The simplification of EKG requirements in recent years is certainly well-documented and also well-appreciated. Brokers and agents, as well as company management, are always looking for ways to decrease acquisition costs and make the insurance process simpler. This has been no more evident than with EKGs and treadmill exams, where the age and amount requirements have become more liberal in requiring them less often.
One newer blood test, referenced often in previous Broker World columns, that has been making progress as both a screening and diagnostic test is the NT-proBNP.
BNP (B-type natriuretic peptide) is a substance secreted from the ventricles of the heart in response to excess stretching of the heart muscle cells. Looking at it a different way, BNP increases when heart failure develops or worsens and is associated with several conditions such as acute coronary syndrome and cardiac failure. If BNP is extremely accurate in picking up conditions that compromise the heart’s function, can a simple blood test replace EKGs and treadmill stress tests in underwriting?
First, let’s discuss what BNP is good at uncovering. BNP rises significantly in what is called a hemodynamically stressed myocardium, meaning a heart having trouble performing at its maximum efficiency. BNP level in blood rises when there is active ischemia—times when the heart is lacking oxygen and failing as an efficient pump and it correlates quite well with three vessel, or advanced, heart disease. BNP level is also very good in diagnosing pump failure in the elderly, whose activity is decreased but overt signs of impending heart failure may not be obvious in physical examination or even in an electrocardiogram at rest.
Like all tests, BNP has its shortcomings and cannot be expected to be a “one-result diagnoses all heart problems.” It doesn’t directly correlate well with ischemia on exercise—one of the most telling ways heart blockage or occlusion at stress manifests. It is not a predictor in and of itself for future cardiac intervention like bypass or angioplasty. It does not show heart valvular disease. In addition, BNP levels can be increased in smokers and obese individuals even though heart function is normal in some circumstances.
When should an EKG be used in underwriting in addition to a blood test? An EKG shows an abnormal heart rate—important in diagnosing many underlying disease abnormalities, whether lower or higher than normal. It shows abnormal heart rhythms, which can lead to morbidity and mortality even in the absence of occult heart failure. In many cases, it shows a previously undiagnosed heart attack, which is important in patient prognosis even when the heart has recovered and a BNP level may have fallen back to normal range. An EKG is a relatively simple test a paramedical can perform even at the point of exam, and doesn’t cause a lot of inconvenience in obtaining it.
The treadmill EKG is a little more labor intensive and likely requires an applicant to go to a facility or doctor’s office to have it performed. It is quite helpful in diagnosing heart ischemia or blockage and, in some cases, can assist in locating a blockage and diagnosing severity. A treadmill EKG can detect abnormal heart rhythms during stress or times of increased heart rate—important because people can die of heart disease in other ways than just heart blockage or cardiac failure. In the face of questionable symptoms of chest pain or shortness of breath, it is an important adjunct to diagnosis.
That being said, a treadmill EKG’s yield as just a screening tool in asymptomatic people hasn’t been cost effective nor has it been worth the inconvenience in obtaining it routinely. Therefore, most companies only require the test in certain narrow age bands and, in fact, may reserve the test for only smokers with high face amount policies (where the incidence of undiagnosed heart disease is much higher). Many of those who have heart disease have already had extensive heart testing as part of their regular medical care, which even further limits the need for stress testing by the insurer.
So what part do NT-proBNP and EKGs have in insurance medicine and underwriting? The BNP is certainly becoming an important underwriting resource in diagnosing heart failure, allowing it to be priced appropriately as a risk factor or obtaining best rate consideration when it is in the normal range.
EKGs certainly still have their place in the current system of cardiac evaluation and medical screening in underwriting—at least until perhaps another “magic bullet” blood test adds to the progress of diagnosis in medicine, both in clinical and insurance medicine.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.