, HDL, and triglycerides all were within the normal range. In March 1987, the coronary artery risk evaluation showed a calculated risk of 3.1. "Consult to nutrition" was noted. The heart was found to be normal on clinical evaluation. A March 1987 electrocardiogram (EKG) report noted "sinus bradycardia" and "early repolarization variant." An August 1987 service examination to qualify for flight status showed the Veteran denied chest pain, angina, shortness of breath, "POE," cough, wheeze, orthopnea, "PND," ankle edema, claudication, syncope, and dizziness. A cardiovascular examination revealed regular heart rate and rhythm and good pedal pulses. The conclusion was no evidence of cardiovascular disease. The report of an August 1987 EKG noted non-specific ST-T wave changes. A 1989 electrocardiographic record noted "baseline artifact," "normal sinus rhythm," and "within normal limits." A treadmill exercise study revealed the Veteran was able to exercise for 15 minutes, stopping due to fatigue, and reaching 99 percent of the predicted maximum heart rate. No symptoms developed during the test. An EKG taken during the study showed less than 1.0 mm of upsloping ST depression at maximal exercise. No arrhythmia was detected. A moderate baseline artifact was present. The conclusion was a normal exercise test. That month, the Veteran was found medically qualified for flying. A February 1989 annual service examination resulted in a normal clinical evaluation with respect to the heart. February 1989 and March 1990 coronary artery risk evaluations are of record. The calculated risk results were 1.3 and 1.4 respectively. A March 1990 periodic flying examination found the heart to be normal. A May 1990 record notes that a March 1990 EKG was within normal limits and there was normal sinus rhythm. In January 1992, glucose, cholesterol and triglycerides were within expected ranges. Cholesterol was 155, well under the maximum desirable level. HDLC was low. In April 1992, cholesterol and triglycerides were above the normal ranges. A January 1993 VA medical examination report noted a reported history of high cholesterol and high triglycerides. On examination, the heart was found to be of normal size. The apical impact was found to be at the fifth interspace in the left midclavicular line. There was regular sinus rhythm at 72. No murmurs were heard. Peripheral pulses were 1+ and dorsalis pedis were decreased on both sides. While seated, pulse was 72, blood pressure was 145/90, and respirations were 18. While recumbent, pulse was 72, blood pressure was 140/90, and respirations were 16. While standing, pulse was 70, blood pressure was 138/88, and respirations were 16. It was noted that the Veteran has good tolerance to exercise. A January 1993 lab test showed a "cardiac risk factor" of 5. Triglycerides and cholesterol were normal. A September 2007 X-ray of the cervical spine showed calcific atherosclerosis of the carotid bulbs. In an August 2009 letter, the Veteran's treating cardiologist states that the Veteran had cardiac risk factors in 1992, and that CAD is not a disease that just happens, but comes on slowly over time. He explains that "it would be expected that [the Veteran] has been progressing toward his current status for 20 or more years." An October 2011 VA medical opinion reported that the Veteran erroneously equates the presence of a risk factor for the development of CAD with the presence of CAD. The examiner noted that, by this standard, all individuals with similar risk factors could claim compensation for the diagnosis of CAD long before its clinical manifestations. The examiner stated that it is standard practice in clinical medicine to identify a diagnosis when clinical manifestations of the underlying disease are apparent, subjectively or objectively. The examiner reasoned that typical symptoms of angina, for example, would be regarded as diagnostic of CAD. The examiner found no evidence in the record that the diagnosis of CAD could reasonably be made by any recorded symptoms or signs of CAD until January 2009. He concluded that "[o]nly when specific signs and symptoms of disease are identified is a diagnosis justifiable re CAD or other entities." The examiner acknowledged the August 2009 letter from the Veteran's private cardiologist. The examiner agreed with the assertions that the Veteran had risk factors in 1992 and that CAD comes on slowly. The examiner reasoned, however, that risk factors are present in the majority of all persons in the United States from an early age. As they increase in number and severity, the manifestations of CAD in the form of ischemia are heralded by clinical signs and symptoms. Thus, the examiner opined, there is no basis for the claim that one or more risk factors are the equivalent of the diagnosis of CAD, and it is not practical to do so. According to the examiner, only when specific signs and symptoms of a disease are identified is a diagnosis justifiable. An April 2012 statement from the Veteran's private physician stated that the Veteran "probably developed signs of atherosclerosis prior to 1992 from [the] clinical findings." No clinical findings were specified. In a June 10, 2015 letter, a private cardiologist explains that "[c]oronary atherosclerosis is a disease process that develops over decades. In most people who have the disease, the process begins many years earlier than when symptoms present themselves clinically. I do believe based on review of his medical record and military medical record that he had the beginnings of coronary atherosclerosis (CAD) before 1992 based on his lab values; however, during this time he was simply asymptomatic." A September 2016 VA examiner concluded that the Veteran's cardiovascular disease was less likely than not related to his service. The examiner reviewed all relevant records, including the August 2009, April 2012, and June 2015 private medical opinions. The examiner concluded that it is was less likely than not that the Veteran's cardiovascular disease manifested within one year of the Veteran's November 1992 separation, explaining that it takes many years to develop and has many etiologies, including age, family history, gender, and risk factors. The Board ordered a new VA medical opinion. In the resultant June 2017 medical opinion, a VA physician Board-certified in Internal Medicine concluded that the Veteran's heart disorders were less likely than not related to his service. Due to the complexity of the examiner's opinion the Board will quote it in full: Veteran's ventricular arrhythmia, valvular heart disease, and hypertensive heart disease are less likely than not related in any way to service, nor did any of these conditions manifest themselves within one year of Veteran's 11/1992 discharge from service for 3 reasons: (1) having risk factors for a condition is not the same as actually having the condition (2) estimates of cardiac risk vary depending on the risk factors considered and formula used and (3) atherosclerosis is not the same thing as ishemic heart disease. First, having a cardiac risk factor is not the same thing as having ischemic heart disease. There are many risk factors for ischemic heart disease, including smoking, hypertension, diabetes, obesity, abnormal cholesterol levels, family history of premature heart disease, kidney disease, age, male gender, lack of exercise, and others (Wilson PWF. Overview of the risk equivalents and established risk factors for cardiovascular disease. UpToDate 4/19/17). STRs clearly indicate that veteran had abnormal cholesterol levels while on active duty, as indicated by an elevated total cholesterol to HDL ratio. In general, a total cholesterol to HDL ratio less than 3.5 is considered ideal while a ratio greater than 5.0 is concerning for increased cardiac risk (Millan J, Pinto X, Munoz A, et al. Lipoprotein ratios: physiological significance and clinical usefulness in cardiovascular prevention. Vasc Health Risk Manag. 2009;5:757-765). While in the military, veteran's cardiac risk was repeatedly assessed with sequential EKGs and evaluations of his age, weight, blood pressure, cholesterol, and smoking status. When his total cholesterol to HDL ratio was noted to be 5.0 at his 3/18/87 coronary artery risk evaluation at Chanute, he was assiduously referred for an exercise stress test to see if he did in fact have ischemic heart disease. The stress test was performed on 8/20/87 and came back as completely normal. In other words, he had a risk factor for heart disease (his abnormal cholesterol levels), but he did not actually *have* ischemic heart disease (based on his normal EKGs, normal exercise stress test, and absence of symptoms). Having a risk factor for a condition is not the same thing as having the condition. For example, owning a gun is an established risk factor for committing suicide, but obviously not everyone who owns a gun commits suicide. Similarly, having abnormal cholesterol is a risk factor for ischemic heart disease, but not everyone with abnormal cholesterol develops ischemic heart disease, which is ultimately the product of many other variables and risk factors. Second, clinical estimates of cardiac risk vary depending on the risk factors considered, and it is essential to compare apples with apples. In his 4/23/15 testimony to the Board of Veterans' Appeals, veteran testified that his cardiac risk factor "ballooned, it spiked to a 5, from last known 1.4 to 5" and that he felt this was evidence of "a dramatic change" in his status. This might be true if veteran were comparing the same numbers, but (and this is an easy mistake for a layperson to make) he is not. STRs indicate that veteran's cardiac risk was calculated by clinicians on several occasions (3/18/87,2/13/89, 3/5/90) based on multiple variables: age, smoking, blood pressure, total cholesterol, HDL, cholesterol/HDL ratio, obesity, and triglycerides. It is not clear exactly what formula the clinicians were using, but it was most likely some variant of the Framingham risk index, based on the risk factors being addressed and the fact that the Framingham risk index was being used for cardiovascular screening in the military at the time (Wortham DC, Jordan LW, Jones SL, et al. Cardiovascular screening in Army personnel over age 40 in the State of Hawaii. South Med J. 1990 Apr;83(4):395-402). For the sake of simplicity, we will tentatively call these calculations veteran's Framingham cardiac risk scores, which were 3.1 on 3/18/87 (when he was sent for an exercise stress test), 1.4 on 2/13/89, and 1.3 on 3/5/90. These numbers are all clearly calculated using the same variables and formula, and they are comparable to each other. However, the cardiac risk factor of 5 that veteran cites from his 1/19/93 lipids done performed at Tampa Clinical Laboratory is a *completely* different number reflecting his total cholesterol to HDL ratio; as such it cannot be compared to his Framingham cardiac risk scores while he was in the military because the two numbers are apples and oranges. Veteran's cardiac risk factor of 5--as documented on his 1/19/93 lipids performed at Tampa Clinical Laboratory--is clearly an automatic lab calculation of cholesterol to HDL ratio because no other clinical variables are documented. Veteran's total cholesterol was listed as 187, and his HDL was listed as 40, for a ratio of 4.675, which was rounded up to 5. Moreover, this number is consistent with his previous in-service total cholesterol to HDL ratios, which were 5.0, 4.5, and 4.5 on 3/18/87, 2/13/89, and 3/5/90, respectively, so there was no dramatic change in these values from 1987 to 1993. It is natural for a layperson to confuse clinician-calculated Framingham cardiac risk scores with lab calculations of cardiac risk based on total cholesterol to HDL ratios, especially when both of these numbers mention "cardiac risk," but they are still completely different numbers. Comparing the two because they both deal with cardiac risk would be like comparing barometer readings with temperature readings because they both record weather conditions. Finally, atherosclerosis is not equivalent to and should not be conflated with ischemic heart disease. This examiner carefully reviewed all 3 statements from Dr. [L.M], veteran's cardiologist, and Dr. [A.F], veteran's PCP, and wholeheartedly agrees with them that veteran most likely had atherosclerosis while he was on active duty. In his 4/13/12 statement, for instance, Dr. [L.M] points out that veteran "probably developed signs of atherosclerosis prior to 1992 from my clinical findings." Similarly, in his 6/10/15 letter, Dr. [A. F.] stated, "I do believe based on review of his medical record and military medical record that [veteran] had the beginnings of coronary atherosclerosis (CAD) before 1992 based on his lab values." This examiner concurs that veteran almost certainly had atherosclerosis while he was on active duty because the presence of atherosclerosis in Western adults is virtually universal, starting in childhood and gradually progressing with age (Zhao, X. Pathogenesis of atherosclerosis. UpToDate 6/9/15). For instance, in an autopsy study of 2876 men and women aged 15-34 who died from non-cardiac causes, *all* individuals had evidence of aortic atherosclerosis (Strong J, Malcom G, McMahan C, et al. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA. 1999;281(8):727). However, atherosclerosis is not the same thing as ischemic heart disease. The National Heart, Lung, and Blood Institute defines atherosclerosis simply as a condition in which plaque builds up on the inside of arteries (https://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis). Atherosclerosis does not cause ischemic heart disease until the plaque deposits are significant enough to limit or obstruct blood flow to the target cardiac tissue. The distinction between atherosclerosis and ischemic heart disease may be more easily illustrated by thinking of household plumbing. Even brand new pipes in a brand new house will, within a few months or years, start to accumulate small deposits of sediment and minerals from the water running through them. Small deposits by themselves generally do not cause a problem, but over years (depending on the quality of the water and size of the pipes), the deposits gradually increase in size until they start significantly obstructing the flow of water, which becomes apparent when the toilet doesn't flush completely or turning a faucet on at full throttle results in only a trickle of water. At this point, the pipes have a significant blockage, and most people call a plumber. Atherosclerosis is comparable to the presence of small non-obstructing deposits of sediment and minerals in the pipes; ischemic heart disease is comparable to when the deposits are big enough to cause problems--except with ischemic heart disease, the problems aren't backed up toilets or trickling water but symptoms (such as angina, shortness of breath, fatigue, arrhythmias, or syncope), abnormal EKGs, or abnormal stress tests. Veteran almost certainly had atherosclerosis while he was on active duty, but he did not have any evidence of ischemic heart disease until 2009, when he had symptoms of syncope, abnormal EKGs showing the presence of life-threatening arrhythmias, and an abnormal stress test. In a June 2017 private medical opinion submitted by the Veteran and authored by the June 2015 physician, the physician explains that the Veteran has undergone "further testing for further cardiovascular risk stratification, quantification, and preventative purposes." A genetic test indicated that the Veteran "has a genetic mutation on one of the allele arms...[demonstrating] an increase in cardiovascular risk higher than that of the standard population by ~ 125%....With this added genetic information there is no doubt that [the Veteran] had [CAD] before 1992, the time when he left active duty." The physician explains that further vascular testing supported this assessment, in which the arterial age of an individual is determined. At testing, the Veteran was "70 years old and had an estimated arterial age of an 85-year-old male. This 15-year age difference is statistically significant for advanced CAD." The physician opined that this testing shows that despite symptoms of CAD not materializing until 2009, the Veteran's CAD is began prior to his 1992 separation from service. "Unfortunately, at the time of his military retirement the cardiovascular information, testing, and capabilities were not around or it might have been possible to stop the irreversible damage that has been caused by his CAD. Again, given his genetics, his CIMT, his military medical record, his labs from his time in the military, his current labs, and how his cardiovascular disease process has progressed, a direct correlative and regression analysis can point to the fact that [the Veteran] had [CAD] long before the age of 45. Given our current date it is more likely that he started developing CAD in his early to mid-thirties." In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board accepts the August 2011, September 2016, and June 2017 VA examiners' opinions that the Veteran's heart disorders are less likely than not related to his military service as highly probative medical evidence on this point. The Board notes that the examiners rendered their opinions after thoroughly reviewing the claims file and relevant medical records. The examiners noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens, 11 Vet. App. at 383; Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Specifically, the Board finds the June 2017 VA examiner's opinion to be of substantial probative value, as the examiner provides a detailed response, tailored specifically to the contentions of the Veteran and his representative. Specifically, the June 2017 VA examiner makes clear that (1) in-service risk factors do not equate to manifestations of a disease entity, (2) the Framingham cardiac risk scores documented in March 1987, February 1989, and March 1990 are not comparable to the January 1993 ratio of cholesterol to HDL, and (3) the presence of atherosclerosis in service does not represent a manifestation of cardiovascular disease, as atherosclerosis by itself is a natural process of aging, evident in individuals who have no manifestations or signs of cardiovascular disease. The Board may favor the opinion of one competent medical professional over that of another so long as an adequate statement of reasons and bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Here, the Board finds the August 2009 and April 2012 private medical opinions to be of minimal probative value. The 2009 opinion simply speaks in terms of "risk factors" and "progressing toward" his current status. These terms are vague as to whether the Veteran actually had manifestations that could as likely as not be attributed to cardiovascular disease. Similarly, the 2012 statement from the private cardiologist asserting that the Veteran "probably developed signs of atherosclerosis prior to 1992 from [the] clinical findings" does not cite any clinical findings and did not identify what signs of atherosclerosis the Veteran probably developed. The statements/opinions are remarkably lacking in reasoning and detail. Thus, the Board finds these opinions unpersuasive. Similarly, the June 2015 private medical opinion is unconvincing as the examiner simply states that "[CAD] is a disease process that develops over decades," often years before symptoms materialize. The examiner's rationale is limited to a "review of his medical record and military record" and "lab values," and provides no additional rationale. When compared to the detail and specific citations of medical literature in the June 2017 VA medical opinion, the June 2015 private opinion is decidedly unpersuasive. The June 2017 private medical opinion focuses on the Veteran's genetic testing and carotid intima-media thickness (CIMT) testing. The examiner simply states that due to the Veteran's genetic mutation, he has an increased risk of cardiovascular disease. The examiner then provides a conclusory statement that due to this information, there "is no doubt" that the Veteran had CAD before his separation. In siting the CIMT testing, the examiner states that due to the 15 year difference between the Veteran's actual age and his estimated arterial age, the Veteran must have had CAD while in service. The examiner reaches these conclusions without further explanation. In this instance, the Board finds the June 2017 VA examiner's opinion to be the most probative as she provided an unequivocal and detailed medical opinion supported by a pertinent rationale based upon a review of the Veteran's claims file, when concluding that the Veteran's cardiovascular disorders were not related to his service. In doing so, the examiner systematically addressed each contention made by the Veteran and his representative, and made clear that there is no evidence of the manifestation of any cardiovascular disease while in service or in the year after separation. In doing so, the examiner clearly distinguished the presence of atherosclerosis from manifestations sufficient to identify the disease entity. The Board has also considered the lay statements of record. Here, the Veteran is competent to report his observations and relate what he was told by medical professionals. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran's lay evidence of onset and continuity is far less probative than the opinion of the VA professionals, as the VA medical opinions are far more detailed and reasoned; thus warranting a greater probative value. The Board finds that the probative value of the general lay assertions are outweighed by the clinical evidence of record. Physical examination during service revealed a normal heart and vascular system, and the Veteran has since denied any relevant symptoms in service. The VA examiners specifically addressed the Veteran's subjective reports. The Board accepts the Veteran's statements with respect to what he was told by medical professionals after service, however, as explained above, finds the opinions of VA medical examiners in this instance to be more probative. Overall, the medical evidence of record is afforded greater probative value than the more general lay assertions of the Veteran. The Board acknowledges the October 2017 contention of the Veteran's representative that the June 2017 VA examiner's opinion was ultimately supportive of a link between the Veteran's cardiovascular disease and service. The examiner did state that she reviewed the August 2009, April 2012, and June 2015 private medical opinions and "wholeheartedly agrees...that [the] Veteran most likely had atherosclerosis while he was on active duty." The representative suggests that is supportive of a manifestation of cardiovascular disease while in service. However, the June 2017 VA examiner clearly distinguishes the presence of atherosclerosis from the manifestations of cardiovascular disease sufficient to identify the disease entity, as atherosclerosis is present in those without cardiovascular disease. Lastly, the Board acknowledges the representative's October 2017 alternative contention that the Veteran's cardiovascular disease is secondary to his service-connected sleep apnea. VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Here there is no competent evidence suggesting that service connection under the provisions of 38 C.F.R. §§ 3.310 is warranted. In sum, there is no reliable evidence linking the Veteran's heart disorders to service. The contemporaneous records establish that there were no objective manifestations of a heart disorder in service, the heart and vascular systems were physically normal upon separation, the Veteran specifically denied any in-service symptoms, there were no manifestations of a heart disorder within one year of separation, and a heart disorder was first manifest many years after separation. Here, a heart disorder was not "noted" during service within the meaning of section 3.303(b). The Veteran has specifically denied in-service symptoms. While the Board acknowledges the Veteran's contention with respect to in-service risk factors and cardiac risk scores, the Board finds that the service treatment records do not show a combination of heart manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Furthermore, the evidence does not establish that a heart disorder was manifest to a compensable degree within one year of separation. 38 C.F.R. §§ 3.307; 3.309. Rather, the examinations during the pertinent time frame were normal. In essence, the evidence establishes that the heart was normal upon separation from service and the onset of a heart disorder occurred many years after service. He did not have characteristic manifestations sufficient to establish the presence of the disease process during service and he did not have continuity of symptomatology (since he did not have symptoms). 38 C.F.R. § 3.303. The Board finds that the contemporaneous in-service and post-service treatment records are entitled to greater probative weight and credibility than the lay statements of the Veteran. The more probative evidence, in this instance service treatment records and VA medical opinions, establishes that he did not have manifestations of a heart disorder during service or within one year of separation. Furthermore, the evidence establishes that the remote onset of a heart disorder is unrelated to service. The Board finds that the preponderance of the evidence is against the claim and the claim must be denied. In sum, for the reasons and bases expressed above the Board finds that the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107 (b). ORDER Entitlement to service connection for a heart disability is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs