Citation Nr: 0726104 Decision Date: 08/21/07 Archive Date: 08/29/07 DOCKET NO. 04-29 412 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for a heart disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Connolly Jevtich, Counsel INTRODUCTION The veteran had active service from August 1966 to August 1969. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision by the Sioux Falls, South Dakota, Regional Office (RO) of the Department of Veterans Affairs (VA). In September 2005, the veteran testified before the undersigned at a Travel Board hearing held at the Cheyenne, Wyoming RO. In a May 2005 decision, the Board reopened the claims of service connection and remanded the case for additional development, which has been completed. FINDINGS OF FACT 1. Hearing loss defect was shown on examination on entrance into active duty and the veteran's hearing loss increased in severity during service; current hearing loss disability is attributable to service. 2. The veteran had a heart defect, heart murmur/trivial mitral regurgitation, prior to entering service and it did not worsen during his period of active service; current heart murmur/trivial mitral regurgitation is not otherwise attributable to service. 3. Coronary artery disease was not manifest during service or within one year of separation, and is not attributable to service. CONCLUSIONS OF LAW 1. Bilateral hearing loss was aggravated by active service. 38 U.S.C.A. §§ 1101, 1110 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.304, 3.385 (2006). 2. A heart defect, heart murmur/trivial mitral regurgitation, clearly and unmistakably preexisted service and was not aggravated by service, and the presumption of soundness at entry is rebutted. 38 U.S.C.A. § 1111 (West 2002 & Supp. 2006). 3. Heart murmur/trivial mitral regurgitation and coronary artery disease were not incurred in or aggravated by service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) With respect to the claimant's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Prior to the initial adjudication of the claimant's claim, a letter dated in December 2003 provided the veteran with VCAA information concerning his claim. Thereafter, an additional VCAA notice was sent in June 2006. Cumulatively, the VCAA notices fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The veteran was aware that it was ultimately the claimant's responsibility to give VA any evidence pertaining to the claim. The VCAA letters asked him to provide any relevant evidence in his possession. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). If there is VCAA deficiency, i.e., VCAA error, this error is presumed prejudicial to the claimant. VA may rebut this presumption by establishing that the error was not prejudicial. See Simmons v. Nicholson, 487 F. 3d 892 (2007); see also Sanders v. Nicholson, 487 F. 3d 881 (2007). The claimant's service medical records, VA medical treatment records, and identified private medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. The claimant was also afforded VA examinations in October 2006. 38 C.F.R. § 3.159(c)(4). The records satisfy 38 C.F.R. § 3.326. The veteran was also sent notice regarding the appropriate disability rating or effective date to be assigned in June 2006. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Hearing loss disability is defined by regulation. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Since November 1, 1967, audiometric results have been reported in standards set forth by the International Standards Organization (ISO)-American National Standards Institute (ANSI). Service department audiometric charts dated after November 1, 1967 are presumed to be in ISO-ANSI units unless otherwise specified; such charts in VA medical records dated after June 30, 1966, are similarly presumed to be in ISO-ANSI units. In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses below. In addition, organic disease of the nervous system such as sensorineural hearing loss as well as valvular heart disease will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of the veteran's separation from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Further, VA regulation provides that, with chronic disease shown as such in service (or within an applicable presumptive period under section 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A claim for service connection generally requires competent evidence of a current disability; proof as to incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence, as the situation dictates; and competent evidence as to a nexus between the inservice injury or disease and the current disability. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Layno v. Brown, 6 Vet. App. 465 (1994). A veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111. A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the" preexisting condition. 38 U.S.C. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity. Townsend v. Derwinski, 1 Vet. App. 408 (1991); 38 C.F.R. § 3.306(a) (2002). In contrast, a flare-up of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). Evidence of the veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder is not presumed to have been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). In a precedent opinion in July 2003, the VA General Counsel held that, to rebut the presumption of sound condition under Section 1111 of the statute, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. If a preexisting defect, infirmity, or disorder is noted on the entrance examination, it will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). In contrast, a flare-up of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). In determining whether service connection is warranted for a disability, 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). Bilateral Hearing Loss Disability On his entrance examination in June 1966, an audiogram was conducted which showed hearing loss disability (as converted). At that time, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 5 (15) 0 (10) N/A 30 (35) LEFT 5 (20) 10 (20) 0 (10) N/A 55 (60) On separation examination, an audiogram was conducted which showed hearing loss disability. At that time, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 60 N/A 40 LEFT 5 5 65 N/A 35 Hearing loss defect was noted on the entrance examination, and he had hearing loss disability, as contemplated under 38 C.F.R. § 3.385, on the separation examination. Since the service medical records show that a hearing loss defect was noted on the entrance examination, however, the presumption of soundness never attached as to the veteran's period of active duty. The record presents clear and unmistakable evidence that a hearing loss defect preexisted active duty service. Preexisting hearing loss defect will be considered to have been aggravated by service, however, where there is an increase in disability during service, unless there is a specific finding that the increase is due to the natural progress of the disease. On his post-service February 1970 examination, an audiogram showed hearing loss disability. At that time, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 N/A 60 LEFT 5 5 5 N/A/ 65 Speech audiometry revealed speech recognition ability of 100 percent in both ears. Again, hearing loss disability was demonstrated. The entrance examination revealed hearing loss of a greater degree at 500 and 1000 Hertz in the right ear and at 500, 1000, and 4000 Hertz in the left ear. However, on the separation examination revealed hearing loss of a greater degree at 2000 Hertz in both ears and at 4000 Hertz in the right ear. As of September 2000, the hearing at 2000 Hertz was reported as being within normal limits. The Board remanded this case for the purpose of obtained a medical opinion regarding whether any preexisting hearing loss underwent a permanent increase in disability during service. If so, the examiner was requested to address whether the increase in disability was due to the natural progress of the disease. To the extent possible, the examiner was requested to distinguish whether there was a permanent increase in disability or whether the veteran had a temporary or intermittent flare-up of preexisting hearing loss disability. The examiner was also requested to state whether the underlying condition, as contrasted with symptoms, worsened during service. The apparent change in the veteran's hearing loss at 2000 Hertz was requested to be addressed. In October 2006, a VA examination was conducted pursuant to the Board's remand and continued to show hearing loss disability within the meaning of 38 C.F.R. § 3.385. The hearing thresholds at 2000 Hertz were 10 decibels on each side. The hearing thresholds at 3000 Hertz were 60 on each side. The examiner stated that the claims file was reviewed. The entrance examination was reviewed and discussed. It was noted that hearing was within normal limits at all Hertz levels except at 4000 Hertz in both ears. The separation examination was also reviewed and discussed. It was noted that hearing loss was shown at 2000 and 4000 Hertz levels, bilaterally. The examiner opined that it was as likely as not that the hearing loss was related to the veteran's military service. The examiner indicated that currently, the veteran had hearing within normal limits at 2000 Hertz, bilaterally. The examiner stated that there was no significant shift at 4000 Hertz shown on the separation examination. However, the examiner indicated that testing was not conducted at 3000 and 6000 Hertz on either the induction or the separation examination and there could have been a significant threshold shift at these frequencies. As noted, hearing was currently abnormal at 3000 Hertz, bilaterally. The VA examiner did not answer all of the questions posed by the Board. The examiner basically indicated that there was hearing loss and entry and on separation. Although the hearing loss was worse at 2000 Hertz, it thereafter returned to normal. However, the examiner indicated that the current hearing loss was in fact attributable to service, citing to possible significant threshold shifts at 3000 and 6000 Hertz, which were not tested during service. The examiner's opinion was not equivocal although his supporting reasoning was not fully explained. Certainly, a clarifying addendum would have been helpful. However, it was not obtained. Although the reasoning in the opinion was somewhat equivocal, the examiner clearly stated that the veteran's current hearing loss disability was as likely as not related to inservice noise exposure. Further, his opinion was based on a review of the claims file, and included an examination of the veteran and discussion of pertinent audiological evidence. The Board finds that the benefit-of-the-doubt rule should be applied as required by law and VA regulations. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, resolving doubt in the veteran's favor, service connection for bilateral hearing loss is warranted. Heart Disability The veteran's entrance examination did not show any pertinent abnormality. Although the veteran noted on his entrance Report of Medical History that he had had rheumatic fever as a teenager, he denied having palpitation or a pounding heart, shortness of breath, pain or pressure ion his chest, or high or low blood pressure. During service, in September 1966, it was noted that the veteran had a history of having rheumatic fever in his early teenage years. The initial impression was rheumatic heart disease. He was referred to the cardiology clinic. In October 1966, the veteran was evaluated. On examination, it was noted that the first heart sound was normal; the second heart sound was normal; and the two components moved physiologically. There was a Grade I/VI very early in short duration ejection murmur, which was heard at the apex and the base. It was felt to be of no hemodynamic significance; diastole was clear. X-rays and an electrocardiogram were normal. The examiner opined that there was no organic heart disease and no evidence of cardiovascular disease. On his separation examination, the veteran reported that he had experienced pain or pressure in his chest as well as palpitation or pounding heart. Physical examination was negative. In March 1970, the veteran was afforded a VA examination. The cardiovascular examination was normal. In the mid 1990's, the veteran reported having chest pain to a private physician. It was noted that the veteran had a brief, soft mid systole ejection murmur at the lower left sternal order that did not change with Valsalva. There was no diastolic murmur. There were no extra cardiac sounds. The impression was chest discomfort, rule out esophagitis, rule out atypical angina. The veteran underwent treadmill testing in April 1994. He had a normal exercise tolerance with no angina pectoris. The veteran was systolic hypertensive. A few years later, the veteran had an inferior wall myocardial infarction. In 2000, it was noted that the veteran had coronary artery disease as well as neurocardiogenic syncope. He continued to be treated thereafter. In February 2002, he underwent an echocardiogram to test for underlying ischemia, which was not shown, but not excluded. In July 2003, he underwent cardiac catherization. The assessment was moderate nonobstructive disease (coronary artery disease). A June 2004 nuclear stress test revealed a low likelihood of ischemia. The Board remanded this case in order to obtain a VA medical examination and opinion. The examiner was requested to opine whether it was likely, unlikely, or at least as likely as not that any current heart disorder was related to service, to include any heart complaints during service. In October 2006, the veteran was afforded a VA examination. The claims file was reviewed. The examiner noted that the veteran had rheumatic heart disease as a child and an auscultated murmur. The inservice findings were reviewed. The examiner noted that the physician in service felt that the chest complaints were not of cardiac origin. The separation examination did not mention a heart murmur. Post- service, the veteran suffered an inferior wall myocardial infarction in 1999 and a single stent was placed in the right coronary artery. During the cardiac workup, there were no concerns regarding valvular heart disease. It was noted that the stress echocardiogram and nuclear stress test did not show ischemia. A current physical examination was performed. The examiner opined that there was no evidence that the veteran had any significant valvular heart disease. The intermittent murmur (that was not heard on this examination) noted in the past was most likely due to his trivial mitral regurgitation noted on his 2002 echocardiogram. The heart murmur/trivial mitral regurgitation more likely than not existed prior to his service and was not aggravated during service. The examiner stated that the mere presence of a heart murmur and the mitral regurgitation did not increase the risk for the development of coronary artery disease. The examiner further opined that the veteran's coronary artery disease was unrelated to service. On the entrance examination, the veteran's heart was noted to be normal on objective examination. Thus, at the time of entry, there is a presumption that the veteran entered in sound health. Here, there is no evidence that at entry, there was any defect, infirmity, or disorder with regard to a heart disability. Thus, the veteran is entitled to a presumption of soundness. Because the veteran is entitled to the presumption of soundness, the Board must determine whether, under 38 U.S.C.A. § 1111, the presumption of soundness is rebutted by clear and unmistakable evidence. In July 2003, the VA General Counsel held that, to rebut the presumption of sound condition under Section 1111 of the statute, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-03 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. Although VA's General Counsel has determined that the definition of "aggravation" used in 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306 does not apply in determining whether the presumption of soundness has been rebutted, the statute and regulation do not otherwise provide any definition of "aggravation" to be applied in making that determination. The word "aggravate" is defined as "to make worse." Webster's II New College Dictionary (1999). After determining whether the presumption of soundness has been rebutted the Board will consider whether the claimed disabilities were "made worse" by his military service. Because the veteran is entitled to a presumption of soundness, the Board must determine whether, under 38 U.S.C.A. § 1111, the presumption of soundness is rebutted by clear and unmistakable evidence. The burden of proof is on VA to rebut the presumption by producing clear and unmistakable evidence that a disability existed prior to service and that it was not aggravated during service. See Wagner v. Principi, 370 F 3d 1089 (Fed. Cir. 2004); VAOPGCPREC 3-03 (July 16, 2003). Under Wagner, the burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. A bare conclusion, even one written by a medical professional, without a factual predicate in the record does not constitute clear and unmistakable evidence sufficient to rebut the statutory presumption of soundness. Miller v. West, 11 Vet. App. 345, 348 (1998). The court in Miller held that the presumption of soundness upon entry into service may not be rebutted without "contemporaneous clinical evidence or recorded history" in the record. Thereafter, the Federal Circuit Court of Appeals for the Federal Circuit (Federal Circuit) explained the Miller decision by noting that "[n]othing in the court's opinion suggests that without such evidence the presumption can never be rebutted," emphasizing that any such determination must consider "how strong the other rebutting evidence might be." Harris v. West, 203 F. 3d. 1347, 1351 (Fed. Cir. 2000). In this case, the service medical records provide a history of preservice rheumatic fever. In addition, the veteran has indicated that he had rheumatic fever with possible heart problems. Post-service medical records document the same history, as reported by the veteran. The inservice findings show that on cardiac evaluation, there was a Grade I/VI very early in short duration ejection murmur, which was heard at the apex and the base. Otherwise, there was no organic heart disease and no evidence of cardiovascular disease. As a matter of law, the presumption of soundness is rebutted by clear and unmistakable evidence consisting of the veteran's own admission of a preservice history of medical problems during inservice clinical examinations. Doran v. Brown, 6 Vet. App. 283, 286 (1994). The Board finds that the medical records and the veteran's statements are competent evidence that a heart defect clearly and unmistakably preexisted service. See Gahman v. West, 12 Vet. App. 406 (1999). The probative evidence constitutes clear and unmistakable evidence that a heart defect existed prior to service entrance. However, VAOPGCPREC 3-03 (July 16, 2003), has established that there are two steps to rebut the presumption of soundness at entry. First, there must be clear and unmistakable evidence that a heart defect preexisted service. Second, there must be clear and unmistakable evidence that the heart defect was not aggravated during service. If both prongs are not met, the presumption of soundness at entry is not rebutted. The Board finds that there is clear and unmistakable evidence demonstrating that the preexisting heart defect was not aggravated by service. The record shows that a heart murmur was noted on cardiac evaluation. There was no organic heart disease or cardiovascular disease otherwise shown. The veteran's chest complaints were not of cardiac origin. There is no documentary evidence that the heart murmur itself had in any way increased in severity. Further, the VA examiner opined that the preexisting heart defect, the heart murmur/trivial mitral regurgitation, was not aggravated during service. Although the veteran contends that his preexisting heart defect worsened during service or that he actually incurred other heart disease during service, he is not competent to make this assessment. The veteran can attest to factual matters of which he had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the veteran as a lay person is not capable of making medical conclusions. Thus, his statements regarding causation are not competent. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Although lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself, the Board retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In Barr v. Nicholson, No. 04-0534 (U.S. Vet. App. June 15, 2007), the Court indicated that varicose veins was a condition involving "veins that are unnaturally distended or abnormally swollen and tortuous." Such symptomatology, the Court concluded, was observable and identifiable by lay people. In Jandreau v. Nicholson, No. 2007-4019 (U.S. Vet. App. July 3, 2007), the court determined that 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 (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Barr. The issue does not involve a simple diagnosis. The veteran is competent to report that he had chest pain or other symptoms during service, but he is not competent to state that this represented a worsening of a preexisting heart defect or that it was the initial manifestations of coronary artery disease. The Board therefore finds that there was no aggravation of the preexisting heart defect, heart murmur/trivial mitral regurgitation. The Board finds that the preservice heart defect did not undergo an increase in severity during service. The Board finds that there is clear and unmistakable evidence that the preexisting heart defect, heart murmur/trivial mitral regurgitation, was not aggravated by service. Accordingly, because there is clear and unmistakable evidence that the heart defect, heart murmur/trivial mitral regurgitation, preexisted service and clear and unmistakable evidence that it was not aggravated during service, the presumption of soundness is rebutted. As to a determination under 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306 of whether the veteran's preexisting heart defect, heart murmur/trivial mitral regurgitation, was aggravated by service, the Board finds that there is no competent medical evidence that such disorder worsened in service. The Board relies on the evidence as outlined above to support this determination. Further, since there is clear and unmistakable evidence that the pre-existing heart defect, heart murmur/trivial mitral regurgitation, at issue was not aggravated during service for the purpose of rebutting the presumption of soundness (38 U.S.C.A. § 1111), it necessarily follows that such disorder was not aggravated during service (38 U.S.C.A. § 1110). The Board has found by clear and unmistakable evidence that the veteran's heart defect, heart murmur/trivial mitral regurgitation, was not aggravated by service in order to rebut the presumption of soundness. VA's General Counsel reasoned that such a finding would necessarily be sufficient to rebut the presumption of aggravation under 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306(b). The Board also finds that the currently diagnosed coronary artery disease was not initially manifest during service, within one year of service, and is not otherwise attributable to service as there is no probative competent medical evidence establishing a nexus between current diagnoses and service. The VA examiner opined that there was no etiological relationship between coronary artery disease and service. As noted, other than the preexisting heart defect, heart murmur/trivial mitral regurgitation, the inservice medical findings specifically showed that there was no organic heart disease or cardiovascular disease. The VA examiner reviewed these records, the post-service records, and examined the veteran, all prior to rendering an opinion. The Board attaches the most probative value to this opinion because it is well reasoned, detailed and consistent with other evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). Further, it is uncontradicted by any other competent opinion. Thus, service connection for a heart disability must be denied. In reaching this decision, the Board has considered the doctrine of doubt, however, as the preponderance of the evidence is against the veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for bilateral hearing loss disability is granted. Service connection for a heart disability is denied. ____________________________________________ CHARLES E. HOGEBOOM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs