BVA9501720 DOCKET NO. 90-54 472 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. P. Harris, Counsel INTRODUCTION The veteran had active service from October 1939 to July 1945. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 1989 rating decision of the Los Angeles, California, Regional Office (RO). The appellant, the veteran's widow, filed a notice of disagreement the following month. In a decision rendered July 23, 1990, the Board denied entitlement to service connection for the cause of the veteran's death. Thereafter, the appellant appealed the Board's decision to the United States Court of Veterans Appeals (Court). The Court rendered a memorandum decision, [citation redacted], which vacated the Board's July 23, 1990, decision, and remanded the matter to the Board for proceedings in accordance with the Court's decision. The Court retained jurisdiction. In January 1993, the Board remanded the case to the RO for additional evidentiary development. In June 1994, the Board referred the case for an opinion by the Office of the Department of Veterans Affairs (VA) Chief Medical Director (CMD) regarding whether the veteran's cigarette smoking in service played a role in his death. A CMD opinion was rendered the following month. Thereafter, the CMD opinion was provided the appellant's representative, who was given an opportunity to submit additional evidence and argument. In November 1994, the representative responded with additional written argument. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in essence, that the veteran's service- connected psychiatric disability materially caused or contributed to his death from cardiovascular disease. The appellant also contends that the veteran's hypertension and organic heart disease had their onset in service. Furthermore, it is claimed that the veteran's service-connected anxiety disorder led to the development of his stress-induced hypertension and organic heart disease. It is asserted that the medical community generally recognizes an etiological relationship between risk factors, such as protracted emotional stress and anxiety, and the development of cardiovascular disease. In support of that proposition, reference is made to VA clinical evidence, including a September 1993 opinion by a cardiologist, that the veteran had stress- related hypertensive disease in service. It is contended that he began smoking in service, and that his service-connected anxiety reaction may reasonably be considered to have increased the frequency of his smoking, thereby causing or contributing to his death. It is asserted that a recent CMD opinion was inadequate, particularly since the opinion did not explain the basis for its conclusions rendered. It is requested that the benefit of the doubt doctrine be applied. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered the evidence and material of record in the veteran's claims file. The Board has determined that only those items listed in the "Certified List" attached to this decision and incorporated by reference herein are relevant evidence in the consideration of the appellant's claim. Based on this review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against allowance of service connection for the cause of the veteran's death. FINDINGS OF FACT 1. All available, relevant evidence necessary for disposition of the appellant's appeal has been obtained. 2. The veteran's death in March 1989 was listed on the certificate of death as caused by cardiac arrest, due to or as a consequence of hypertensive coronary artery disease. No other significant condition contributing to the cause of death was reported on the death certificate. No autopsy was performed. 3. At the time of death, service connection was in effect for anxiety reaction, which had been evaluated as 30 percent disabling; and malaria, which had been rated as noncompensable. 4. Chronic organic heart disease and essential hypertension were not present in service or proximate thereto, and were first medically shown decades after service. 5. Chronic organic heart disease and essential hypertension were not caused by and were not related to the service-connected disabilities, specifically anxiety reaction. 6. The veteran's service-connected disabilities, specifically anxiety reaction, played no material role in the development or progress of the underlying cardiovascular disease which resulted in his death. CONCLUSIONS OF LAW 1. Chronic organic heart disease and essential hypertension were not incurred in or aggravated by the veteran's active service, and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). 2. Chronic organic heart disease and essential hypertension were not proximately due to or the result of service-connected disease or disability. 38 C.F.R. § 3.310(a) (1993). 3. A service-connected disability did not cause or contribute substantially or materially to cause the veteran's death. 38 U.S.C.A. § 1310 (West 1991); 38 C.F.R. § 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As an initial matter, the appellant's claim for service connection for the cause of the veteran's death is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See [citation redacted]. Since the claim presented is plausible, theBoard must examine the record and determine whether VA has anyfurther obligation to assist in the development of her claim. 38 U.S.C.A. § 5107(a). After reviewing the record, the Board is satisfied that all relevant facts have been properly developed and that no useful purpose would be served by again remanding the case with instructions to provide additional assistance to the appellant. The service medical records appear complete, and include an examination for service separation dated in July 1945. The examination for service separation is particularly probative, since it assessed the veteran's medical status at the time of service discharge. Additionally, there are a number of postservice clinical reports proximate to service, which adequately detail the veteran's physical and mental health. While VA examination reports dated in November 1946 and December 1947 referred to the veteran's treatment by a private physician in Framingham, Massachusetts, this was for his "nerves," not cardiovascular disease or disability; and therefore said records, even if existent, would not appear to be material. Pursuant to the Court's directive, the Board in January 1993 remanded the case, in part, to obtain all relevant records of the veteran's treatment from certain VA medical facilities; and for a VA cardiologist to render an opinion as to whether the service- connected anxiety reaction caused, or was a material factor in the development of, the fatal hypertensive coronary artery disease. Subsequently, the RO contacted the appellant by letter in March 1993, and requested that she submit any additional evidence that she may have relevant to the claim and information regarding VA medical facilities which may have provided the veteran relevant treatment. However, no additional relevant evidence or related information was received from her. The RO did request records from VA medical facilities specified in the Court's memorandum decision, and these were associated with the claims folder. These records pertain to the veteran's treatment from the 1970's to early 1989, shortly prior to his death at his place of residence in March 1989. An opinion by a VA cardiologist was rendered in September 1993, which adequately responded to the question raised as to whether an etiological relationship existed between the veteran's service-connected psychiatric disability and cardiovascular disease. In June 1994, the Board requested a CMD opinion regarding whether the veteran's cigarette smoking played a role in his death. A CMD opinion was rendered the following month, which was responsive to the question raised, as well as the question of the etiology of the veteran's fatal cardiovascular disease. The appellant's representative contends that the CMD opinion was inadequate, alleging in particular that it failed to state reasons and bases for its medical conclusions reached. However, the Board finds otherwise. It is apparent that the CMD opinion was based upon a review of the material evidence in the claims folder. It is clear that the June 1994 letter from the Board to the Chief Medical Director, which requested a CMD opinion, in and of itself sufficiently set forth in detail all material facts contained in the claims folder, with respect to the questions at issue that were the focus of the CMD opinion. The July 1994 CMD opinion indicates that the physician who rendered it was adequately apprised of the pertinent circumstances regarding the veteran's smoking history and risk factors for heart disease, which could only have been derived from the material facts contained in the claims folder (including the June 1994 Board letter in question). The death certificate substantiates that the veteran's death was due to underlying hypertensive coronary artery disease, and it is not otherwise contended. In order to respond to the contention that an etiological relationship exists between the veteran's fatal cardiovascular disease and a service-connected disability, the Board will cite passages from a medical text, namely 1 Cecil, Textbook of Medicine, 296-300 (James B. Wyngaarden, M.D., et al., eds., 19th ed., 1992). The aforecited pages of said medical text were referred to by the appellant's representative in an August 1992 informal hearing presentation. In that August 1992 informal hearing presentation, the representative stated, "[w]e further call the Board's attention to Cecil, Textbook of Medicine, 19th ed., pages 296 through 300." See August 1992 informal hearing presentation, at page 3. Moreover, the informal hearing presentation provided detailed discussion of the material set forth in those pages of said medical text, dealing with cardiovascular disease. Therefore, since those pages of said medical text have been relied upon by the appellant's representative as evidence in this case, the Board will do likewise. It should be added that since the appellant's representative obviously reviewed said material, the due process considerations expressed in Thurber v. Brown, 5 Vet. App. 119 (1993), have not been violated. Thus, for the foregoing reasons, the Board concludes that the duty to assist the appellant in the development of facts pertinent to her claim as contemplated by 38 U.S.C.A. § 5107(a) has been satisfied. In order to establish service connection for the cause of the veteran's death, the evidence must show that a disease or disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death but rather, it must be shown that there was a causal connection. Service- connected diseases or injuries involving active processes affecting vital organs should receive full consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. There are primary causes of death which, by their very nature, are so overwhelming that eventual death can be anticipated irrespective of co-existing conditions, but even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service-connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. The veteran died at age 69 in March 1989 from cardiac arrest due to, or as a consequence of, hypertensive coronary artery disease. No other significant condition contributing to the cause of death was reported on the death certificate. The death certificate is prima facie evidence of the cause of death. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Where a veteran served continuously for ninety (90) days or more during a period of war or during peacetime service after December 31, 1946, and cardiovascular disease including hypertension or organic heart disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131; 38 C.F.R. §§ 3.307, 3.309. An issue for resolution is whether the veteran's essential hypertension and organic heart disease were initially manifested during service or within the one-year presumptive period after service. The examination at the time of entry into service revealed that clinical evaluation of his cardiovascular system was negative. The service medical records reveal that in January 1940, he had a history of smoking a half tin [of tobacco] daily. A family history of heart trouble was reported (his father). Clinically, pulse rate readings ranged from 76 to 108 beats per minute, and his heart was unremarkable. During hospitalization in March 1940, his blood pressure was 116/76, pulse rate readings ranged from 76 to 104 beats per minute, and his heart was unremarkable. During a March 1944 hospitalization, pulse rate readings ranged from approximately 72 to 98 beats per minute. The service medical records reflect that in September 1944, the veteran complained of left chest pain related to heavy lifting, of approximately one year's duration. However, clinically, the findings with respect to the left chest were limited to muscle tenderness. While tachycardia was noted, the examiner elaborated that the veteran admitted to having nervous spells. A few weeks later, a chest X-ray study was normal. Later that month, his sitting pulse rates were recorded as ranging from 88 to 108 (with exercise, pulse rates ranged from 118 to 128) over three consecutive days. Over three consecutive days, his blood pressure was recorded as 138/88, 134/84, 138/84, 128/80, and 134/80. From September 28 through October 5, 1944, he was hospitalized for further observation, following his having persistently rapid pulse rates on three consecutive days, and a history of a 12-pound weight loss during the past several months. He complained of nervousness of 18 months' duration, and reported that he smoked one pack of cigarettes daily. During that hospitalization, pulse rate readings ranged from 68 to 110. Significantly, on October 2nd, a physician reported that the veteran's pulse as a rule was normal in rate, but occasionally rapid; and he stated that the occasionally rapid pulse rate was "a reaction of disgust and transitory upset-emotionally." The veteran's heart was clinically described as normal, and a chest X-ray study was negative. A report of examination for separation from service dated in July 1945 revealed that his pulse was 72 (sitting), 112 (after exercise), and 82 (two minutes after exercise). Blood pressure was 128/86. Clinically, the cardiovascular system was normal, and a chest X-ray study revealed no significant abnormality. A report of Department of Veterans Affairs (VA) examination in November 1946 revealed that the veteran complained of nervousness, but not any cardiovascular-related problems. Clinically, he had marked tachycardia, but it was noted that he apparently was very nervous and would have shortness of breath after exercise. His pulse rate was 130 (sitting), 130 (standing), 160 (immediately after exercise), and 120 (three minutes after exercise). His blood pressure was 160/80. A chest X-ray study was negative. The diagnosis was limited to anxiety. A VA examination in December 1947 revealed that the veteran complained of tremulousness, palpitations, chest pain, headaches, hot flashes, and cold sweats. He appeared nervous, and was described as very preoccupied with his neurotic symptoms. He reportedly smoked a pack of cigarettes daily. Significantly, his cardiovascular system was clinically described as normal except for a fast pulse rate of 104. Also of significance is that moderate anxiety reaction manifested by tension, apprehension, profuse perspiration, gastric distress, and headaches was diagnosed, but not a cardiovascular disease or disability. It should be pointed out that an intermittently elevated heart rate is not necessarily indicative of an underlying cardiac disease or disability. It is commonly known that heart rates increase directly proportional to anxiety levels and other emotional factors. It is uncontroverted that the veteran was a significantly anxious person during service and thereafter, and that the evidence reveals that, during service and proximate thereto, his tachycardia appeared whenever he was nervous. See service medical records dated in September and October 1944, and VA examination reports dated in November 1946 and December 1947. It is reiterated that during the October 1944 inservice hospitalization, a physician opined that the veteran's occasionally rapid heart rate was a reaction to emotional upset; and no underlying cardiac disease or disability was reported or diagnosed. It is highly probative that despite occasionally elevated heart rates during service and proximate thereto, no cardiovascular disease or disability was clinically shown. For informational purposes, without reliance thereon, a medical text states, "Although the normal heart rate ranges from 50 to 100 beats/min[.], both slower and more rapid rates may occur in normal individuals or may reflect noncardiac conditions such as anxiety...." Barry M. Massie, M.D., et al., Cardiovascular Disease in Current Medical Diagnosis and Treatment, 258 (Steven A. Schroeder, M.D., et al. eds., 1992). Thus, the veteran's slightly elevated heart rates during service and proximate thereto appear more likely related to anxiety and emotional turmoil, not underlying cardiovascular disease or disability. Additionally, despite occasionally slightly rapid heart rates, no clinically significant cardiac arrhythmias were reported during the veteran's lifetime. Furthermore, the death certificate listed the underlying cause of death as hypertensive coronary artery disease, not cardiac arrhythmia. The service medical records reflect that the veteran's blood pressure readings ranged from 76 to 88 (diastolic) and 116 to 138 (systolic). According to the medical text referred to by the appellant's representative in her informal hearing presentation: Elevation in blood pressure is an important risk factor associated with increased incidence of atherosclerosis....The risk of atherosclerosis and its sequelae increases progressively with increase in blood pressure, and when the blood pressure exceeds 160 mm Hg systolic and 95 mm Hg diastolic in middle-aged men the risk is five times greater than in normotensive men with blood pressure of 140 mm Hg systolic and 90 mm Hg diastolic or less. Russell Ross, Atherosclerosis in 1 Cecil, Textbook of Medicine, 296 (James B. Wyngaarden, M.D., et al., eds., 19th ed., 1992). As this medical text indicates, normotensive blood pressure is medically defined as 140/90 or less. Conversely, blood pressure exceeding 140/90 on a sustained basis can be considered hypertensive. See also 38 C.F.R. § 4.104, Diagnostic Codes 7007 and 7101, pertaining to hypertensive heart disease and hypertensive vascular disease (essential arterial hypertension), respectively, referring to essential hypertension as persistently elevated blood pressure readings. Significantly, the veteran's blood pressure readings during service and on examination for separation from service were within normal limits, and no cardiac abnormalities were clinically shown or diagnosed. While a single blood pressure reading of 160/80 was reported on VA examination in November 1946, this was more than one year after service separation. Again, this single blood pressure reading of 160/80 (representing slightly elevated systolic but normal diastolic pressure) does not constitute persistently elevated blood pressure (i.e., essential hypertension). Likewise, the single blood pressure reading of 140/82 (representing borderline systolic but normal diastolic pressure) recorded on VA examination in December 1947, more than two years after service, does not constitute persistently elevated blood pressure indicative of essential hypertension. Additionally, in September 1993, a VA cardiologist, after review of the entire claims folder, apparently concluded that the veteran had labile, not continuous [essential] hypertension during service. See September 1993 VA cardiologist's opinion, wherein he stated "It would seem difficult linking his service connected hypertension (stress related)...to a coronary occlusion 48 years later...." The cardiologist explained that labile hypertension, since it is stress-related, is entirely reversible versus continuous hypertension (essential hypertension), which represents a pathologic disorder. "...labile hypertension, which is related to stress and therefore a physiological response to stress -- totally reversible once the stress is eliminated or fixed hypertension (hypertensive disease) not necessarily related to stress but continuous and therefore a pathological response." Id. It is apparent from the text of this opinion that the cardiologist's references to "service connected hypertension" did not mean that the veteran had essential hypertension in service, but only that any elevated blood pressure in service (which is not shown in the record) was labile and related to stress. The Board has considered the fact that the veteran complained of chest pain during a December 1947 VA examination, years after service. While the appellant's representative contends that this represented angina pectoris indicative of underlying cardiovascular disease, this is mere speculation and is not supported by any medical evidence. To the contrary, the veteran's cardiovascular system was described as normal on that examination, except for an elevated pulse rate. Parenthetically, the elevated pulse rate and complaints of chest pain appear more likely to have been related to the veteran's well-substantiated anxiety and somatic manifestations of a psychiatric disorder. In any event, the chest pain complaint on that examination was not diagnosed as cardiac in nature, nor was it complained of during subsequent examinations. A single, slightly elevated blood pressure reading of 152/90 was recorded on VA examination in March 1961, more than 15 years after service separation, at a time too remote to be reasonably related to service. A chest X-ray study was negative. Significantly, persistently elevated blood pressure readings were initially reported even later in a January 1977 private medical statement, and hypertension was diagnosed on VA examination in April 1977. During that April 1977 examination, the veteran reported a 10-year history of elevated blood pressure, but that he had not received any treatment until four months ago. An electrocardiographic study revealed left axis deviation, but this was medically interpreted as not clinically significant. Diagnoses were exogenous obesity, moderate hypertension, and no heart disease found. Significantly, the September 1993 opinion by a VA cardiologist, a specialist in cardiovascular diseases, concluded that during service, the veteran had labile or stress-related hypertension, which by definition, was completely reversible and therefore nonpathologic. Moreover, the actual service medical records and clinical reports proximate to service do not reveal the presence of essential hypertension or organic heart disease. The Board concludes that there is simply no credible evidence that essential hypertension or organic heart disease was present during or proximate to service, since persistently elevated blood pressure readings and organic heart disease were initially clinically shown many years after service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. There is no continuity of symptomatology to relate the veteran's essential hypertension or organic heart disease shown many years after service to his military service. 38 C.F.R. § 3.303. Additionally,with regard to the question of the onset of the veteran's hypertensive heart disease in service, the Board finds no probative value in the August 1989 statement from Ramesh Karody, M.D. Dr. Karody apparently reviewed records from 1977, and although he noted that the veteran had received treatment from the VA since 1945, he did not indicate that this treatment had anything to do with heart disease as opposed to the service- connected anxiety disorder. Dr. Karmody's statement did not relate the onset of hypertension to service not did he make any conclusion or present any evidence of the manifestation of heart disease within one year of service discharge. His statement as to this issue is therefore not relevant. The appellant additionally argues that the veteran's fatal cardiovascular disease was causally or etiologically related to his service-connected disabilities, specifically, anxiety reaction, or that the service-connected anxiety reaction played a significant role in his death. Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). As previously stated, the Board concedes that the veteran was an anxious individual during his lifetime, and this is well documented by the clinical evidence of record. The appellant alleges that the veteran's anxiety disorder materially caused or contributed to his death from cardiovascular disease. However, the appellant's opinion as to the cause of the veteran's death is not competent evidence, for lack of medical expertise to offer an opinion regarding medical relationships or diagnoses. Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). VA outpatient treatment reports dated in November 1980 and March 1981 stated that the veteran's hypertension may be due, in part, to anxiety. However, it is commonly known that anxiety may intermittently elevate blood pressure. See also September 1993 opinion by VA cardiologist, referring to stress-related labile hypertension as entirely reversible and nonpathologic. In other words, the VA outpatient treatment reports did not state that the veteran's essential hypertension was causally or etiologically related to the service-connected anxiety reaction. In his August 1989 statement, Dr. Karody opined that the veteran's chronic anxiety may have contributed to the fatal hypertensive coronary artery disease. However, Dr. Karody's opinion was based on mere possibility, and therefore resorted to speculation. The realm of possibility implies a resort to mere speculation versus probability, and is prohibited by the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b) (West 1991). Dr. Karody did not indicate the allocation of the various risk factors to the cause of the veteran's death (i.e., whether the risk factor(s) materially caused his death) nor did he relate the various risk factors to service. See Van Slack v. Brown, 5 Vet.App. 499 (1993), wherein the Court affirmed the Board's denial of service connection for the cause of the veteran's death, by citing to a private physician's statement that referred to the service-connected disability as a contributory factor, rather than as indicating a causal connection between the service-connected disability and the veteran's death. As stated in Gilbert v. Derwinski, 1 Vet.App. 49 (1990), "By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility." Again, Dr. Karody's opinion was speculative and incomplete, particularly since his conclusions were based upon mere possibility and he reviewed only selective portions of the veteran's records. Neither the September 1993 opinion by a VA cardiologist nor the July 1994 CMD opinion supports the appellant's contention that the veteran's fatal cardiovascular disease was causally or etiologically related to his service-connected anxiety reaction, or that the service-connected disability played a material role in his death. The September 1993 opinion by the VA cardiologist, after his review of the claims folder, referred to multiple risk factors for heart disease that the veteran had, specifically obesity, carbohydrate intolerance, elevated lipids, smoking, positive family history, and caffeinated drink user. While he acknowledged that the veteran had labile or stress-related hypertension in service, a completely reversible, nonpathologic condition, he stated that he was unaware of any scientific study linking chronic psychoneurosis to hypertension/coronary artery disease. The July 1994 CMD opinion, which appears based upon the material evidence of record, unequivocally stated that the veteran's service-connected disability did not contribute to his fatal heart disease. The Board concludes, therefore, that in the present case, it would be mere speculation to assume that the veteran's fatal cardiovascular disease was the proximate result of his service-connected anxiety reaction. There is no credible medical, lay or other evidence that persuasively shows that his cardiovascular disease was secondary to his service-connected psychiatric disorder or related to military service, for the aforestated reasons. Moreover, the death certificate indicates that the veteran suffered cardiac arrest due to his underlying hypertensive coronary artery disease, which was of sudden onset, and was so overwhelming an event that it was the proximate cause of his death regardless of co-existing conditions (i.e., anxiety reaction). Thus, the service-connected disability did not have a debilitating effect as to render him materially less capable of resisting the effects of the fatal cardiovascular disease, or have a material influence in accelerating death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. Parenthetically, the Board acknowledges that emotional and psychological factors have been suspected to be risk factors in the development of cardiovascular disease. For informational purposes, without reliance thereon, a medical text states that: As an aid to medical assessment of causality in coronary artery heart disease and its ischemic sequelae, the cardiac disorder by far the most frequent basis of heart claims, the reader is referred to the "Report of the American Heart Association's Committee on Stress, Strain, and Heart Disease." Although originally published in 1977, the conclusions of this committee are currently valid without modification, have not been supplanted by any other formal set of medical causality guidelines, and are generally accepted by the medical profession. The conclusions pertinent to a medical assessment of causality in cardiac claims arising under workers' compensation are summarized below: * * * * Continued, protracted psychologic, emotional stress to which an individual may have been subjected over a long period of time has not been established scientifically as a causative or worsening agent in the genesis or acceleration of atherosclerotic disease, although the possibility of some contribution cannot be excluded in individual cases. * * * * So-called risk factors, such as cigarette smoking, elevated blood cholesterol, diabetes mellitus, hypertension, and positive family history of coronary disease, are often put forth by defense counsels as mitigating or alternative, not of legal liability, elements arguing against the claim's validity in regard to questions of causality assessments in coronary heart disease. In this regard, it should be recognized that risk factors are of importance primarily in epidemiologic studies applicable to groups, not to an individual. For any given person, the presence or absence of medical background risk factors does not necessarily indicate the premature development of this condition nor an escape therefrom. Thus, although statistically related to the presence of coronary heart disease, generally accepted risk factors for coronary atherosclerosis cannot be viewed medically as causative elements in the production of the disease. In any consideration of so-called personality types A and B as risk factors, it should be further recognized that, in addition to the practical impossibility of definitely separating human beings categorically into type A or type B personalities, it must be kept in mind that the role of personality type, if any, in the pathogenesis of coronary atherosclerosis has not been scientifically established and, therefore, should not be presented to a court of law as within the realm of medical "probability" or "reasonable medical certainty. Additionally, in medical causality assessments in coronary atherosclerotic heart disease, it must be appreciated that although physical stress may be definable quantitatively to some degree, emotional stress defies quantitative measurement...." Elliot L. Sagall, M.D., Cardiac Evaluations for Legal Purposes in The Heart, Arteries and Veins, 1659-1661 (J. Willis Hurst, M.D., et al., 7th ed., 1990). As the credible medical evidence indicates, whether chronic psychoneurosis may be a risk factor in the development of cardiovascular disease is to resort to mere speculation, since scientifically it cannot be proven to a reasonable probability in a particular case. In any event, in this case, the Board finds no competent or credible evidence that the veteran's anxiety reaction was a probable material risk factor in the development of his cardiovascular disease, and, in fact, the opinions of cardiologists in this case are to the contrary. Another matter in controversy is whether the veteran's fatal cardiovascular disease was causally or etiologically related to his history of smoking (nicotine dependence). Significantly, the death certificate, which is prima facie evidence of the cause of death, did not list smoking or nicotine dependence as a significant condition contributing to death. It is reiterated that the appellant's opinion as to the cause of the veteran's death is not competent evidence, for lack of medical expertise to offer an opinion regarding medical relationships or diagnoses. Espiritu. The Board recognizes that if nicotine dependence is considered a disease or injury for purposes of compensation under Title 38, United States Code, then, if such dependence began in service and tobacco use resulting from that dependence led to development of a disabling condition subsequent to service, service connection could be established for disability resulting from that condition pursuant to 38 C.F.R. § 3.310(a). Alternatively, if nicotine dependence is not a disease or injury for compensation purposes, service connection could only be established for a tobacco- related disability if resulting disease commenced in service or a disabling disease process could be linked to an event in service. See VA O.G.C. Prec. Op. No. 2-93 (Jan. 13, 1993). However, whether or not nicotine dependence is a disease or injury is not determinative in this case, since there is no credible or competent evidence that tobacco use led to the development of the veteran's fatal hypertensive heart disease. The August 1989 statement from Dr. Karody and the VA medical opinions dated in September 1993 and July 1994 accurately state that tobacco use is but one of multiple risk factors for the development of heart disease. Dr. Karody's statement did not include any opinion that tobacco smoking related to service was a factor in the veteran's death. Neither the September 1993 opinion by a VA cardiologist nor the July 1994 CMD opinion stated that the veteran's tobacco use was a material risk factor for the development of his fatal cardiovascular disease. In fact, the cardiologist concluded that "the natural course of events were not altered by the decedent's military service"; and the July 1994 CMD opinion unambiguously stated that the veteran's smoking in service had no effect on his death. The Board has carefully considered the evidentiary record, which indicates that the veteran smoked approximately a pack a day of cigarettes since service. See service medical records and VA examination reports dated in December 1947 and April 1951. A VA examination report in April 1977 reported that his smoking had decreased to a half a pack of cigarettes daily. A VA hospital report in October 1984 reported that he had smoked a pack of cigarettes daily between 1940 and 1983, and then had reduced to 3 to 4 cigarettes per day. There is no evidence that the veteran's service-connected psychiatric disability led to increased smoking, since the rate and amount of smoking remained fairly consistent over the years. Again, even Dr. Karody's August 1989 statement recognized that the veteran had multiple risk factors, including diabetes, that might have contributed to his death. The evidentiary record reflects a strong family history of heart disease, on the paternal side. See service medical records and the September 1993 VA cardiologist's opinion. Additional risk factors included obesity and elevated lipids (cholesterol). See September 1993 VA cardiologist's opinion. The actual clinical records revealed elevated cholesterol levels in the 1970's and diabetes mellitus and obesity in the 1980's. Even assuming arguendo that anxiety, stress, or other psychiatric symptoms and tobacco use may be risk factors or contribute in some manner to the development of cardiovascular disease, including hypertensive heart disease, the effects of psychiatric symptoms and tobacco use are unascertainable from a quantitative viewpoint, and are not definitely identifiable from a cause-and-effect assessment. Again, it is pointed out that the veteran had a number of considerable risk factors for the development of cardiovascular disease, including altered lipid metabolism, family history of heart disease, diabetes mellitus, and obesity. See also Cecil, Textbook of Medicine, supra, 296. It is mere speculation to suggest that but for the service- connected psychiatric disability, or history of tobacco use, the veteran would not have developed essential hypertension or organic heart disease; or that the service-connected psychiatric disability or tobacco use probably played a material role in the development or acceleration of his fatal cardiovascular disease. For informational purposes, without reliance thereon, a medical text states, "Cigarette smoking acutely raises blood pressure, again by increasing plasma norepinephrine, but the long-term effect of smoking in essential hypertension is less clear." Barry M. Massie, M.D., Systemic Hypertension in Current Medical Diagnosis and Treatment, 369 (Lawrence M. Tierney, Jr., M.D., et al. eds., 1994). The negative evidence outweighs the positive, since there is no ascertainable method to determine, within reasonable probability, that the veteran's service-connected psychiatric disability or history of tobacco use, singularly or in combination, materially caused or contributed to his death from cardiovascular disease. There is no competent or credible medical, lay or other evidence that persuasively suggests that his cardiovascular disease was secondary to the service-connected psychiatric disorder or related to military service, for the aforestated reasons. Therefore, the Board finds that service connection for the cause of the veteran's death is not warranted. Since the preponderance of the evidence is against allowance of this claim, the benefit of the doubt doctrine is inapplicable. 38 U.S.C.A. § 5107(b). ORDER Service connection for the cause of the veteran's death is denied. HOLLY E. MOEHLMANN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.