High blood pressure is one of the most common illnesses in the UK. However, without regular testing it is difficult to detect. David Butler explains
One of the most common conditions underwriters are exposed to is high blood pressure. It is the pressure of blood inside the arteries that constantly rises and falls, in a cycle, as the heart pumps blood throughout the body. It comes in varying guises; including raised blood pressure, hypertension, white coat hypertension and essential hypertension - all essentially describing the same thing.
Blood pressure is recorded as two figures - for example 140/80 mmHg, described as "140 over 80". These two figures signify the pressure of the blood in the arteries at two specific times. The top figure, the systolic, is the pressure in the arteries when the heart contracts, while the bottom figure, the diastolic, is the pressure in the arteries when the heart rests between each beat.
Blood pressure does not usually cause any symptoms, and unless a person's blood pressure is checked they may have no idea the risk of developing cardiovascular disease has increased. Therefore, it is recommended that everyone should have regular blood pressure checks every three to five years.
In some instances, blood pressure readings should be taken more regularly. Older people and those with a history of high blood pressure, in particular, should check their blood pressure more frequently. Diabetics also need regular checks as the risk of developing hypertension when diabetic is higher than if not.
Testing
The conventional way of measur-ing blood pressure is by using a sphygomomanometer and stethoscope. The sphygomomano-meter uses a mercury column and a cuff around the arm. The cuff is pumped up and the stethoscope placed on the arm to listen to the pulse. The measurements are then taken to give a reading.
There are well-established guidelines on how to achieve the most accurate results when measuring the blood pressure in this way. They are as follows:
• Equipment needs to be equilibrated, maintained and accurate.
• The observer needs to be trained and must avoid rounding to the nearest five or 10mmHg so as not to create false readings.
• The environment in which the recording is done should be quiet and relaxed.
• A series of blood pressure readings should be taken at different times and on different days.
• Variable positioning of the arm, with respect to the heart and alterations in posture, could affect the reading.
• Blood pressure can vary from beat to beat, so solitary-raised readings should be treated with caution.
• Blood pressure is based on sounds heard through the stethoscope, so accurate placement of the instrument must be made to ensure a correct result.
There are several risk factors connected with high blood pressure. For example, it is a risk factor for developing cardiovascular disease, including heart attack or stroke, and kidney damage. High blood pressure over a period of years could also damage the arteries in which the blood flows and put a strain on the heart. Generally, the higher the blood pressure the greater the risk.
People need to be aware of the risk factors that could cause raised blood pressure and lead to other more serious health issues later in life. Some of the risk factors are fixed and cannot be altered. These include:
• Gender - male or early menopausal women.
• Age - older people are more likely to develop atheroma, a cardiovascular disease.
• Strong family history - father or brother who developed heart disease or had a stroke before 55, or a mother or sister before 65.
Other risk factors are based around lifestyle but by changing their habits individuals can lessen the risk. They include:
• Smoking - although not directly affecting blood pressure it greatly affects the health risk and is a major cause of cardiovascular disorders.
• Lack of physical activity - regular exercise reduces blood pressure.
• Obesity - another major cause of cardiovascular disorders.
• Poor diet - eating the wrong type of food, for example, having a high salt intake can cause blood pressure to rise.
• Excess alcohol - this can have a direct effect on blood pressure. However, a small amount of alcohol may help prevent heart disease.
Classification
Blood pressure that is 140/90 mmHg or above would be classed as high blood pressure. Therefore, readings of just a high systolic pressure, for example over 140, or just a high diastolic pressure, for example over 90, could be diagnosed as high blood pressure. If a reading is 140/90mmHg or above, but below 160/100 mmHg, a patient with no other cardiovascular risk factors would be advised that the blood pressure should be lower but the overall risk from mild high blood pressure is small, and medication may not be needed initially.
If a blood pressure reading is 160/100 mmHg or above, medication is usually offered.
While each reading can be different, high blood pressure can be split into three different categories:
• Primary/essential hypertension - when no underlying cause can be established for high blood pressure readings. This type accounts for the majority of patients diagnosed with the condition.
• Secondary hypertension - where raised blood pressure is due to an underlying cause, such as kidney disease, glandular or hormonal problems or pregnancy (otherwise known as pre-eclampsia).
• Malignant/accelerated hypertension - this is a life threatening acute elevation of the blood pressure, which can damage the kidneys, brain or the heart, with the damage sometimes being irreversible.
Once identified, blood pressure can be controlled using various medications. One may work, but for some individuals several different tablets may be needed. Lifestyle changes may be addressed initially to see if a patient's blood pressure can be reduced. Otherwise, the main way of controlling high blood pressure is by using drugs.
This can be complicated as there are seven major classes of drugs currently used to control blood pressure. As high blood pressure is a strong indicator of cardiovascular disease the medication used to treat the condition can also be of help in preventing other conditions:
• Thiazide diuretics - particularly helpful to elderly people or where there is also co-existent heart failure.
• Beta-blockers - for patients with associated ischaemic heart disease, but may not be good for asthma sufferers, peripheral vascular disease and heart block.
• Calcium channel antagonists have anti-anginal action and are often used in older patients.
• Angiotensin converting enzyme (ACE) inhibitors assist hypertensive diabetics and patients with heart failure
• Angiotensin II receptor antagonists are similar to ACE inhibitors.
• Alpha-blockers - are particularly useful if there is associated prostatism.
• Vasodilators - like methlydopa and minoxidil may also be used for hypertension.
By making lifestyle changes and being prescribed drug treatment normal blood pressure can be achieved. However, without taking action at the appropriate time, the risk of stroke, renal failure and cardiovascular disease greatly increases.
David Butler is life and disability underwriter at Aegon Scottish EquitableUnderwriting implicationsWhen considering an applicant with raised blood pressure, many factors readily available on the application form need to be taken into account.
If the client provides good application disclosure with none of the associated cardio-vascular risk factors and good blood pressure readings on the application form then it may not be necessary to write to the applicant's GP.
If the disclosure is limited then a specific blood pressure questionnaire will be sought from the policyholder's GP.
If the applicant has been diagnosed with essential hypertension, and none of the associated risk factors are evident, the underwriter simply needs to see that the blood pressure control is good, for example readings on or below 140/80mmHg, to accept the case at standard rates.
If the blood pressure is not adequately controlled or evidence of control has not been obtained for over a year, the underwriter will possibly request a blood pressure check. They can then accurately assess the client's application.
Poorly controlled blood pressure with additional cardiovascular risk factors can lead to an increased premium, especially for critical illness cover were the risk is greater due to the type of policy applied for. Ratings can be anything from 50% to 100%.
If blood pressure is poorly controlled over a period of time and urgent attention is needed from the applicant's GP, the application will be delayed and the underwriter will write to the client's GP regarding this.Factsn About half of people over 65, and about one in four middle-aged adults, have high blood pressure.
n At least one in 20 adults have blood pressure of 160/100mmHg or above.
n Treatment with one drug achieves blood pressure control in about one third of hypertensives, a further third require at least three drugs for adequate control.
