Citation Nr: 22018149 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 14-34 699A DATE: March 28, 2022 ORDER Entitlement to service connection for hypertension is denied. FINDING OF FACT The persuasive evidence is against a finding that hypertension began during active service, manifested to a compensable degree within one year of service, or is otherwise etiologically related to service. CONCLUSION OF LAW The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1131, 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 Army from June 1968 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO). In a February 2019 decision, the Board denied the Veteran's claim of entitlement to service connection for hypertension. The Veteran timely appealed. In February 2020, the Court of Appeals for Veterans Claims (CAVC) vacated the Board's decision and remanded the issue for further evidentiary development. Specifically, CAVC determined that the Board relied on an expert opinion that did not explain if the Veteran's hypertension began during service or within the presumptive period after service. Additionally, CAVC determined that the Board did not provide adequate reasons and bases for discounting the Veteran's testimony and statements that he was initially diagnosed with hypertension in September 1970 and was prescribed hypertension medication. Based on the Court's vacatur, the Board has remanded the claim to the AOJ several times for additional opinion. See Board Remands dated August 2020, July 2021, and November 2021. The Board finds substantial compliance with the most recent remands as an opinion on certain aspects of the claim were obtained by a doctor of internal medicine, and the AOJ confirmed the credentials of the examiner. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran is seeking service connection for hypertension. Specifically, he contends that his diagnosed hypertension is related to taking "constant dosages of salt tablets" throughout basic training, advanced individual training, and while training during regular service. See Board Hearing Transcript p. 3. He asserts that, within one year of service discharge, he was prescribed medications to treat severe hypertension and that he has manifested chronic hypertension since that time. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, such as hypertension, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Lay persons are competent to provide opinions on some medical issues falling within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A claimant bears the evidentiary burden to establish entitlement to the benefit sought. See Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The benefit of the doubt applies when the evidence for and against is in "approximate balance" or "nearly equal," but does not apply when the evidence persuasively favors one side or the other. Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc). VA regulations state that hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). In promulgating this note, VA made the following comment: Two commenters requested we clarify the meaning of the note. Standard medical texts recommend multiple blood pressure readings for the diagnosis of hypertension, although the number of measurements varies, with "at least three sets over at least a three-month interval" (Braunwald, 818) and "at least two measurements on two separate evaluations (Harrison, 1001) among the specific recommendations. We have revised the note to require that hypertension be confirmed by readings taken two or more times on each of at least three different days. This will assure that the existence of hypertension is not conceded based solely on readings taken on a single, perhaps unrepresentative, day. 62 Fed. Reg. 65,207, 65,215 (Dec. 11, 1997). VA has also defined when hypertension is deemed a disability for VA purposes - diastolic blood pressure of 90 mm Hg or more, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). In promulgating this note, VA cited to Cecil's Textbook of Internal Medicine at p. 253, based on a 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. 62 Fed. Reg. at 65,215. A compensable, 10 percent rating for hypertension is warranted for hypertension with diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. Upon review of the evidence, the Board concludes that service connection is not warranted on either a direct or presumptive basis, as the persuasive evidence is against a finding that the Veteran's hypertension was incurred in, caused by, or otherwise etiologically related to his period of service, or manifested to a compensable degree within one year of discharge. Turning to the facts of the case, the Veteran's service treatment records are silent for any complaints, treatments, or manifestations of hypertension. Upon entrance in June 1968, the Veteran's blood pressure was 128/74 while his May 1970 separation examination reflected a blood pressure of 144/78. Upon discharge, his relevant systems were clinically normal. Post-service, an October 1970 VA examination noted that the Veteran's blood pressure was 130/82 and there was no report that the Veteran was taking anti-hypertensive medications at that time. The next available post-service records are from Dr. B which first reflect a description of elevated blood pressure in June 2001. A medication list notes "Date Started" for medications as Propecia in January 1999, Zestoretic in June 2001 and Lisinopril HCT in November 2007. A problem list first reflects increased blood pressure in June 2001. In an August 2014 written statement, the Veteran's private physician, Dr. B., stated "[The Veteran] has been a patient of mine since 1980. During that time, he has been treated for hypertension." In support of his claim, the Veteran has submitted articles from medical websites that indicate excessive salt in the diet can lead to increased blood pressure. See WebMD and Mayo Clinic Website Excerpts. The claims file also contains a website excerpt indicating that the FDA recommends daily sodium consumption be limited to 2,300 milligrams per day, and an additional excerpt indicating salt pills contain 1000 milligrams of salt per tablet. At the October 2017 Board hearing, the Veteran testified to taking "constant dosages of salt tablets" throughout basic training, advanced individual training, and while training during regular service. The Veteran is competent to report his experience taking salt tablets. The Board finds the Veteran's testimony regarding his in-service experience to be credible and probative of the issue on appeal In written correspondence, the Veteran reiterated his in-service experience of ingesting salt tablets. He also asserted that he was first diagnosed with hypertension by a private physician in September 1970 he recalled being told that he had extreme hypertension with a blood pressure reading of 190/110. See VA Form 21-4142 received May 2013. At that time, he was prescribed an unnamed diuretic. He variously recalls that this was a "routine" visit, see VA Form 21-4138 received May 2013, or a visit for muscle relaxers due to back pain, see Memo for the record dated February 2013; VA Form 21-4138 received September 2014, or that he cannot clearly recall the reason for the visit. See October 2017 hearing transcript. In the December 2013 Notice of Disagreement, the Veteran summarized his hypertension history as follows: I was never treated or complained about [hypertension] while in the service because I never knew I had it. I didn't discover this condition until September 1970, 3 months after discharge from the Army, that I had extreme hypertension. At this point in time, there is no way for me to retrace those events and get records from that particular doctor and the drug store where I filled the prescription for diuretics. I had no health insurance during those years immediately following discharge from the Army and I didn't go to the doctor again. It wasn't until years later that I worked at the Navy Yard that I finally got employer provided healthcare. I never put in a claim with the VA at the time I was diagnosed since I wasn't aware that that was even a possibility. The Veteran has otherwise specified that, after the initial prescription, he lived with his hypertensive condition "until 1980 when I got health insurance and began getting treated." VA Form 21-4138 received September 2014. He otherwise testified that he was prescribed a diuretic in September 1970 which was the "only prescription I took because I wasn't working." See October 2017 hearing transcript. The doctor in 1970 suggested that he should be hospitalized. He lived with this condition until he received "steady" treatment in "1980." Id. He didn't recall the name of the initial prescription but was currently on Lisinopril. He didn't think he took medication steadily until 1987, when he was informed that he could not donate blood due to his high blood pressure reading. Id. In September 2018, VA obtained an expert medical opinion regarding the etiology of the Veteran's hypertension. The expert reviewed the claims file and noted the Veteran's elevated blood pressure readings during service. The expert determined that the Veteran's hypertension was not etiologically related to service, to include consumption of sodium tablets; rather, the expert determined that the Veteran's hypertension was genetic. The expert opined that while studies reflect sodium consumption causes short term elevation of blood pressure, a return to normal diet causes a return to normal blood pressure. The expert stated that chronic hypertension is not caused by short term sodium tablet consumption. Further, the expert noted the Veteran's family history of stroke, and opined that the majority of patients, including the Veteran in this case, have essential hypertension, which is a genetic disorder. In April 2021, the Veteran was afforded a VA examination to determine the nature and etiology of his hypertension by a medical doctor. Upon review of the record and examination of the Veteran, the examiner ultimately found that hypertension was less likely than not incurred in or caused by service or manifested within one year of discharge. In so finding, the examiner recounted the Veteran's medical history, to include his lay contentions. The examiner reasoned that the earliest available blood pressure readings, dated June 1968 (128/74), May 1970 (144/78) and October 1970 (130/82) document systolic blood pressure readings well below 160. Further, the examiner noted that subsequent post-service treatment records indicate that the first indication of hypertension was in 2001, well after his discharge from service. Moreover, the examiner found that if the Veteran had a 50-year history of hypertension disability since 1970, as he claimed, there would be evidence of ancillary complications, such as end organ damage or kidney disease. However, as the Veteran's diagnostic testing values remained within normal limits, it was unlikely that his hypertension began in 1970. The examiner also acknowledged the Veteran's reports of being diagnosed with hypertension in September 1970 after an elevated blood pressure reading of 190/110. However, the examiner cited medical literature for the premise that in order to properly diagnose hypertension, an average of two to three blood pressure readings obtained on two to three separate occasions is recommended in order to minimize error. As there was no consistent objective evidence to support the September 1970 diagnosis, the examiner ultimately found that hypertension was not manifested within one year of discharge. In an August 2021 addendum opinion, a different VA examiner, an internist as requested by the Board's remand directives, found that the Veteran's blood pressure reading at separation from service, while indicative of a slight systolic pressure elevation, was not consistent with hypertension. In addition, when viewed in the context of the Veteran's overall medical history, the reported blood pressure reading of 190/110 in September 1970 was not likely to be valid. In so finding, the examiner found that while blood pressure may have been elevated at that time, the standard of care for diagnosing hypertension includes multiple readings at different times over several days. Moreover, the examiner continued, the Veteran's elevated reading was contemporaneous to treatment for back pain. The examiner explained that severe pain could have transiently elevated his blood pressure reading at that time. The examiner also opined that a diuretic was not appropriate to manage this degree of blood pressure elevation. In regard to the October 1970 reading of 130/82, the examiner found that if the alleged September 1970 reading of 190/110 was valid, it is unlikely that his blood pressure would normalize to such a degree in one month. Finally, the internist agreed with the April 2021 examiner in finding that if the Veteran had uncontrolled hypertension for such a long period of time, there would be some degree of chronic kidney disease. Upon consideration of the evidence, the Board finds that service connection for hypertension is not warranted on either a presumptive or direct basis. In regard to presumptive service connection, the main crux of the Veteran's claim is that he was prescribed a diuretic in September 1970 due to being diagnosed with hypertension based on a blood pressure reading of 190/110. The Veteran is competent, as a lay person, to attest to what he experienced, to include any discussions he had with his health care provider. Jandreau, 492 F.3d at 1376-77. However, he is not shown to be competent to provide an etiological opinion, to self-diagnose hypertension or determine the validity of any particular diagnosis. Id. On this point of evidence, the Board notes that it has no competence to arrive at its own medical opinions in any given case. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Notably, the Veteran's competence to relate being prescribed a diuretic based on a blood pressure reading of 190/110 and a diagnosis of hypertension does not, in and of itself, establish that the Veteran's recollections are accurate or that the presumed diagnosis of hypertension in September 1970 was in fact valid. The Board has sought medical opinion as necessary to decide this claim. As a general matter, the probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The "factually accurate, fully articulated, sound reasoning for the conclusion" contributes probative value to a medical opinion. Id. On the other hand, a medical opinion based on an inaccurate factual predicate has reduced probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board has the responsibility of determining the credibility of non-medical facts. See generally Kahana, 24 Vet. App. 428 (2011). A medical examiner opinion may assist the Board to determine whether the Veteran's recollections of facts that are medical in nature are, in fact, true. Id. at 442-43. The record does not contain any available documentation to determine the specific circumstances, diagnosis and treatment in September 1970. Nonetheless, the Veteran has consistently asserted that, in September 1970, he had a blood pressure reading of 190/110, had been told he had hypertension, and had been placed on a diuretic. The Veteran's recollections have some probative value. The Board has asked examiners to consider these recollections in the context of the entire evidentiary record in light of medical principles applicable to the diagnosis and treatment of hypertension. The Veteran asserts that, at the time of a VA examination in October 1970, he was on a diuretic which explains his blood pressure reading of 130/82. Again, the Veteran's recollections have some probative value. The Board has asked examiners to consider this recollection in the context of the entire evidentiary record in light of medical principles applicable to the diagnosis and treatment of hypertension. Beyond these specific facts, the Veteran has provided inconsistent and unreliable recollections of his treatment history. With respect to the circumstances of his doctor visit in September 1970, he has variously recalled that this was a "routine" visit, see VA Form 21-4138 received May 2013, or a visit for muscle relaxers due to back pain, see Memo for the record dated February 2013; VA Form 21-4138 received September 2014, or that he cannot clearly recall the reason for the visit. See October 2017 hearing transcript. This is a significant inconsistency of recollection tending to show a failure of memory of the actual circumstances of his September 1970 doctor visitation. The Veteran has also provided unreliable recollections of when he was continuously prescribed anti-hypertension medications. He has consistently reported that, after the initial one-time prescription of a diuretic in September 1970, he did not take any anti-hypertensive medications until many years later. He recalled on one occasion that chronic anti-hypertensive medication use began in 1980. See VA Form 21-4138 received September 2014. At his hearing in October 1987, he testified to unspecified "steady" treatment for hypertension beginning in 1980 with an anti-hypertensive medication which he did not take consistently until 1987. It is unclear the type of "steady" treatment he received in 1980. A letter from Dr. B states "[the Veteran] has been a patient of mine since 1980. During that time, he has been treated for hypertension." Dr. B. does not directly state that hypertensive treatment began in 1980 but, rather, literally states that somewhere during the time period from 1980 to the present he has treated the Veteran for hypertension. Dr. B's available records first reflect a description of elevated blood pressure in June 2001 with a medication list of "Date Started" for medications as Propecia in January 1999, Zestoretic in June 2001 and Lisinopril HCT in November 2007. A problem list first reflects increased blood pressure in June 2001 which correlates with the prescription of Zestoretic in June 2001. Overall, the record clearly reflects that other than the reported one-time prescription of a diuretic in September 1970 - the Veteran did not receive any hypertensive care prior to 1980. The available records first record increased blood pressure and a "Date Started" of Zestoretic in June 2001. The only medication prescribed by Dr. B. prior to June 2001 was Propecia in 1999, and there is no argument or suggestion that Propecia was used to treat hypertension. See https://www.rxlist.com/propecia-drug.htm (Propecia, known by the generic name of finasteride, is used to treat symptoms of benign prostatic hyperplasia and male pattern hair loss). See generally Smith (Brady) v. Derwinski, 1 Vet. App. 235, 238 (1991) (Courts may take judicial notice of facts not subject to reasonable dispute). The most reliable evidence, the actual treatment records from Dr. B., document treatment for hypertension with anti-hypertensive medications beginning in 2001. Due to incomplete records, however, the Board cannot discount that an anti-hypertensive medication was not prescribed prior to June 2001 but the faulty memory of the Veteran prevents a reliable assessment as to when he began chronic anti-hypertensive treatment. Based on this factual record, the Board finds that the evidence is persuasively against a finding that the Veteran was diagnosed with chronic hypertension within his first post-service year. To that end, the Board finds that the most probative evidence on the issue of whether hypertension was manifested within one year of discharge consists of the April 2021 and August 2021 VA medical opinions. Notably, the April 2021 examiner opinion was provided by a medical doctor which did not technically comply with the Board's request for an opinion by an internist. There is no argument presented that this examiner, a doctor in medicine, is not competent to render an opinion in this case. The Board obtained technical compliance with its prior remand directives by obtaining an addendum by an internist, who provided his own assessment but also endorsed aspects of the opinion by the April 2021 medical doctor. Thus, there is no reason to completely discount the opinion of the April 2021 examiner. These examiners provided negative nexus opinions after review of the Veteran's medical history and, in the case of the April 2021 examiner, physical examination of the Veteran. The examiners accurately recounted the relevant points of the Veteran's history, to include his recollected September 1970 elevated blood pressure readings, diagnosis of hypertension, and prescription of a diuretic. First, the August 2021 examiner viewed the Veteran's recollected blood pressure reading of 190/110 in September 1970 in the context of the entire record. The examiner explained that the diagnosis of hypertension in September 1970 was not likely to be medically valid. The examiner explained that the proper standard of care for diagnosing hypertension requires multiple readings at different times. This is consistent with VA's own stated standard for properly diagnosing hypertension in Note (1) of Diagnostic Code 7101 by requiring multiple readings on different days "to assure that the existence of hypertension is not conceded based solely on readings taken on a single, perhaps unrepresentative, day." 62 Fed. Reg. at 65,215. This is also consistent with the April 2021 VA examiner explanation, based by reference to medical literature, that a proper diagnosis of hypertension should be based on an average of two or three blood pressure readings obtained on two or three separate occasions to minimize the potential for error. The Veteran has testified to only one office visit that resulted in the hypertension diagnosis with no follow-up treatment until 1980 - which does not comply with the medical standard for properly diagnosing hypertension identified by the medical examiners as well by VA's own standards. The August 2021 examiner further noted that, if the Veteran had been evaluated for back pain in September 1970 as claimed at one point in this appeal, severe pain could transiently elevate a blood pressure reading. There is further evidence in this case that use of sodium tablets could, at the very least, transiently elevate blood pressure readings. The Veteran's recollections of the reasons for his September 1970 visitation are unreliable either a routine visit, a visit for back pain or he cannot recall. Notably, a determination as to whether or not the Veteran was receiving treatment for back pain or not in September 1970 is not essential to adjudicate the case. Rather, the fact that the Veteran recalls being diagnosed with hypertension based upon one visitation without accurate evidence of any transient variable(s) that may have affected his blood pressure readings underscores the fact that, according to the medical examiner opinions, a diagnosis of hypertension based on one visitation calls into question the validity of a diagnosis of hypertension in September 1970 according to accepted medical principles. Second, the August 2021 examiner opined that prescription of a diuretic would not have been appropriate treatment for a blood pressure reading of 190/110 and, additionally, that it was unlikely that a blood pressure reading of 190/110 in September 1970 would have normalized to the reading of 130/82 as documented on the VA examination in October 1970 even if the Veteran had been on a diuretic. Thus, the VA examiner questioned the validity of actually having hypertension in September 1970 based on a blood pressure reading of 190/110 from a medical standpoint of appropriate treatment and the medical likelihood the Veteran's blood pressure readings would have lowered from 190/110 to 130/82 with one month of diuretic treatment. The examiner also reviewed the reported blood pressure reading of 190/110 in September 1970 with the recorded blood pressure reading of 144/78 in May 1970, which the examiner found was not consistent with a finding of significant hypertension in the 1970s. As noted above, the Veteran is competent to relate his recollection of his blood pressure reading in September 1970, but the accuracy of the actual blood pressure reading is subject to question given his significant failure of memory of the actual circumstances of his September 1970 doctor visitation and his treatment history of hypertension in general. The Board places significant probative weight to the expert opinion that a valid diagnosis of hypertension in September 1970 is medically unlikely given medical principles of diagnosis and treatment for hypertension. Third, the April 2021 and August 2021 examiners both concurred in the medical fact that, if the Veteran had manifested uncontrolled hypertension for a long period of time, there would be some degree of ancillary complications such as end organ damage or chronic kidney disease, and that current diagnostic values are currently within normal limits. The Board acknowledges that the April 2021 relied on a factual history that hypertension was first documented in 2001, which the Board finds is entirely consistent with Dr. B's records first reflecting a notation of increased blood pressure readings and a prescription of medication. Even assuming, arguendo, that the Veteran had earlier treatment with hypertensive medications as claimed in some statements (such as 1980 or 1987) this would not negate the validity of the first two stated examiner reasons for discounting the validity of an actual diagnosis of hypertension in September 1970. Overall, the August 2021 examiner explained in medical terms why the September 1970 diagnosis of hypertension was not valid. The April 2021 examiner opinion is consistent with this assessment. The Board finds these opinions, taken together, are highly probative as to the issue of presumptive service connection. The probative value of the only remaining evidence, the Veteran's lay statements, is substantially outweighed by that of the probative April 2021 and August 2021 VA opinions. In this respect, the Veteran is recollecting what his doctor told him in 1970 which is more than 50 years ago, and the Board does not accurately know what the Veteran's doctor actually diagnosed and prescribed, whether the recollection of 190/110 is accurate, how many readings were taken, and other factors which may have affected his blood pressure readings such as pain or sodium tablets. The Veteran's memory is shown to be significantly faulty on key facts in this case such as the reason for his actual doctor visit in September 1970 and when he began chronic anti-hypertensive treatment. The examiner opinions in this case have opined that it is medically unlikely that the Veteran manifested hypertension in September 1970 given the totality of the evidence including medical principles for diagnosing and treating hypertension. These opinions hold significantly greater probative weight than the Veteran's recollections and personal opinion. Moreover, there is no continuity of symptomatology after service to support the Veteran's claim under 38 C.F.R. § 3.303(b). The service treatment records lack the documentation of the combination of manifestations sufficient to diagnose hypertension and sufficient observation to establish chronicity during service. The Veteran himself was unaware of hypertension until his post-service doctor visit, and the September 2018 VA examiner provided opinion that hypertension was not manifested in service. Thus, as there is no evidence of continuity of symptomatology to support the claim of service connection for hypertension, the persuasive evidence is against the claim of service connection for hypertension based on continuity of symptomatology under 38 C.F.R. § 3.303(b). Similarly, the Board finds that the evidence preponderates against a finding that service connection is warranted on a direct basis. On this point, the September 2018 VHA expert medical opinion addressed the Veteran's contentions related to his in-service consumption of salt tablets. Upon review of the record, including any medical articles, the expert adequately explained why the Veteran's current diagnosis of hypertension is not related to any in-service consumption of salt tablets. Specifically, the expert opined explained that sodium consumption causes short term elevation of blood pressure and that a return to normal diet causes a return to normal blood pressure. The Board finds this opinion to be highly probative as it applies the specific facts of the Veteran's case to sound medical principles to arrive at a rationalized conclusion. Additionally, the August 2021 examiner reviewed the blood pressure readings at entry and separation from service, the reported blood pressure reading of 190/110 in September 1970, the blood pressure reading at the October 1970 examination and the documented blood pressure readings after 1970. This examiner opined that it was not likely that the Veteran had significant hypertension in the 1970s except for the Veteran's reported elevated reading in September 1970, which the examiner found was not a valid diagnosis. In support of direct service connection, the Veteran has provided medical articles, which suggest a relation between salt consumption and hypertension. However, the Board finds that the medical opinion dated September 2018 is more probative as it based on the specific facts of the Veteran's case rather than a generalized article that sodium can increase and/or cause blood pressure. The remaining evidence consists of the Veteran's lay statements. To the extent the Veteran attributes his hypertension diagnosis to his period of service, to include consumption of salt tablets, the Board finds that his statements are not competent. Such an opinion requires medical training and knowledge of pathology, the cardiovascular system, and the interaction between multiple organ systems in the body. Jandreau, 492 F.3d 1372 (Fed. Cir. 2007). In sum, the persuasive evidence establishes that the Veteran's hypertension was not manifested during service, or within one year of discharge and is not otherwise etiologically related to service. Accordingly, the claim is denied. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Orie, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.