As one of the main causes of deaths in the UK, coronary heart disease needs careful assessment. Joanne Braham explains
Coronary or Ischaemic Heart Disease (CHD) is one of the most common causes of death in Europe, North America and Australia.
In the UK, about a quarter of deaths in men and a fifth of deaths in women under the age of 75 are now caused by CHD, with a further 13% - 14% resulting from other conditions affecting the heart and blood vessels.
There are many important risk factors that lead to the development and progression of CHD.
Aside from age, family history and gender, the four main risk factors are smoking, lack of physical activity, raised blood pressure and raised cholesterol.
Cholesterol is a type of fat found among the lipids in the bloodstream, which is part of all animal cells.
It is essential for many of the body's metabolic processes, including hormone and bile production.
The body produces its own cholesterol in the liver and is transported round the blood by lipoproteins (a combination of cholesterol and protein).
The two most common types of lipoprotein are lowdensity lipoprotein (LDL) and high-density lipoprotein (HDL).
Some foods are also found to be rich in cholesterol, such as eggs and seafood.
An increase in cholesterol is known as hypercholesterolaemia or hyperlipidaemia and is a major factor in CHD and stroke.
LDL transports cholesterol away from the liver through the blood stream.
It is important to keep this low as increased levels can cause deposits to be formed and clog up the arteries.
This is often referred to as the 'bad' cholesterol.
The British Heart Foundation recommends LDL levels should be less than 3mmol/l.
HDL helps to return the excess cholesterol that is not needed in the body to the liver.
This is known as the 'good' cholesterol and the higher the level, the less risk of developing CHD.
Lifestyle changes In Britain today, 46% of all deaths from CHD under the age of 75, were found to have raised cholesterol.
CHD is caused when the blood vessels to the heart are narrowed by a gradual build-up of fatty material within their walls.
This condition is called atherosclerosis.
The fatty substance is called atheroma.
Atheroma develops when LDL cholesterol is chemically changed (oxidation) and is taken up by cells in the coronary artery walls, which is where the narrowing process begins.
On the other hand, HDL cholesterol removes cholesterol from the circulation and appears to protect against CHD, which is why they are known as good and bad cholesterol.
Raised cholesterol can be treated either by medicine or lifestyle changes.
The main drugs used in lowering cholesterol are known as statins.
These reduce the amount of cholesterol produced in the liver and increase the ability of the liver to remove LDL cholesterol from the blood.
The recommended cholesterol level should be less than 5mmol/l.
Lifestyle changes play a major role in reducing cholesterol.
Saturated fat causes cholesterol levels especially LDL to increase, so a reduction of fat intake is crucial.
Smoking increases the ability of LDL cholesterol to get into an individual's cells and cause damage.
Regular exercise increases HDL levels and reduces LDL levels.
Physical exercise Poor lifestyle and diet are not the only causes for raised cholesterol.
One in 500 people have a condition known as familial hyperlipidaemia (FH).
FH is when the way LDL cholesterol is removed from the blood is only half as effective as normal, which results in cholesterol levels almost doubling.
So in an adult, the average level is between 9 and 12 mmol/l.
Statin use would be recommended from an early age but the risk of heart disease remains high, and it is important that someone with FH does not smoke.
Surprisingly, 37% of deaths from CHD occuring below the age of 75 have been related to a lack of physical exercise.
The BHF states that seven out of ten people in the UK do not take enough exercise.
While the Government recommends 20-30 minutes of moderate physical activity five times a week.
Exercise not only helps to reduce cholesterol, it helps to reduce raised blood pressure, which is another major cause of CHD.
One in four people in the UK have high blood pressure and of those, around one third remain untreated, putting their health at risk.
Most sufferers have no symptoms but the effects are damaging.
It can cause the heart to become abnormally large and less efficient, which further increases the risk of a heart attack.
Target blood pressure for adults is 140/85.
Apart from medication, lifestyle risks play an important role in reducing readings.
Up to 18% of CHD deaths are associated with smoking.
In general, smokers have roughly twice as much chance of having a heart attack as people who do not.
This number increases substantially under the age of 50, where smokers are around ten times more likely to have a heart attack.
Smokers' hearts are often deprived of enough oxygen as carbon monoxide is carried round the body.
Nicotine stimulates the body to produce adrenaline, which makes the heart beat faster and raises blood pressure.
For a smoker who has raised blood pressure and cholesterol, the risk of developing CHD is around 30 times higher than a non-smoker with normal blood pressure and low cholesterol.
Joanne Braham is life and disability underwriter at Scottish Equitable Protect When the underwriter receives an application form where raised cholesterol is disclosed, a GP report will always be requested.
This is to check control and to see if the necessary lifestyle changes have been made.
In well controlled cases and with no other risk factors, the underwriter will look to offer standard rates for all benefits.
However, with the presence of other risk factors, especially for critical illness (CI) cover - where heart events such as coronary artery bypass graft and heart attack are defined conditions, it is likely the underwriter would be far more cautious and generally apply a small rating even if cholesterol control has been established.
It goes without saying that lifestyle risks come hand-in-hand, and in general, people who disclose raised cholesterol and/or blood pressure are smokers and are overweight with a body mass index of 25 or over.
In some cases a client may not have disclosed any risk factors, apart from a young family history.
Again we would be more concerned for CI cover and would normally obtain Scottish Equitable Protect's fasting lipid blood test, which measures the total cholesterol, LDL and HDL levels.
In a male, family history is very important and would always be considered.
For disability benefits such as income protection and waiver of premium, again the underwriter would use the same air of caution.
In cases where a client has multiplicative risks, an underwriter would consider declining disability benefits, as the probability of becoming unable to work would be higher than normal.
Sources: British Heart Foundation www.familydoctor.co.uk
www.betterhealthchannel.com
www.americanheart.org www.bbc.co.uk/news Underwriting implications
