Director of underwriting & claims at VitalityLife puts coronary artery bypass surgery under the microscope
Coronary heart disease (CHD) is a leading cause of death both in the UK and worldwide. It generally affects more men than women, although from the age of 50 the chances of developing the condition are similar for both sexes. Apart from angina pectoris, (chest pain), the main symptoms of CHD are heart attacks and heart failure. It is also sometimes referred to as ischaemic heart disease (IHD).
One of the most common treatments for CHD is Coronary Artery Bypass Grafting (CABG) or 'Cabbage' as it's sometimes colloquially known. The definition of CABG is that of "open-heart surgery in which a section of a blood vessel is grafted from the aorta to the coronary artery to bypass the blocked section of the coronary artery and improve the blood supply to the heart." The grafts used generally come from one of the arteries that supplies blood to the chest wall (the Internal Mammary or Thoracic Artery) or from a vein in the leg (the Saphenous Vein). The number of grafts needed will depend on the severity of the disease and the number of coronary blood vessels affected by blockages.
This has become such a common and well-known procedure that it's tempting to see it in relative terms as a low-risk, routine procedure. However, that has not always been the case and it's informative to look back at its history and origins and indeed, the part it played in the development of serious illness cover.
Origins of CHD Diagnosis
Coronary heart disease was described as far back as 1876, by Adam Hammer, an American physician. He postulated that angina and heart attacks could be the consequence of the interruption of blood supply by blocked coronary arteries. He subsequently confirmed his theory by autopsy. Later in the 19th century heart surgery was performed infrequently and with poor results.
A British surgeon, Stephen Paget, observed in 1896, that 'Surgery of the heart has probably reached the limit set by nature to all surgery; no new method and no new discovery can overcome the natural difficulties that attend a wound of the heart'. That same year however, a German surgeon, Ludwig Rehn, performed the first successful repair of a stab wound of the heart and arguably, the era of cardiac surgery had begun.
The modern era of cardiac surgery
In the 1930s, cardiac surgery became more feasible with the development of the heart-lung machine which enabled cardio-pulmonary bypass. The first procedure to use an implanted artery to treat CHD occurred in 1950 but it was not until the 1960s that great advances were made in coronary artery surgery. The first actual CABG is credited to Robert Goetz, an American surgeon, in 1961. Although the patient died 13 months later, an autopsy showed that the graft was still patent (unobstructed). The first successful surgery using the internal mammary artery was performed in 1964.
However, the father of what we see today as the standardised procedure for CABG was Dr Rene Favolaro, an Argentinian surgeon who pioneered the use of the saphenous vein graft. He performed his first coronary bypass operation in May 1967 and his surgical techniques came to form the basis of routine and safe coronary bypass surgery. He demonstrated that CABG was reproducible, lifesaving, and life-changing therapy for coronary heart disease. Even though surgical techniques and procedures continue to evolve, such minimally invasive techniques using thoracotomy, Favolaro's influence endures to this day.
The number of CABG operations carried out annually in the UK is just under 20,000 although other interventions such as angioplasty are much higher. Worldwide, it's estimated that over 800,000 CABG procedures are performed each year. The success of CABG surgery was one of the driving forces behind the development of serious illness cover in South Africa in the 1980s, owing to the costs of treatment and the limitations of private medical insurance.
UK CHD Facts & Figures
In the UK, heart and circulatory diseases cause more than a quarter of all deaths, that's nearly 170,000 deaths each year - an average of 460 deaths each day or one every three minutes. Around 7.4 million people are living with heart and circulatory disease, more than twice as many as cancer and Alzheimer's disease combined. Coronary heart disease (CHD) is the most common type of heart and circulatory disease and the most common cause of heart attack. In the UK there are more than 100,000 hospital admissions each year due to heart attacks: that's one every five minutes. Around 1.4 million people alive in the UK today have survived a heart attack. (BHF UK Factsheet April 2019).
Quality of life following a heart attack or heart surgery will depend on the severity of the episode. For example, if there is a significant amount of heart muscle damage, the pumping ability of the heart is impaired, leading to a condition known as heart failure which has symptoms of breathlessness and tiredness. On the other hand, those who engage with good cardiac rehabilitation and lifestyle modification (diet, weight control, exercise, smoking cessation) can go on to enjoy a normal quality of life.
As the surgical techniques for CABG have evolved, so too has the assessment of the risks posed by CABG procedures. It was once held, that CABG merely alleviated the symptoms of coronary artery disease but did not necessarily herald improved life expectancy. Consequently, the underwriting of CABG risks tended to reflect that view. However, that has changed and, in most cases, terms will be available for most applicants who have undergone a CABG.
Underwriters will segment risks according to the severity of the underlying coronary disease, including the number of affected arteries and the importance of those arteries. For example, the involvement of the left main coronary, the largest major coronary artery is a less favourable feature.
The age of the applicant is also very important; the younger the age at which the procedure is carried out or history of a prior heart attack, the heavier will be any extra premium. Depending on current cardiac health and age, extra premiums in the order of 2.5 times normal at younger ages or even 1.5 times at older ages are possible. In order to obtain the best terms, underwriters will want to see the most up to date assessment of cardiac health. Terms are unlikely to be available for serious illness or disability cover.
John Downes is Director of Underwriting & Claims at VitalityLife
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