Assessing Elderly Heart Disease Risk
The prevalence of cardiovascular disease - hypertension, coronary heart disease, heart failure or stroke - increases with age. Often, multiple cardiac conditions coexist with other illnesses, and this makes risk assessments for applicants aged 70 and above extremely complex for underwriters.
With ageing comes a predictable increase in the likelihood of ischaemic heart disease (IHD). Less certain is how to manage stable angina in older people. In practice the best medical treatment for it is just as effective as interventional cardiology in preventing myocardial infarction and death.
Screening for IHD involves an electrocardiogram (ECG). In very old or frail people, practical considerations may limit using an exercise ECG but it’s an important test because the workload achieved has predictive value. In risk assessment, it’s important to know the impact of IHD on cardiac function and, if possible, the severity of the disease as revealed by the results of angiography or CT angiography.
IHD is a major trigger for heart failure in older people. Dilated cardiomyopathy, valvular heart disease and diabetes may contribute; heart failure itself can be a manifestation of systolic or diastolic dysfunction.
Abnormal heart function is detected using an echocardiogram to measure ejection fraction (EF). Heart failure with preserved systolic function (diastolic dysfunction) becomes more common with age. This makes it hard for underwriters to rely on an EF value to rule out its presence. While diastolic heart failure is difficult to diagnose, certain features of an echocardiogram and the results of blood tests such as proBNP may be helpful.
The electrical activity of the heart can also become compromised. Ageing is associated with a reduction of pacemaker cells leading to sinus node dysfunction. Other components of the heart’s conduction system may be affected, leading to various forms of heart block.
It’s not uncommon for the ECG of an older person to show a right or a left bundle branch block - an indication of defective impulse transmission. Either type may reflect underlying cardiac disease but a block can even occur in an apparently structurally normal heart. It can therefore be difficult to decide how much importance to assign to abnormalities like these, although right bundle branch block is generally considered more “benign.”
Atrial fibrillation (AF) is the chaotic heart rhythm associated with hypertensive and coronary heart disease, heart failure and valvular heart disease. AF has been shown to cause or aggravate left ventricular dysfunction. It is associated with cognitive decline and vascular dementia, even in patients on anticoagulation therapy. While AF has conventionally been viewed as a nuisance causing only minor problems, it’s now understood to contribute to cardiac and cerebrovascular morbidity as well as higher mortality from sudden cardiac death, heart failure and stroke.
As people work and live longer, underwriters will be faced with assessing life and disability applications from an increasing number of elderly people. In addition assessments must be made for the long term care (LTC) products that are becoming more relevant.
Older people often disclose multiple co-existing cardiac conditions and comorbidities. This means underwriters must critically assess many different conditions to evaluate the combined risk that they pose to morbidity and mortality.