Life insurance underwriting: What is a complete cardiac work up?
Partners Advantage Insurance Services
Unfortunately there is no single test that can provide a total assessment of the heart. The best coronary artery disease work ups typically include multiple tests that evaluate cardiac, rhythm, electrical conduction, wall motion, perfusion, coronary artery visualization and exercise capability. For this reason, an underwriter cannot advise “what a complete cardiac work up may consist of when determining a client’s cardiac health.” Only a physician can determine which combination of tests may best determine what is or isn’t happening inside of a client’s heart.
Often times, some aspect of a client’s cardiac health history is questionable. Perhaps there is history of a myocardial infarction (heart attack), an irregular heartbeat, angina (chest pain), shortness of breath, questionable valve function or plaque obstruction, heart enlargement or ventricular function (how efficiently the heart is pumping blood throughout the body). Abnormal diagnostic test results obtained by a carrier or found during a review of the applicant’s records may indicate that a client may have an increased risk of having a cardiac issue.
So, what do the different diagnostic tests tells us about the heart? While both the electrocardiogram and the echocardiogram are non-invasive and painless, they provide very different information regarding the heart.
An electrocardiogram, or EKG, is a very basic test to record the electrical activity of the heart during a short time interval. It is a snapshot of what the heart was doing at one particular point in time. An EKG can tell us that something isn’t quite right, but the test is too basic to tell anyone exactly what may be wrong. An irregular EKG can tell us that the heart may have been damaged due to a heart attack, that a heart block may exist or that heart disease may be an issue. It does not tell us how efficiently the heart and valves are functioning. Further testing often ultimately proves that the heart is fine.
An echocardiogram creates an image of the heart using sound waves. It shows the heart structure and how the chambers and valves in the heart are functioning and how blood is or isn’t flowing efficiently through the heart.
A Holter monitor test is a 24-hour test used to measure cardiac rhythm. This is a much broader picture of heart rhythm than is available from a resting EKG. Because the monitor is worn for a 24-hour timeframe, activities of daily living are completed and heart rate and rhythm changes may be evaluated as they occur throughout the day. However, the Holter Monitor will not provide any information regarding diseased coronary vessels, obstructions, etc.
An exercise stress test (treadmill test or graded exercise test) is a good measure of functional capacity of the heart during strenuous activity. Coronary artery disease may not show during a resting EKG, but will often reveal itself when the heart’s demand for oxygen increases with exercise. The heart may respond with rhythm and conductive disturbances, shortness of breath, jaw or arm pain or persistent ST segment depression (downward sloping results of at least 2 mm) in the heart rhythm. An adenosine stress test may be used to assess those unable to exercise on a treadmill or bicycle due to orthopedic conditions. But the results obtained are of the same value of those available from an exercise stress test.
A stress echocardiogram is a very good test to evaluate the structure of the heart. The echocardiogram allows the chamber sizes to be visualized and the wall thickness to be measured. Heart valves are visualized and assessed to determine if they are opening and closing correctly and left ventricular ejection fraction is calculated to tell us how efficient the ventricles are as pumps during various stages of exercise stress.
A perfusion test or a thallum test is used to compare blood flow in different areas of the myocardicum. It is used to evaluate critical obstruction, but does not identify minor areas of obstruction when plaque may be forming.
Ultrafast computed tomography, ultrafast CT, electron beam computed tomography: These tests identify and quantify the overall degree of calcification noted in the coronary circulation. However, they will not clearly detail the site specific degree of the obstruction in any particular artery, only the total calcification burden of that artery.
Cardiac cath, angiography or left ventriculography: These are the most widely used and measure of obstructive coronary artery lesions. Dye is injected into the arteries to visualize the distribution and severity of obstructive coronary lesions within the large and medium sized coronary arteries. Serial catheterizations can be used to reveal the rate of progression of CAD over time.
MUGA, radionuclide angiography and gated blood pool study involve injection radioactive isotopes into the heart. Wall motion and left ventricular ejection fraction is available. It provides some, but not all of the information that would be available with an echocardiogram.
Positron emission tomography (PET scan) uses radionuclide tracers to evaluate the metabolism of the myocardium and the availability of oxygen to the myocardium. It does determine obstructive coronary lesions, but is expensive and therefore not frequently used.
Cardiac magnetic resonance (CMR) is also expensive and rarely used, but can identify the presence of infarcted myocardium as well as the magnitude and extend of obstruction in the coronary arteries.
A complete cardiac work up could consist of one or of several of these tests in order to fully assess heart function and health.
Underwriters are not medical professionals and are unable to diagnose or recommend treatment options for any medical condition. Therefore, what is needed in order to determine cardiac health is traditionally determined by a client’s personal physician and reviewed under the guidance of a carrier’s medical director (a MD who works as a professional consultant for a life insurance company).