Citation Nr: 18147383 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 05-27 002 DATE: November 5, 2018 ORDER Service connection for hypertensive cardiomyopathy, status post myocardial infarction, stenting, mitral valve prolapse, and implantable cardioverter defibrillator (ICD) implant (heart disease), is denied. FINDING OF FACT The Veteran’s heart disease did not manifest to a compensable degree within one year of separation from service; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury, disease, or event. CONCLUSION OF LAW The criteria for service connection for heart disease are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from July 1980 to August 1991, with additional Reserve service. Procedural History This matter comes before the Board of Veterans’ Appeals (“Board”) on appeal from a June 2004 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In a January 2008 decision, the Board denied this appeal. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In December 2008, the Court granted a Joint Motion for Partial Remand (JMPR) submitted by the Veteran and the Secretary of Veterans Affairs (Parties), vacated the January 2008 decision so far as it denied the issue now on appeal, and remanded that matter to the Board for compliance with the instructions of the JMPR. The Parties agreed in the JPMR that this appeal should be remanded because the January 2008 Board decision did not discuss the Veteran’s in-service blood pressure readings. See JPMR at 3-4. No other favorable evidence was discussed in the JPMR. In May 2009, the Board remanded this matter to the agency of original jurisdiction (AOJ) for additional development, to include affording the Veteran an examination and obtaining a medical opinion discussing his in-service blood pressure readings. In January 2011, the Veteran presented for a VA examination and a medical opinion was obtained. In a May 2012 decision, the Board again denied this appeal, and the Veteran timely appealed that decision to the Court. In August 2013, the Court issued a Memorandum Decision in which it vacated the May 2012 Board decision on the grounds that the January 2011 medical opinion relied upon by the Board did not address the key question in this case: whether the Veteran’s in-service pre-hypertensive blood pressure readings demonstrate a relationship between his current heart disease and his service. See Memorandum Decision at 7-8. In March 2014, the Board remanded this matter to the AOJ, and directed that the Veteran be afforded a VA examination by “an appropriate specialist” who should provide a medical opinion as to the etiology of the Veteran’s heart disease. See March 2014 Board Remand at 6. In July 2014, the Veteran presented for a VA examination. The examiner, a physician’s assistant, provided a July 2014 medical opinion and an October 2014 addendum opinion. He opined that the Veteran’s heart disease was less likely than not caused by the Veteran’s hypertension or an in-service event, and was instead caused by his age, tobacco use, genetics, and cholesterol issues. See July 2014 VA Medical Opinion; October 2014 VA Addendum Opinion. The Veteran’s attorney objected, arguing that the March 2014 remand directed that an opinion be provided by an “appropriate specialist,” and that an opinion from a physician’s assistant violated the March 2014 remand directives. See March 2016 Board Remand at 3. Thus, in March 2016 the Board again remanded this claim, and directed that another examination and medical opinion be provided by an “appropriate specialist,” defining “appropriate specialist” as “a physician specializing in an appropriate medical field.” Id. at 7. 2017 & 2018 VHA Opinions In accordance with the March 2016 remand directives, the Veteran was scheduled for a February 2017 VA examination. However, the Veteran reported that he was unable to attend that examination, as he had recently undergone a heart transplant in July 2016. See March 2017 File Note. The March 2017 supplemental statement of the case (SSOC) states that when the Veteran was contacted about scheduling the VA examination, he stated that he “had a heart transplant and the examination was no longer needed.” See March 2017 SSOC at 8. Neither the Veteran nor his attorney has disputed that the Veteran received a heart transplant in July 2016, or that he declined to report to the February 2017 VA examination. Thus, in October 2017 the Board requested an opinion from a Veterans Health Administration (VHA) cardiologist. Dr. P.S., a noninvasive cardiologist, provided the Board with the requested opinion in December 2017 (2017 VHA Opinion). Dr. P.S. noted that he was not a hypertension specialist, and that “[a]n opinion from a hypertension expert may also be obtained regarding pre-hypertension.” See 2017 VHA Opinion at 1. He opined that 1) it was less likely than not that the Veteran demonstrated pre-hypertension, 2) pre-hypertension did not lead to and was not etiologically related to the Veteran’s heart disease, and 3) the Veteran’s heart disease is not related to his service, and it is not possible to determine when the Veteran’s heart disease had its onset. Id. at 2. The Veteran’s attorney objected, again arguing, among other things, that Dr. P.S. was not an “appropriate specialist.” See March 2018 Correspondence at 9-10. The Board determined that an internist would be an appropriate specialist, and in May 2018 requested another VHA opinion, which was provided in June 2018 by Dr. W.O. (2018 VHA Opinion). Dr. W.O., an internist, opined that it was more likely than not that the Veteran could be considered to have had pre-hypertension during his active service, as of his forty-three in-service blood pressure readings, thirty-one were in the range of pre-hypertension, with two of those thirty-one in the range of hypertension. Dr. W.O. noted, however, that these readings do not meet the diagnostic criteria for a diagnosis of chronic systemic hypertension in service. See 2018 VHA Opinion at 2-3. In response to the Board’s question of whether it was at least as likely as not (50 percent or greater probability) that the Veteran’s pre-hypertension led to or is etiologically related to his heart disease, Dr. W.O. opined that the Veteran’s heart disease developed many years after his service, without continuity to his symptoms in service, and is not etiologically related to the Veteran’s pre-hypertensive blood pressure readings or pre-hypertension in service. Dr. W.O. explained that 1) pre-hypertension is not a chronic medical condition per accepted medical principles, 2) pre-hypertension is reversible, and 3) pre-hypertension does not meet the criteria for a diagnosis of chronic systemic hypertension. He further explained that blood pressure readings in the pre-hypertensive range are “simply an indication to doctors and a warning to their patients that they should follow a lifestyle that does not promote and encourage the onset of chronic systemic hypertension.” Dr. W.O. explained that there was no evidence of heart disease at the time that the Veteran exhibited pre-hypertensive blood pressure readings during active service, “which is what would be expected for blood pressure readings in the prehypertensive range with no causal relationship between this range of blood pressure readings and heart disease.” See 2018 VHA Opinion at 3. Finally, Dr. W.O. opined that it is less likely than not that the Veteran’s heart disease is related to, or had its onset during, the Veteran’s lengthy period of service, or that it had its onset within one year of separation from his lengthy period of service. He explained that a “review of the Veteran’s medical records [was] significant for heart disease that developed many years after active duty service that ended on 8/1/91, and therefore is without continuity to military service[,] to include one year after separation.” Dr. W.O. further explained that there were no line of duty determinations attributing the Veteran’s heart disease to his service in the Reserves. See 2018 VHA Opinion at 4. Veteran’s Contentions The Veteran’s attorney argues that both the 2017 VHA Opinion and the 2018 VHA Opinion are inadequate and not in compliance with the Board’s March 2016 remand, and requests that the Board again remand the Veteran’s claim to the RO for a new, adequate VA examination with a hypertension specialist. See September 2018 Correspondence at 6. Specifically, the Veteran’s attorney argues that the VHA opinions are inadequate because they were not in-person examinations and thus do not comply with the March 2016 Board remand. She also argues that the VHA opinions do not comply with the March 2016 Board remand because they did not discuss the Veteran’s in-service notations of elevated cholesterol and possible hyperlipidemia. Id. at 5. The Veteran’s attorney further argues that the VHA experts fail to provide adequate rationales for their opinions. Specifically, she argues that the 2018 VHA Opinion does not provide an adequate rationale for its conclusion the Veteran’s heart disease was not related to his military service, “especially in light of the November 2017 examiner’s opinion that it was not possible to determine when the Veteran’s heart disease first onset.” She additionally argues that the VHA opinions do not adequately discuss the Veteran’s pre-hypertension readings and his elevated cholesterol “as a whole,” and that these opinions are not “thorough” as they do not adequately consider the Veteran’s lay statements regarding the onset of his hypertension and symptoms since service. Id. Finally, the Veteran’s attorney argues that the Board breached its duty to assist the Veteran by not obtaining a medical opinion from a hypertension expert “as suggested by the December 2017 examiner.” Id. at 6. Analysis Initially, the Board notes that, as reflected in the Memorandum Decision, the Court did not object to or otherwise find insufficient the Board’s general recitation of the facts or procedural history of this case. Rather, the Memorandum Decision reflects the Court’s specific determination that the Board erred by relying upon the January 2011 VA examination, which did not answer “the critical medical question that prompted the Board to seek [that] examination in the first place- namely, whether and to what extent prehypertensive blood pressure readings in service demonstrate a relationship between the Veteran’s current heart disease and his service.” Memorandum Decision at 7. Accordingly, in the interest of judicial economy, the Board will focus the current analysis on this identified area of deficiency, namely whether the Veteran’s blood pressure readings during service demonstrate a relationship between the Veteran’s heart disease and his military service. Furthermore, in the interests of judicial economy, the Board hereby incorporates all other facts and analysis of the May 2012 vacated Board decision by reference. See generally Carter v. Shinseki, 26 Vet. App. 534, 542-43 (2014), vacated on other grounds sub nom Carter v. McDonald, 794 F.3d 1342 (Fed. Cir. 2015). Board Remand Directives As indicated above, the Veteran’s attorney argues that Board did not comply with the March 2016 remand, as 1) Dr. P.S. and Dr. W.O. are not “appropriate specialists,” 2) Dr. P.S. and Dr. W.O. did not personally examine the Veteran, and 3) Dr. P.S. and Dr. W.O. did not discuss the Veteran’s in-service notations of elevated cholesterol and possible hyperlipidemia. A remand by the Board confers on the claimant a legal right to compliance with the remand order. Memorandum Decision at 6 (citing Stegall v. West, 11 Vet. App. 268 (1998)). Substantial compliance, not strict compliance, with the remand order is required. Memorandum Decision at 6 (citing Donnellan v. Shinseki, 24 Vet. App. 167 (2010); Dyment v. West, 13 Vet. App. 141 (1999)). When a claim is remanded to provide the claimant with a VA medical examination, VA must ensure that the examination provided is adequate. Memorandum Decision at 6 (citing Barr v. Nicholson, 21 Vet. App. 303 (2007)). The Board finds that the 2018 VHA Opinion substantially complied with the directives of the prior remands. The Board observes that the critical goal of each of the remands during the fifteen-year history of this case has been to obtain an opinion as to the nature and etiology of the Veteran’s heart disease, specifically in light of the Veteran’s blood pressure readings in service. This was the only issue raised in the JPMR, and it was why the Court vacated and remanded the May 2012 Board decision. Thus, the Board finds that as the 2018 VHA Opinion has adequately answered the key question in this case (as discussed further below), obtaining that opinion constitutes substantial compliance with the Board remands. However, given the long and litigious history of this appeal, the Board will further discuss this issue. Assuming arguendo that obtaining an opinion that adequately answers the key question of this case does not, standing alone, constitute substantial compliance, the Board still finds that there has been substantial compliance with the prior remand directives. While Dr. W.O. did not personally examine the Veteran, the Board finds that the Veteran could not present for a VA examination in light of his July 2016 heart transplant. Moreover, the March 2017 SSOC stated that when the Veteran was telephoned about missing the February 2017 examination, he stated that “no further examination was necessary.” Thus, as the Veteran would not or could not present for any future examinations, strict compliance with the remand directive that the Veteran be examined was impossible, and obtaining a VHA opinion constituted substantial compliance. The Board further finds that obtaining a medical opinion from Dr. W.O. substantially complied with the remand directive to obtain an opinion from an “appropriate specialist.” The March 2016 remand defined “appropriate specialist” as a “physician specializing in an appropriate medical field” regarding the Veteran’s claimed heart disease. While the Board initially sought an opinion from a cardiologist, the critical question in this case relates to the Veteran’s pre-hypertension, and the VHA cardiologist that authored the 2017 VHA Opinion stated that he was not a hypertension specialist. The Board notes that hypertension is an aspect of internal medicine. As Dr. W.O. is an internist, hypertension is within his area of expertise, and as discussed in greater detail below, Dr. W.O. provided a thorough and detailed opinion that was consistent with the competent evidence of record. Cf. D’Aires v. Peake, 22 Vet. App. 97, 105 (2008) (finding substantial compliance where the Board discussed adequately explained its reliance on a specialist’s opinion). Moreover, he did not express any reservations as to his ability to appropriately address the Board’s questions concerning hypertension. To the extent that the Veteran’s attorney argues that an opinion from a “hypertension specialist” or “hypertension expert” more specialized or recognized than Dr. W.O. is required, the Board does not find that to be required by its interpretation of its own remands. Finally, the Board notes that while Dr. W.O. did not specifically discuss the Veteran’s in-service notations of elevated cholesterol and possible hyperlipidemia, it finds that the 2018 VHA Opinion substantially complies with the remand directives in this case. Critically, the JMPR and the Memorandum Decision focus on the Veteran’s blood pressure readings in service, and thus the Board finds that the discussion of this issue is the key to substantial compliance with the remand directives in this case. Moreover, the Board observes that Dr. W.O.’s opinion demonstrates that he reviewed the Veteran’s records, that Dr. W.O. is competent to determine what evidence is relevant to the etiology of the Veteran’s heart disease, and therefore that he is best-equipped to determine what evidence should be discussed in his rationale. Furthermore, the Veteran has not submitted any competent medical evidence that these issues warrant discussion given the facts of his case. Accordingly, the Court finds that Dr. W.O.’s 2018 VHA Opinion substantially complied with the Board remand directives. Duty to Assist The Veteran’s attorney argues that the Board breached its duty to assist the Veteran by not obtaining a medical opinion from a hypertension expert “as suggested by the December 2017 examiner.” September 2018 Letter at 6. The Board finds that it has satisfied its duty to assist in this respect. The Board obtained an opinion from a specialist in internal medicine, and finds that here the opinion of an internist is appropriate in light of the 2018 VHA Opinion’s adequate rationale, discussion of the evidence, and on-point answer to the key question in this case. See D’Aires, 22 Vet. App. at 105. Moreover, the Board finds that Dr. P.S.’s statement that the Board “may” obtain the opinion of a “hypertension specialist,” coupled with his statement that he was not a hypertension specialist, constituted a disclaimer of his own expertise concerning hypertension and was neither a suggestion that the Veteran’s case was unusually complex, nor a statement that an opinion of an internist would be inappropriate. See Jackson v. Virginia, 443 U.S. 307, 319 (1979) (stating it is “the responsibility of the trier of fact fairly to... draw reasonable inferences from basic facts to ultimate facts”); Bastien v. Shinseki, 599 F.3d 1301, 1306 (Fed. Cir. 2010) (“The evaluation and weighing of evidence and the drawing of appropriate inferences from it are factual determinations committed to the discretion of the fact finder.”). Service Connection for Heart Disease The Veteran asserts that his heart disease is related to his elevated blood pressure readings in service. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish entitlement to service connection, a veteran must show (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For veterans who have served continuously for 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including cardiovascular disease and hypertension, are presumed to have been incurred in service if manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If symptoms of a chronic disease are noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required to presumptively establish service connection. 38 C.F.R. § 3.303. The Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s heart disease manifested to a compensable degree within one year of separation from service, began during service, or is otherwise related to an in-service injury, disease, or event. See Holton v. Shinseki, 557 F.3d 1363 (Fed. Cir. 2009). The Board concedes that the Veteran has current heart disease and had in-service pre-hypertensive blood pressure readings. Thus, the key question in this case whether there is a nexus between the Veteran’s heart disease and his service. Here, there is no competent medical opinion of record showing that the Veteran’s heart disease is related to his service, had its onset in service, or manifested to a compensable degree within one year of separation. Notably, the 2018 VHA expert found that it was less likely than not that the Veteran’s heart disease was related to his service, had its onset in service, or manifested to a compensable degree within one year of separation. Additionally, and as discussed below, the Board finds that the 2018 VHA expert’s opinion contains an adequate rationale to support its conclusions. The Veteran’s attorney argues that the VHA opinions lack adequate rationale, as 1) the VHA opinions do not adequately discuss the Veteran’s pre-hypertension readings and his elevated cholesterol “as a whole,” 2) the VHA opinions do not adequately consider the Veteran’s lay statements regarding the onset of his hypertension and symptoms since service, and 3) the June 2018 opinion does not provide an adequate rationale for the opinion that the Veteran’s heart disease was not related to his military service, “especially in light of the November 2017 examiner’s opinion that it was not possible to determine when the Veteran’s heart disease first onset.” A VA medical examination is adequate where it is based upon consideration of a veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one. Memorandum Decision at 6 (citing Stefl v. Nicholson, 21 Vet. App. 120 (2007)). Although there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file to render an adequate opinion, a medical examination report or opinion must sufficiently inform the Board of a medical expert’s judgment on a medical question and the essential rationale for that opinion. Memorandum Decision at 6 (citing Monzingo v. Shinseki, 26 Vet. App. 97 (2012)). In other words, the examiner must provide not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Memorandum Decision at 6 (citing Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008)). Initially, the Board notes that it only relies upon the 2018 VHA Opinion in this decision, and therefore will only address arguments that relate to that opinion. The Board finds that Dr. W.O.’s 2018 VHA expert’s opinion is supported by an adequate rationale. Critically, the 2018 VHA expert squarely addresses the deficiency identified in the Memorandum Decision. Dr. W.O. conceded that the Veteran’s blood pressure readings during service constituted pre-hypertension, and then explained that pre-hypertension is not a chronic condition, is reversible, and is not chronic systemic hypertension. See 2018 VHA Opinion at 2-3. The Board finds that Dr. W.O.’s statement that pre-hypertension “is simply an indication to doctors and a warning to their patients that they should follow a lifestyle that does not promote and encourage the onset of chronic systemic hypertension” demonstrates his opinion that pre-hypertension is not itself a medical condition or manifestation of disease. Importantly, Dr. W.O. explained that while the Veteran had blood pressure readings in the hypertensive range, “there was no evidence of heart disease, which is what would be expected for blood pressure readings in the prehypertensive range with no causal relationship between this range of blood pressure readings and heart disease.” See 2018 VHA Opinion at 3 (emphasis added). Moreover, Dr. W.O. explained that there was no other indication that the Veteran developed heart disease during his active duty or Reserve service. See 2018 VHA Opinion at 4. Dr. W.O.’s opinion directly answers the question posed by the Court: the Veteran’s in-service blood pressure readings occurred in the absence of evidence of heart disease, and his in-service pre-hypertension was not a manifestation of or causally related to his later-diagnosed heart disease or causally related to his later-diagnosed heart disease. Specifically, the Board notes Dr. W.O.’s response to “Question #2” of the VHA request, where he explained that pre-hypertension is reversible, and is a warning to patients that they should try to avoid activities that would cause them to develop hypertension in the future. The Board finds that Dr. W.O.’s opinion that the Veteran’s blood pressure in service is not related to his current heart disease is supported by his explanation that 1) although the Veteran had elevated blood pressure constituting pre-hypertension during service, 2) there was no evidence of heart disease during service in his medical records, and 3) pre-hypertension is not a chronic condition and does not, itself, cause heart disease, thus 4) his current heart disease is not related to his service, as that is the medically expected result where there is pre-hypertensive blood pressure readings in the absence of evidence of heart disease. See 2018 VHA Opinion at 2-3. Furthermore, Dr. W.O.’s opinion that the Veteran’s heart disease is not otherwise related to his service, i.e., his response to “Question #3” of the VHA request, is also supported by an adequate rationale: 1) based on a review of the Veteran’s medical records, his heart disease developed many years after his active duty, 2) there is no continuity linking the Veteran’s military service to his heart disease, and 3) there are no line of duty determinations linking attributing the Veteran’s heart disease to reserve service, and thus 4) the Veteran’s current heart disease is less likely than not related to his service, or had its onset during or within a year of his separation from service. See 2018 VHA Opinion at 3-4. While the Veteran’s attorney asserts that Dr. W.O. was required to discuss the Veteran’s blood pressure and cholesterol readings “as a whole” when rendering his opinion, as well as the Veteran’s lay statements regarding the onset of his hypertension and symptoms since service, the Board notes that Dr. W.O. determined that the Veteran’s heart disease developed many years after service and is not etiologically related to his service based upon a review of the Veteran’s medical records, which included this information. Critically, Dr. W.O. opined that at the time that the Veteran exhibited prehypertensive blood pressure readings, i.e., during active service, there was no evidence of heart disease. Furthermore, the Board finds that there is no medical evidence of record contrary to Dr. W.O.’s opinion. Thus, the Board finds that as Dr. W.O. opined that nothing in the Veteran’s records tends to show that the Veteran had heart disease, there was no need for Dr. W.O. to discuss that evidence. See Monzingo v. Shinseki, 26 Vet. App. 97 (2012) (examiner not required to discuss every piece of evidence). The Board cannot substitute its own judgment for that of a competent medical professional when determining what is or is not evidence of heart disease. To the extent that the Veteran or his attorney asserts that a relationship exists between the Veteran’s cholesterol and blood pressure “as a whole,” they are not competent to provide such an opinion. See Memorandum Decision at 8; see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this regard, the Board observes that the footnote in the attorney’s April 2009 letter to the Board only concerned pre-hypertension, which Dr. W.O. discussed in detail, and that footnote did not concern cholesterol either alone or in combination with hypertension. See April 2009 Letter. There is no competent medical opinion in favor of the claim. In this regard, while the Veteran is competent to report his symptoms, any opinion regarding the etiology of his hypertension or heart disease requires medical expertise that the Veteran has not demonstrated. Jandreau, 492 F.3d 1372. Moreover, the Board emphasizes that the Veteran has reported smoking since the age of 27 or 28, and was still smoking at the time he received treatment at age 59 in November 2013. See 38 U.S.C. § 1103; 38 C.F.R. § 3.300; January 2011 VA examination report; November 2013 VA treatment record. Finally, the Board disagrees with the argument of the Veteran’s attorney that the rationale of the 2018 VHA Opinion in insufficient given the statement in the 2017 VHA Opinion that it was not possible to determine the onset of the Veteran’s heart disease. The Board sought out the 2018 VHA Opinion from a physician specializing in internal medicine after Dr. P.S., the author of the 2017 VHA Opinion, stated that he was not a hypertension specialist. See 2017 VHA Opinion at 1. Moreover, the Veteran’s attorney specifically argued Dr. P.S. was not an appropriate specialist based on that statement. See March 2018 Correspondence at 9-10. The Board finds that Dr. W.O.’s opinion adequately explained that the Veteran’s heart disease did not develop until many years after his service. Moreover, the Board finds that, in the context of Dr. P.S.’s concession that he was not a hypertension specialist, his opinion as to the impossibility of determining when the Veteran’s heart disease had its onset concerned the limitations of his own knowledge, and was not a statement as to the limits of medical knowledge in general. See Jackson, 443 U.S. at 319; Bastien, 599 F.3d at 1306. Thus, the Board finds that Dr. P.S.’s statement concerning the impossibility of determining the onset of the Veteran’s heart disease is not probative. Conclusion In sum, the Board finds that the remand directives have been substantially satisfied and that the Board has fulfilled its duty to assist the Veteran. Moreover, the Board finds that the 2018 VHA expert opinion, which is adequately supported by its rationale, is the most probative evidence of record. Thus, as the preponderance of the probative evidence of record weighs against the Veteran’s claim, service connection for heart disease is denied. S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.M. Badaczewski, Associate Counsel