Simon Taylor outlines the underwriting implications of coronary heart disease ' the most common cause of death in the UK
Coronary or ischaemic heart disease (CHD) is the most common cause of death in the UK. One in four men and one in six women die from the disease ' resulting in 125,000 deaths in the UK in 2000.
It is also the most common cause of premature death, with 24% and 13% of premature deaths in men and women due to CHD.
There are an estimated 66,000 heart attacks among men and 20,000 among women under the age of 65 in the UK every year. The incidence rate in men between the ages of 30 and 69 is about 600 per 100,000 and among women is 200 per 100,000. There are an estimated 450,000 men and 250,000 women under the age of 75 living in the UK who have angina.
Death rates vary across the UK with Scotland, Northern Ireland and the North of England having the highest rates. Meanwhile death rates for manual workers are 58% higher than non-manual workers.
CHD occurs when the coronary arteries are unable to supply sufficient blood to the heart muscle and is mainly due to progressive atherosclerosis, the furring up of the coronary arteries, or sudden thrombosis secondary to the rupture of a vulnerable plaque of atherosclerosis. This lack of blood supply is called ischaemia and when prolonged ischaemia occurs, death of part of the heart muscle takes place. This is called coronary thrombosis or myocardial infarction ' a heart attack.
Intermittent ischaemia can lead to the diagnosis of angina symptoms which can vary in severity and be brought on by exercise, cold weather, or in the worst cases even at rest.
Risk factors
There is no single cause of CHD, but many factors contribute to the development and rate of progression of the disease. Besides age and gender, cholesterol, smoking, diabetes, hypertension, family history and obesity are all important risk factors.
Cholesterol has emerged as one of the most important risk factors for CHD. Almost half of CHD deaths in both men and women are due to raised cholesterol levels, which is taken to be a cholesterol level above 5.2.
It is estimated that 10% of CHD deaths could be avoided if everyone had a cholesterol level below 6.5. Cholesterol comprises several different types and where the high density lipoprotein level (HDL) is greater than 1.0, this provides some protection against a high total cholesterol level where a HDL below 1.0 would increase the risk. For example, a total cholesterol level of 6.2 with a HDL of 2.0 would be preferable to a total cholesterol of 5.5 where the HDL was only 0.7.
The chances of a smoker suffering CHD is two to three times greater than a non-smoker and continued smoking after a coronary event increases the risk of future occurence. If the patient can stop smoking then after a year the risk of a future event reduces to about 50%. In 1998 28% of male sufferers and 26% of female sufferers were smokers.
Type two diabetes (non-insulin dependent) also increases the risk of CHD, with men having a two to four times and women a three to five times greater annual risk.
Diabetes also increases the incidence of other risk factors such as hypertension, raised cholesterol and so on. Type two diabetes affects 3% of adult men and women.
Around 14% of CHD deaths in men and 12% in women are due to hypertension (raised blood pressure). Estimates suggest that 6% of deaths could be avoided if the number of people with hypertension were reduced by 50%. The British Hypertension Society said in 1999 that treatment should be considered if blood pressure is over 140/90. However, of the 41% of men and 33% of women who have hypertension it is estimated that 70% to 80% of them are not on regular treatment.
Around 5% of CHD deaths in men and 6% in women are due to obesity. In England 17% of men and 21% of women are obese with 46% of men and 32% of women in the overweight category. The risk increases with age as at ages 16 to 24 , 26% and 27% of men and women are overweight or obese yet at age 55 this has increased to 76% and 68%.
Obesity is diagnosed when the body mass index (BMI) is over 30. This is calculated by dividing your weight in kilograms by your height in metres squared, for example 88 kgs and 1m 78cm would give a BMI of 28. Being overweight is described as having a BMI of 25 to 30 (see February issue of COVER).
Diagnosis
Diagnosis will be made based on a history of symptoms, chest pain and so on, and physical examinations including ECG, exercise ECG, cardiac enzyme tests are carried out if a heart attack is suspected. Other investigations can include an echocardiogram and perfusion or thallium scans.
Angiography has always been considered the most accurate method of determining the extent of any atherosclerosis (narrowing of the coronary arteries) and the number of vessels affected, although there is evidence that this method can underestimate the extent of the disease. A catheter is inserted in a vein in the leg and the coronary arteries are viewed. This allows the cardiologist to decide whether treatment should be conservative and medical, or interventional and involve surgery.
Treatment will either be medical or surgical depending on the extent of the disease and the severity of symptoms. Initial treatment where a heart attack has occurred will involve therapy to dissolve any clots that have formed to limit the death of heart muscle. Longer-term treatment will involve reducing the risk factors that led to the heart attack or angina symptoms, so beta blockers, blood pressure and cholesterol lowering medication may be introduced as well as advice to stop smoking, reduce weight and improve diet.
Treating CHD
Surgical treatment may be decided upon and as stated this will depend on the number of vessels affected and extent of the disease. If only one vessel is affected angioplasty may be performed where a balloon is inserted via a catheter and the affected narrowed part of the artery is widened as the balloon is inflated. Stents may also be inserted to prevent the artery narrowing again.
Coronary artery bypass grafting (CABG) has increased five-fold since 1980 and has doubled in the last 10 years. Around 28,000 operations are carried out each year in the UK, with a similar number of angioplasties also performed.
Interestingly the availability and incidence of CABG depends on which NHS district the patient lives in. For example, only six are carried out per 100,000 population in the Isle of Wight compared to 161 per 100,000 in Ealing.
Death rates from CHD have fallen by 40% in the last 10 years for adults under 65 years as medical and surgical treatment have improved and due to preventative screening and treatment being introduced for some of the risk factors ' especially cholesterol.
The number of cholesterol-lowering drugs prescribed has increased 14-fold in the last 10 years and the cost of these prescriptions in the first half of 2001 was £193m. CHD cost the healthcare system about £1.6bn in the UK in 1996 and costs the UK economy a total of £10bn a year.
On receipt of an application from someone who has suffered CHD, the underwriter will consider terms based on the age of the applicant, whether a heart attack has occurred or not and the absence or presence of other risk factors, such as current cholesterol and blood pressure levels, weight, smoking and whether angina symptoms, still occur. Terms will not usually be available until a full six months have passed since the heart attack or any surgery, such as CABG, and will depend on the area of the heart affected.
For example, six months since a single heart attack, basic ratings would be in the region of:
Under 40 Usually declined
41-44 +300/350%
45-49 +200/300%
50-59 +150/200%
60-69 +100/150%
Basic ratings for CABG would depend on how many vessels had been bypassed and the extent of disease, but would be in the region of:
Under 40 Usually declined
41-44 +150 to +300%
45-49 +100 to +250%
50-59 +75 to +200%
60-69 +50 to +150%
Terms would usually only be quoted for life cover. Additional benefits such as critical illness cover and sickness-related benefits would normally be declined.
Simon Taylor is a senior life and disability underwriter at Scottish Equitable Protect
