Cardiac arrhythmia is a common heart problem. Paula Kemp explains what advisers should know when sufferers apply for life and health cover
An arrhythmia is a change in the regular beat of the heart. The heart may seem to skip a beat, beat irregularly, very quickly or very slowly. Many arrhythmias cause no symptoms and may go unnoticed, however they may lead to palpatations - a feeling of fluttering in the chest. Occasionally, arrhythmia can cause sudden death.
There are three main causes of arrhythmias:
• The sinoatrial node (SAN) misfires, making the heart beat too fast or too slow.
• Another part of the heart takes over the job of the SAN.
• There is an interruption to the normal conduction of nerve signals in the heart. This may be caused by a heart attack that has damaged the heart muscle.
Everyone experiences some variation in their heartbeat at certain times and palpatations can be normal. If there is a co-existing heart disease, then it is this and not the arrhythmia that poses the greatest risk to the patient. However, in a very small number of people with serious symptoms, arrhythmias themselves can prove dangerous. For example, a few people have a very slow heartbeat (bradycardia), causing them to feel light-headed or faint. If left untreated, the heart may stop beating and these people could die without urgent medical attention.
Arrhythmia types
Arrhythmia types originating in the atria (the upper chamber of the heart) are:
• Sinus arrhythmia - cyclic changes in the heart rate during breathing. Common in children and often found in adults.
• Sinus tachycardia - the SAN sends out electrical signals faster then usual, speeding up the heart rate - usually to more than 100 beats per minute. This is a normal response in some situations, such as during exercise, stress or strong emotions, or as a result of fever. It can also be related to heart disease, respiratory disease, metabolic disease and can be induced by excess caffeine, alcohol, cigarettes and certain drugs.
• Supraventricular tachycardia, paroxysmal atrial tachycardia (PAT) - a series of early beats in the atria speed up the heart rate. In PAT repeated periods of very fast heartbeats begin and end suddenly.
• Atrial fibrillation - electrical signals in the atria are fired in a very fast, uncontrolled manner. Electrical signals arrive in the ventricles in a completely irregular fashion therefore the heart beat is completely irregular. This condition may cause a blood clot to form in the heart, which can then be transported to other parts of the body, sometimes to the brain where it can cause a stroke.
• Atrial flutter - rapidly fired signals cause the muscles in the atria to contract quickly, leading to a very fast regular heartbeat.
• Wolff-Parkinson-White syndrome (WPW) - abnormal pathways between the atria and ventricles cause the electrical signal to arrive at the ventricles too soon and to be transmitted back into the atria. Very fast heart rates may develop as the electrical signal ricochets between the atria and the ventricles. WPW syndrome occurs in four to nine out of every 10,000 people and about two-thirds of the cases occur in otherwise healthy young people without a history of cardiac disease.
• Sick sinus syndrome - abnormal functioning of the natural pacemaker (the SAN of the heart). This causes episodes of slowing or speeding or even short periods of heart stoppage. It is commonly known as the tachycardia-bradycardia syndrome.
Arrhythmia types originating in the ventricles (lower chambers of the heart):
• Premature ventricular complexes - an electrical signal from the ventricles causes an early heart beat that generally goes unnoticed. The heart then seems to pause until the next beat of the ventricle occurs in a regular fashion.
• Ventricular tachycardia - the ventricles contract rapidly but the rate in the atria remains normal. This usually causes sudden collapse. It often happens after a heart attack.
• Ventricular fibrillation - this is when the whole heart stops beating properly and just flutters. It may follow from ventricular tachycardia. Blood is not circulated to the brain and the rest of the body. If the heartbeat is not rapidly restarted with a defibrillator, death will result. There is a significant risk of recurrence and those without a reversible cause have a recurrence rate in the first year of 35%.
These are some of the most common arrhythmias, varying from the innocent palpatations to the life-threatening arrhythmias.
Various treatment options are available which help to control these conditions The removal of any recognised triggers, such as coffee or alcohol, is one such treatment. Drug treatment includes the use of digoxin, adenosine and flecainide, or for those at risk of blood clots, for example, atrial fibrillation blood thinning drugs such as warfarin may be advised.
There are surgical options such as cardioversion whereby a doctor applies an electrical shock to the chest wall (defibrillator), catheter ablation techniques that involve the destruction of the abnormal areas in the heart that are creating the arrhythmia or a pacemaker or cardioverter-defibrillator may be implanted into the chest.
Paula Kemp is a life and disability underwriter with Scottish Equitable Protect
Underwriting implications
Due to the variety of different arrhythmias and complications that can occur, most applications with a history of palpatations will require further medical evidence to support the application, usually in the form of a report from the client's GP.
The underwriting implications for particular conditions are:
• Sinus arrhythmia. This condition is innocent and therefore standard rates could be offered on all benefits.
• Sinus tachycardia. For applicants under the age of 70, this may warrant a small rating if the underlying cause is not known. Applicants over age 70 are subject to individual consideration.
• Supraventricular tachycardia, paroxysmal atrial tachycardia (PAT). As long as full cardiac investigations are normal, standard rates can be considered. Insurers may charge a small rating for life and critical illness if the cause is unknown and they suffer less than 10 attacks a year. For other circumstances, each applicant will be assessed on their own merits.
• Atrial fibrillation. For fully investigated cases with no underlying heart disease, less than five attacks a year and under the age of 50 insurers can usually consider standard rates. A small loading may apply to older lives and ratings in excess of +150% apply to lives with more than five attacks a year.
• Atrial flutter. It is assessed in a similar fashion to atrial fibrillation, but underlying heart disease is much more common in this condition.
• Wolff-Parkinson-White syndrome. WPW with a history of PAT would be considered in the same way as PAT, however with a history of atrial fibrillation without surgical intervention it is possible that terms would not be offered.
• Sick sinus syndrome. Due to risk of sudden death, the best terms that can be offered for life cover are +100% rating unless the patient has had a pacemaker inserted, in which case the insurer may be able to offer better terms. However, it may be necessary to decline offering terms.
• Premature ventricular complexes. For cases that have been fully investigated, then insurers consider standard rates, otherwise a loading would apply based on the number of premature beats.
• Ventricular tachycardia. This is a more serious arrhythmia and would be postponed for a minimum of two years after the last attack and would then be rated a minimum of +200% on life cover and possibly declined. Critical illness cover would be declined.
• Ventricular fibrillation. Most applications with a history of ventricular fibrillation will be declined.
Cardiac arrhythmia: the statistics
Atrial fibrillation (A.F) is the most common sustained cardiac arrhythmia, present in up to 5% of people over age 6.0
Source: www.dcs.gla.ac.uk
Findings published in the journal Circulation indicate women are at least 30% more likely than men to die early as a result of A.F. Source: BBC news online
According to the British Medical Journal, in 1995 the prevalence in the UK of A.F. was nine per 1,000 people.
Source: www.wansford.co.uk
A.F. is found in 15% of all stroke patients and in 2% and 8% of transient ischaemic attack (mini-stroke) patients. The overall incidence of stroke in A.F. is 5% a year.
Source: www.wansford.co.uk
Warfarin treatment can reduce the risk of stroke by 66%.
Source: www.wansford.co.uk
Radiofrequency ablation of the accessory pathways to treat arrhythmias has a 90% success rate and a low complication rate, according to the Trent Institute for Health Services Research in 1996.
22,000 people in the UK are fitted with pacemakers every year to correct cardiac arrhythmias
Source: www.bbc.co.uk
