Citation Nr: 0510899	
Decision Date: 04/15/05    Archive Date: 04/27/05

DOCKET NO.  98-16 123A	)	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:	Robert K. Gruber, Attorney at 
Law


WITNESSES AT HEARING ON APPEAL

The veteran and his spouse


ATTORNEY FOR THE BOARD

A. P. Simpson, Counsel


INTRODUCTION

The veteran served on active duty from April 1957 to July 
1960.

This case comes before the Board of Veterans' Appeals (the 
Board) on appeal from a September 1998 rating decision of the 
Denver, Colorado, Department of Veterans Affairs (VA) 
Regional Office (RO).  The RO denied service connection for a 
heart disorder.  

In September 2000, the Board remanded the claim for 
additional development and adjudicative action.  In March 
2002, the Board denied the claim for service connection for a 
heart disorder.  The veteran appealed the Board decision to 
the United States Court of Appeals for Veterans Claims 
(Court).  In March 2003, the veteran and the Secretary of VA 
filed a joint motion to vacate the March 2002 Board decision 
and remand it because the Board had not provided adequate 
reasons and bases as to VA's duty to provide the veteran with 
notice of the allocation of the burdens of obtaining evidence 
necessary to substantiate his claim.  See 38 U.S.C.A. 
§ 5103(a) (West 2002).  The Court granted the motion that 
same month.

The Board remanded the claim for additional development and 
adjudicative action consistent with the March 2003 joint 
motion.  The case has been returned to the Board for further 
appellate review.


FINDINGS OF FACT

1.  The more probative evidence is against a finding that the 
veteran has a heart disability due to a heart murmur in 
service.

2.  The more probative evidence is against a finding that the 
current diagnosis of hypertension with mild left ventricular 
hypertrophy is attributable to service.




CONCLUSION OF LAW

A heart disability, to include hypertension with mild left 
ventricular hypertrophy, was not incurred in or aggravated by 
service, nor may it be presumed to have been incurred in 
service.  38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5103, 5103A, 
5107, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 
3.307, 3.309 (2004).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

I.  Duty to Notify & Assist

The President signed into law the VCAA on November 9, 2000.  
38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002).  The 
legislation provides, among other things, for notice and 
assistance to claimants under certain circumstances.  VA has 
issued final rules to amend adjudication regulations to 
implement the provisions of the VCAA.  See 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159, and 3.326(a).  These regulations 
establish clear guidelines consistent with the intent of 
Congress regarding the timing and the scope of assistance VA 
will provide to a claimant who files a substantially complete 
application for VA benefits.  

As required by 38 U.S.C.A. § 5103(a), prior to the initial 
unfavorable agency of original jurisdiction decision, the 
claimant must be provided notice consistent with 38 U.S.C.A. 
§ 5103(a) and 38 C.F.R. § 3.159(b) which must: (1) inform the 
claimant about the information and evidence not of record 
that is necessary to substantiate the claim; (2) inform the 
claimant about the information and evidence that VA will seek 
to provide; (3) inform the claimant about the information and 
evidence the claimant is expected to provide; and (4) request 
or tell the claimant to provide any evidence in the 
claimant's possession that pertains to the claim, or 
something to the effect that the claimant should give VA 
everything the veteran has in his possession pertaining to 
the claim.  

In the instant case, VA has notified the veteran of the 
information and evidence not of record that is necessary to 
substantiate his claim for service connection for a heart 
disability in a December 2003 letter.  VA informed the 
veteran that in order to establish service connection for a 
disability, he would need to bring forth evidence of a 
disease or injury in service, a current disability, and a 
relationship between the current disability and service.  VA 
noted that evidence of a current disability and of a 
relationship between the current disability and service was 
usually shown by medical evidence.  The Board notes that the 
veteran has submitted evidence of a current disability and 
evidence of a nexus between the current disability and 
service and, therefore, he is fully aware of the evidence 
necessary to substantiate his claim.

The letter also notified the veteran that VA was responsible 
for getting relevant records held by any federal agency, 
which included medical records from the military, from VA 
hospitals (including private facilities where VA authorized 
treatment), or from the Social Security Administration.  VA 
also told the veteran that on his behalf, it would make 
reasonable efforts to obtain any relevant records not held by 
a federal agency, which could include records from state or 
local governments, private doctors and hospitals, and current 
or former employers.  VA noted that in order to obtain any 
records, the veteran would need to provide it with enough 
information about the records so that VA could request them 
from the person or agency who had them.  Finally, VA told the 
veteran, "If there is any other evidence or information that 
you think will support your claim, please let us know."

Additionally, VA has notified the veteran the reasons why 
service connection has been denied in the September 1998 
rating decision on appeal, the October 1998 statement of the 
case, the October 1999 Hearing Officer's decision, and the 
October 1999, September 2001, September 2003, and August 2004 
supplemental statements of the case, and the March 2002 Board 
decision.  The October 1998 statement of the case and the 
September 2003 supplemental statement of the case also fully 
provided the laws and regulations pertaining to entitlement 
to the benefit sought.  Initially, the veteran had not 
brought forth competent evidence between a current heart 
disorder and service.  Subsequently, when the veteran 
submitted such evidence, VA informed the veteran that it had 
accorded more probative value to the April 2001 VA medical 
opinion than the private medical opinions submitted by Dr. 
Daniel Citron and provided its reasons for such 
determination.  The Board finds that the duty to notify the 
veteran has been satisfied under the circumstances of this 
case.  38 U.S.C.A. § 5103.

The Board recognizes that the VCAA notice sent to the veteran 
was subsequent to the rating decision which gave rise to this 
appeal; however, the Board finds no prejudice to the veteran.  
First, the veteran's claim was submitted in 1998, which was 
prior to the enactment of the VCAA and therefore a VCAA 
letter could not have been sent prior to the issuance of the 
rating decision on appeal.  Regardless, the veteran was 
adequately furnished with the type of notice required by VCAA 
in September 2003 and has had an opportunity to identify 
evidence and submit evidence in connection with his claim.  
In August 2004, the veteran, through his representative, 
indicated he had no additional evidence to submit.  Any error 
resulting from VCAA notice subsequent to the initial rating 
decision was harmless error, as it pertains to this issue.  
See Bernard v. Brown, 4 Vet. App. 384 (1993).  The RO's 
subsequent actions and notice to the veteran effectively 
cured any VCAA notice defect.  See Pelegrini v. Principi, 
18 Vet. App. 112 (2004).  The veteran was informed of the 
evidence necessary to substantiate his claim.  The provisions 
of VCAA have been substantially complied with and no useful 
purpose would be served by delaying appellate review of this 
claim for further notice of VCAA.

VA must also make reasonable efforts to assist the claimant 
in obtaining evidence necessary to substantiate the claim for 
the benefit sought, unless no reasonable possibility exists 
that such assistance would aid in substantiating the claim.  
38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2004).  In connection 
with the current appeal, VA has obtained private medical 
records.  The veteran has not indicated the existence of any 
additional records that would aid in substantiating the 
claim, and, in fact, has stated he has no additional evidence 
to submit.  Finally, the veteran was provided with VA 
examinations, and a medical nexus opinion has been obtained.  

For the foregoing reasons, the Board concludes that all 
reasonable efforts were made by the VA to obtain evidence 
necessary to substantiate the claim.  The Board finds that 
the evidence of record provides sufficient information to 
adequately evaluate the claim, and the Board is not aware of 
the existence of any additional relevant evidence which has 
not been obtained.  Therefore, no further assistance to the 
veteran with the development of evidence is required.  
38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d).  

II.  Decision

The veteran asserts that service connection for a heart 
disability is warranted.  He states that the heart murmur 
that was shown in service has caused his current heart 
disease.  

A March 1957 report of medical examination shows that 
clinical evaluation of the heart was "abnormal."  The 
examiner noted the veteran had rheumatic fever at 10 years 
old, which was asymptomatic.  The examiner stated there was, 
"No murmur."  The veteran' blood pressure was 120/80 
(systolic/diastolic).  An April 18, 1957, report of medical 
examination shows that clinical evaluation of the heart was 
"abnormal."  The examiner stated there was a Grade III left 
parasternal murmur, which was "harsh."  His blood pressure 
reading was 138/88.  The veteran was hospitalized at that 
time because of the murmur.  Examination on admission 
revealed that the heart was of normal size and rhythm with a 
grade II apical and left sternal border systolic murmur and a 
fairly loud protodiastolic third sound.  The examiner stated 
that he was unable to hear a "definite diastolic murmur, 
however."  A chest x-ray revealed a normal-size heart and 
configuration.  An EKG was normal.  The examiner stated that 
the veteran had been admitted for observation and extensive 
laboratory studies were done.  He added that while the 
veteran had a "definite cardiac murmur," it was "of 
questionable significance."  The examiner reasoned that 
there was no x-ray or EKG finding of any cardiac disease, and 
he believed that the murmur was "insignificant."  He noted 
the veteran was asymptomatic.  The diagnosis was 
"Observation, medical, evaluation of heart murmur.  No 
disease found.  LD, yes."

In October 1957, the veteran was admitted to the hospital 
with malaise, fever, and a nonproductive cough.  The examiner 
noted that there was a questionable history of rheumatic 
fever at age 7.  The veteran's blood pressure reading was 
148/82.  Physical examination revealed a grade I to II apical 
systolic murmur.  A chest x-ray was normal.  The examiner 
stated that the veteran's course in the hospital was 
"uneventful."  The diagnosis was viremia.  In a separate 
October 1957 medical record, the veteran's blood pressure 
readings were 160/80 and 162/82.  

A June 1960 report of medical examination shows that clinical 
evaluation of the heart was "abnormal."  The examiner noted 
there was a Grade II blowing systolic murmur along the left 
border, which varied in intensity with position.  The 
veteran's blood pressure was 130/76.  In the adjoining report 
of medical history, the examiner noted the veteran had been 
hospitalized in April 1957 for investigation of a cardiac 
murmur and that, "No organic heart disease found apparently, 
and was discharged to active duty."  

A May 1988 private report indicates that the veteran had 
chest pain, but this was not related to a specific 
cardiovascular diagnosis.

The earliest post-service medical evidence specifically 
concerning cardiovascular problems consists of private 
medical records, dated from January 1994, that indicate 
treatment for chronic high blood pressure.  Procardia was 
prescribed for the veteran in the same year, and an 
impression of hypertension was rendered in May 1994.

A June 1998 statement from an insurance provider indicates 
that the veteran applied for life insurance in 1976 and was 
declined "for medical reasons due to . . . heart history."

In a January 1999 statement, a private physician, Dr. Howard 
Kerstein, stated he had treated the veteran since 1995 and 
that the veteran initially had hypertension, but that in 
March 1996, the veteran had had transient chest pains.  He 
stated an electrocardiogram revealed T wave changes in the 
precordial leads and a treadmill and cardiology consult were 
advised.  He stated the veteran had switched to another 
physician and had come back to his practice in January 1999.  
Dr. Kerstein stated that physical examination revealed a 
systolic murmur and that he again advised the veteran to have 
a cardiology evaluation.

A September 1999 cardiac ultrasound report shows a finding 
that there was no evidence of rheumatic heart disease from 
"this study."  A September 1999 electrocardiogram was 
considered "abnormal."  A September 1999 VA examination 
report shows the examiner had an opportunity to review the 
claims file.  He stated that the diagnosis of rheumatic heart 
disease had not been confirmed.  Examination of the heart 
revealed the apex and fifth intercostal space in clavicular 
line.  S1 was normal, and S2 was "normally split."  The 
examiner stated he was unable to appreciate any S3 murmurs, 
rubs, gallops, or clicks.  He concluded that without 
historical evidence to document rheumatic heart disease, with 
normal clinical examination, and the echocardiogram results, 
that there was insufficient evidence to warrant a diagnosis 
of rheumatic heart disease.  He added that with an abnormal 
electrocardiogram, there was also insufficient evidence to 
warrant a diagnosis of atherosclerotic heart disease.

At the May 2000 hearing before the undersigned, the veteran 
testified that when he was in basic training, he collapsed 
and could hardly breathe.  He stated that he went to see a 
doctor and was told that he had a heart murmur when he 
entered service.  He stated he was hospitalized and was told 
he had a heart murmur and was discharged from the hospital 
and told to come back if he had any other problems.  The 
veteran testified that he continued to have problems, such as 
chest pain, during service and following service.  

In an undated letter received in October 2000, Dr. Daniel 
Citron diagnosed chronic hypertension with left ventricular 
hypertrophy, mitral regurgitation, which was non-rheumatic 
and had "occurred [in] 4/57 in Basic training," and an 
abnormal electrocardiogram secondary to above.  He stated 
there was no clinical history of ischemia.  

In a January 2001 letter, Dr. Citron stated he had examined 
the veteran in October 2000.  He stated his impression was 
that the veteran had hypertensive cardiovascular disease and 
mitral regurgitation, non-rheumatic, which occurred 
"probably due to a ruptured chordae on 4/57 during his Basic 
training."  He enclosed a copy of the undated document 
described above.

In a January 2001 letter, Dr. Kerstein stated the following, 
in part:

Obviously, I did not attend [the veteran] 
in 1957, and it would be impossible for 
me to comment on the severity of his 
heart murmur increasing during that time.  
Suffice it to say that I do not think 
there is any doubt that this gentleman 
does have significant heart disease with 
abnormal electrocardiogram that was done 
over the last year.  He certainly did 
have a heart murmur in 1957, however[,] I 
am not at this time able to tell you what 
relationship that heart murmur had with 
his current cardiac problems.  I feel 
that the present cardiac abnormality is 
related to anterolateral ischemia.  

An April 2001 VA examination report shows that the examiner 
had an opportunity to review the evidence in the claims file.  
He reported the clinical findings shown in the service 
medical records and the post-service medical records.  
Physical examination revealed a resting heart rate of 
approximately 72, rhythm regular, resting respiratory rate is 
14.  Cardiac examination disclosed a faint, grade 1/6 
systolic ejection murmur, which was maximal along the left 
sternal border and unaccompanied by systolic ejection sounds 
(click or gallop) or diastolic murmur or friction rub.  There 
was also no evidence on palpation of overactivity along the 
left sternal border or at the apex.  The examiner stated the 
following, in part:

The question then is whether or not this 
examiner believes, on review, that a 
heart murmur had its origins during 
service or increased in severity during 
service[,]as well as whether any aspect 
of the veteran's current heart pathology 
can otherwise be attributed to service.

In response to these questions, I offer 
the following: A heart murmur is not a 
disease.  It is a sound and its 
significance is due solely to the 
underlying abnormality - if any - which 
produces the sound.  In this veteran's 
case, he is described as having had a 
heart murmur intermittently over an 
extended period of time.  If this murmur 
was significant in terms of representing 
an underlying structural abnormality, it 
is extremely unlikely, that is highly 
unlikely in the opinion of this examiner, 
that from the time in question in the 
late 1950s ending in 1960 until the 
present time, we would end up without any 
consequential evidence of underlying 
heart disease capable of producing a 
murmur.  Nevertheless, that is exactly 
the case.

The question then is, can a heart murmur, 
per se, be aggravated by service.  The 
answer is, a heart murmur could be 
changed and appear to be aggravated - 
that is, increased in intensity or 
decreased, if the structural deformity 
causing it is materially affected.  Since 
we have absolutely no evidence of a 
structural abnormality of the heart or 
valvular function, there is no reason to 
suggest that his heart murmur per se was 
consequential then or now.

This examiner recognizes the extreme 
difficulty the reviewing authority is 
under when there are letters from other 
physicians that would suggest that the 
murmur was aggravated.  I would challenge 
the statement that the murmur was 
aggravated since the murmur is not a 
disease and is a product of whatever 
produces it, in this case, no underlying 
valvular heart disease.  Murmurs may be 
produced by rapid heart rates or by 
anemia or viscosity of the blood or by a 
number of other things and almost every 
individual at one time or another will 
have a heart murmur provoked by differing 
sets of circumstances.  In the 
overwhelming majority of these cases, the 
heart murmurs are not indicative of 
underlying structural disease of the 
heart.  Therefore, in conclusion, I would 
say that the individual did not have 
evidence during his period of service nor 
until 1994, of any underlying 
cardiovascular disease and the heart 
murmur then and now is inconsequential.

The abnormality of mild left ventricular 
hypertrophy and mild left atrial 
enlargement noted on echocardiography in 
1999 is perfectly compatible with a 
hypertension which is noted beginning in 
1994 some 34 years after the completion 
of military service.  The current EKG 
suggests anterolateral and inferior 
ischemia, likely to result from coronary 
artery disease - for which this veteran 
is at increased risk as he is male, age 
66 and is hypertensive.  I have no 
evidence to suggest the EKG abnormalities 
now present are in any way related to his 
military service or to the veteran's 
heart murmur.

DIAGNOSIS

1.  Hypertension with mild left 
ventricular hypertrophy per 
echocardiogram, onset documented in 
1994/5: EKG-abnormal and suggests 
ischemia of anterolateral and inferior 
wall.

2.  Rheumatic Heart Disease at age 10 per 
patient's history, with no evidence of 
valvular heart disease per 
echocardiography 1999 and no clinical 
evidence to suggest presence of valvular 
heart jeffreycurtis@example.net.

3.  Heart murmur, as described, with 
insufficient clinical evidence to warrant 
a diagnosis of any chronic pathologic 
cardiac disorder or residuals thereof. . 
. .

(Emphasis added.) 

In April 2003, Dr. Citron stated he had reviewed the 
"entire" VA record and re-examined the veteran at that 
time.  He stated the veteran had signs of well-controlled 
hypertension and a mitral murmur "first documented in April 
1957.  This is a non-rheumatic mitral regurgitation, probably 
traumatic in nature, based on evaluation while in the 
military in 1957."  He enclosed a copy of this January 2001 
letter and his curriculum vitae.  

Service connection may be granted for disability resulting 
from disease or injury incurred in or aggravated by service.  
38 U.S.C.A. § 1131 (West 2002).  Service connection for heart 
disease may be granted if manifest to a compensable degree 
within one year of separation from service.  38 U.S.C.A. 
§§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) 
(2004).  Service connection may be granted for any disease 
diagnosed after service when all the evidence establishes 
that the disease was incurred in service.  38 C.F.R. 
§ 3.303(d) (2004).

The chronicity provision of 38 C.F.R. § 3.303(b) is 
applicable where the evidence, regardless of its date, shows 
that the veteran had a chronic condition in service or during 
an applicable presumption period and still has such 
condition.  Such evidence must be medical unless it relates 
to a condition as to which, under the Court's case law, lay 
observation is competent.  Savage v. Gober, 10 Vet. App. 488, 
498 (1997).  In addition, if a condition noted during service 
is not shown to be chronic, then generally a showing of 
continuity of symptomatology after service is required for 
service connection.  38 C.F.R. § 3.303(b) (2004).

When all the evidence is assembled, VA is responsible for 
determining whether the evidence supports the claim or is in 
relative equipoise, with the veteran prevailing in either 
event, or whether a preponderance of the evidence is against 
the claim, in which case, the claim is denied.  Gilbert v. 
Derwinski, 1 Vet. App. 49 (1990).  See also 38 U.S.C.A. § 
5107(b) (West 2002).

The Board has carefully reviewed the evidence of record and 
finds that the preponderance of the evidence is against the 
grant of service connection for a heart disability.  The 
issue before the Board is not whether the veteran has a 
current heart disability-that has been shown by competent 
medical evidence, as the veteran has been diagnosed with 
hypertension with left ventricular hypertrophy.  The issue is 
whether the veteran has a current heart disability that is 
due to service, to include the inservice finding of a heart 
murmur.

Evidence supporting the veteran's claim are the April 1957 
report of medical examination and the letters from Dr. 
Citron.  The April 1957 record shows that a heart murmur was 
found in service, which was not shown at the time the veteran 
entered service.  The letters from Dr. Citron establish that 
he finds that the veteran's current heart disability, 
diagnosed as hypertension, is related to the inservice 
murmur, which he determined was "probably traumatic in 
nature."  The Board is aware that Dr. Citron has had an 
opportunity to review the veteran's VA records and has 
reviewed Dr. Citron's curriculum vitae.  

The Board finds, however, that the evidence against the 
veteran's claim outweighs the evidence that supports the 
veteran's claim.  The service medical records clearly show 
that at the time the veteran entered service, a heart murmur 
was specifically not found.  Therefore, he is entitled to the 
presumption of soundness.  38 U.S.C.A. § 1111 (West 2002).  
Regardless, the service medical records show that the murmur 
found in service had no underlying disease process.  The 
veteran was hospitalized in April 1957 for eight days and was 
subject to observation and "extensive laboratory studies."  
The examiner stated that the veteran's murmur was of 
questionable significance.  Following additional testing, the 
examiner determined that the murmur was "insignificant," 
the veteran was asymptomatic, and that there was "no disease 
found."  

Lending support to this determination is the April 2001 
medical opinion by the VA physician.  There, he reported the 
specific clinical findings shown in the service medical 
records and those shown in the post-service medical records.  
He determined that the heart murmur in service was of no 
significance.  He reasoned that if the inservice murmur was 
significant that it would be "highly unlikely" that "we 
would end up without any consequential evidence of underlying 
heart disease capable of producing a murmur."  He further 
stated that since there was no evidence of a structural 
abnormality of the heart or valvular function, that there was 
no reason to suggest that the veteran's heart murmur was 
consequential while in service or at the present time.  The 
VA physician specifically refuted the determination that a 
murmur was aggravated in service, since there was no 
underlying valvular heart disease.  

The April 2001 VA physician's medical opinion is supported by 
the service medical records, which found no underlying heart 
disease.  Also, the VA examiner stated that the there was 
"no clinical evidence" that the veteran had valvular heart 
disease.  He also determined that there was no evidence to 
suggest that the abnormal EKG was "in any way related to 
[the veteran's] military service or the veteran's heart 
murmur."  The Board has accorded high probative value to the 
service medical records, as those records were created 
contemporaneously to service, and the examiner at that time 
was in the best position to determine the significance of the 
veteran's heart murmur at that time.  The veteran was in the 
hospital for eight days and underwent "extensive laboratory 
studies" and observation.  The final determination was that 
there was no underlying heart disease.  Again, the service 
medical records are accorded high probative value since the 
testing done at that time failed to show an underlying 
disease process.  The VA physician's April 2001 determination 
corroborates the inservice finding and he supports his 
determination with both evidence in the claims file and 
medical principles.  Most importantly, he supported his 
determination with the post service medical records, which 
failed to show valvular heart disease, and he provided 
extensive reasons for his determination.  Dr. Citron, 
however, stated that the veteran's heart murmur was 
"probably traumatic" in nature.  While he stated he 
reviewed the service medical records, he made no mention of 
the fact that the veteran's heart murmur had been found to be 
of no significance by the service doctor.  He also did not 
state upon what evidence he based his assessment that the 
veteran had a traumatic heart murmur in service, nor did he 
provide reasons for his determination.  Therefore, his 
opinion has been accorded lessened probative value as a 
result.

The veteran's representative has asserted that because Dr. 
Citron had an opportunity to review the April 2001 medical 
opinion and the service medical records and reaffirmed his 
January 2001 opinion, that his opinion should be accorded 
more weight.  He also stated that the expertise of the VA 
examiner was not known.  The Board has explained why it has 
accorded the VA examiner's opinion more probative value-he 
substantiated his medical opinion with objective medical 
evidence in the claims file and medical principles, and his 
bases were extensive.  Dr. Citron, however, did not provide 
any basis or bases for his determination that the veteran had 
a traumatic murmur in service, which was related to the 
current heart disability.  On the April 2001 medical 
examination report, it shows that the VA physician is a 
"Consultant in Cardiology."  Thus, it would appear that he 
has sufficient knowledge of the heart to render a competent 
medical opinion in this matter.

The Board has not found that Dr. Kerstein has provided either 
a positive or a negative opinion regarding the veteran's 
claim.  Rather, his opinion is only that the veteran had a 
heart murmur in service, which is shown in the service 
medical records, and that the veteran has a current heart 
disability.  He has not made any positive or negative 
connection between the current heart disability and the 
veteran's service.  

Therefore, for the reasons stated above, the Board has 
determined that the preponderance of the evidence is against 
a finding that the veteran has a current heart disability 
that is attributable to the inservice heart murmur.  Service 
connection is warranted for 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, 1131; see also 38 C.F.R. § 3.303(a); see Sanchez-
Benitez v. Principi v. Principi, 259 F.3d 1356, 1361 (Fed. 
Cir. 2001) (absent a disease or injury incurred during 
service, a veteran cannot satisfy the basic VA compensation 
statutes).  Here, the Board has determined that the 
preponderance of the evidence is against a finding that the 
veteran has a current heart disability attributable to the 
inservice heart murmur.  See Brammer v. Derwinski, 3 Vet. 
App. 223, 225 (1992) (Court stated "Congress specifically 
limits entitlement for service-connected disease or injury to 
cases where such incidents have resulted in a disability," 
and held "[i]n the absence of proof of a present 
disability[,] there can be no valid claim"); Rabideau v. 
Derwinski, 2 Vet. App. 141, 143-44 (1992).

Regarding the veteran's diagnosis of hypertension with left 
ventricular hypertrophy, the Board finds that the 
preponderance of the evidence is against a finding that such 
diagnosis is attributable to service.  The service medical 
records do not show that the veteran was diagnosed with 
hypertension.  There were some elevated blood pressure 
readings, but none of the diastolic readings were above 88 
(which diastolic reading was shown one time).  The first 
objective showing of hypertension following service was in 
1994, which is more than 30 years following the veteran's 
discharge from service.  In the April 2001 VA examination 
report, the examiner noted that there was no evidence during 
the veteran's service until 1994 of any underlying 
cardiovascular disease.  Therefore, there is no objective 
evidence that hypertension was manifested to a compensable 
degree within one year following the veteran's discharge from 
service.  The VA examiner made a specific determination that 
hypertension had its onset in 1994.  Such is evidence against 
a finding that hypertension is attributable to service.  

Dr. Citron's medical opinions do not appear to attribute the 
diagnosis of hypertension to service; rather, they appear to 
attribute the mitral regurgitation to service.  Regardless, 
even if Dr. Citron attributed the diagnosis of hypertension 
to the veteran's service, the Board finds that the April 2001 
medical opinion outweighs, in terms of its probative value, 
that of Dr. Citron.  Again, the VA examiner provided detailed 
findings in the record and explained his determination based 
upon evidence in the record and medical principles.  He 
determined that the veteran's hypertension had its onset in 
1994, and, as mentioned previously, there was no superimposed 
element of cardiovascular pathology found to have been 
attributable to the murmur initially detected in service.  
Dr. Citron has not provided the basis or bases for his 
expressed opinion.  Therefore, the Board has accorded more 
weight to the VA examiner's determination.  

The Board also notes that, even accepting the June 1998 
statement from an insurance provider as evidence of heart 
problems in 1976, there is a gap of at least 15 years between 
the veteran's separation from service and any indication of a 
cardiovascular problem.  The Court has held that a 
significant gap in time between service and initial post-
service treatment is a factor warranting consideration in 
reaching a determination on a claim for service connection.  
See generally Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 
2000). 

The Board acknowledges the veteran's arguments made during 
his October 1998 and May 2000 VA hearings and in multiple lay 
statements.  However, neither the veteran nor his spouse, who 
has also offered testimony, has been shown to have the 
requisite training, credentials, or expertise needed to offer 
a competent opinion as to medical causation.  See Espiritu v. 
Derwinski, 2 Vet. App. 492, 494-95 (1992).

For the reasons stated above, the Board finds the 
preponderance of the evidence is against the veteran's claim 
for service connection for a heart disorder, and the claim 
must be denied.  In reaching this determination, the Board 
acknowledges that the VA is statutorily required to resolve 
the benefit of the doubt in favor of the veteran when there 
is an approximate balance of positive and negative evidence 
regarding the merits of an outstanding issue.  However, that 
doctrine is not applicable in this case because the 
preponderance of the evidence is against the veteran's claim.  
See Gilbert, 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b).


ORDER

Service connection for a heart disability, to include 
hypertension with left ventricular hypertrophy, is denied.



____________________________________________
JEFF MARTIN
Veterans Law Judge, Board of Veterans' Appeals



 Department of Veterans Affairs



{'dataset': 'bva_opinions'}