Increased QRS voltage in the limb leads

Increased QRS voltage accompanied by repolarization abnormalities in a life insurance applicant's electrocardiogram should alert the medical director to the possibility of left ventricular hypertrophy. If confirmed, left ventricular hypertrophy or increased left ventricular mass is a strong independent risk factor for future cardiac events and all cause mortality. The use of the electrocardiogram to diagnose left ventricular hypertrophy can be helpful, but there are limitations that need to be considered. This ECG case study illustrates some of the pitfalls in the electrocardiographic diagnosis of left ventricular hypertrophy.     

Subtle ECG changes--a mortality risk?

Population studies have consistently reported the increased risk of coronary heart disease mortality and sudden death in subjects with resting electrocardiogram evidence of unambiguous ST depression or T wave abnormalities. However, more subtle variations in normal electrocardiographic findings may also provide predictive and prognostic information. This case study illustrates the potential risk selection implications of such changes.     

Short PR interval

A short PR interval may be associated with an otherwise normal electrocardiogram or a myriad of bizarre electrocardiographic abnormalities. Clinically, the individual may be asymptomatic or experience a variety of complex arrhythmias, which may be disabling and rarely cause sudden death. In life insurance applicants, it is important to recognize these abnormalities and to assess their risk appropriately.     

Bradycardia in a former professional athlete

A mild bradycardia is noted in the electrocardiogram of a former professional hockey player applying for life insurance. The electrocardiographic differential diagnosis and prognostic implications are discussed.     

The challenge of inferior Q waves

The presence of unexpected Q waves in an applicant's electrocardiogram poses a diagnostic dilemma for the medical director. On the one hand, the Q waves may be the remnants of a previously unsuspected "silent" myocardial infarction. Conversely, unexpected Q waves may represent a normal or positional variant, or an important noncoronary type of heart disease. This case study illustrates some of the pitfalls in interpreting applicants' electrocardiograms containing Q waves in the inferior leads.     

Q waves--does depth matter?

Deep narrow Q waves in an electrocardiogram may be significant and should suggest several possible diagnoses. By considering the leads where they are observed, the presence of additional ECG abnormalities, the applicant's age and any relevant clinical information, one can considerably narrow the diagnostic possibilities.     

Right atrial abnormality

Occasionally, a prominent P wave is encountered in a life insurance applicant's electrocardiogram. Prominent P waves may be normal variants or alert the medical director to prognostically significant structural heart or pulmonary disease. This case study reviews the commonly used criteria for the ECG pattern of right atrial abnormality and some of the pitfalls associated with its use.     

Second-degree AV block

Second-degree AV block includes a variety of conduction patterns of variable prognostic significance. Careful analysis of the pattern of PR and R-R intervals, the QRS axis and duration, as well as the presence or absence of structural heart disease should allow the medical director to assess the applicant's risk for life insurance.     

Screening potential elderly preferred markers: exploratory analysis of Cardiovascular Health Study (CHS) data

The Cardiovascular Health Study (CHS) analyzes risk factors for coronary heart disease and stroke in people age 65 and older. Since CHS is designed to comprehensively study cardiovascular risk factors in an elderly population, it provides a unique opportunity to study the association of risk factors with mortality, as well as morbidity risk. With the growth of the elderly as population and life insurance market segments, the need to more precisely stratify mortality within a standard risk group of the elderly has grown as well. This exploratory analysis assesses medical factors that could be used to improve mortality risk stratification within a "standard" mortality population, using the CHS public use data set. Participants with a personal history of cardiovascular disease, diabetes, or major electrocardiographic abnormalities were excluded from the analysis in order to mimic a standard life insurance selection process. Then, Cox proportional hazards regression was used to study 10 medical risk factors. This model suggested that forced vital capacity >80% predicted, serum creatinine <1.5 mg/dL (133 mcmol/L), hemoglobin >11 g/dL (110 g/L), and serum albumin >3.5 mg/L (35 mmol/ L) are significantly associated (p = 0.05) with favorable mortality. C-reactive protein <1 mg/L is associated with favorable mortality at borderline significance levels (p = 0.09). On the other hand, a family history of cardiovascular disease (MI and/or stroke) and low BMI (<26 kg/m2) are associated with unfavorable mortality in the analysis. Total to HDL cholesterol ratio of <6, presence of supine systolic blood pressure < or = 140 mmHg, and the presence of minor rest electrocardiographic findings were not statistically significant factors in the multivariate model. Further assessment of the predictive value of the "significant" medical factors identified is required in insured lives.     

Positive computer-generated exercise electrocardiogram

The use of computerized averaging of the electrocardiogram (ECG) during stress testing has facilitated the removal of motion artifacts and baseline shifts. However, this process can introduce errors, which may not be appreciated by medical directors. Such errors can lead to significant ST depression in the absence of coronary artery disease. Such false-positive tests may lead to anxiety in the applicant, delays in accepting the application and unnecessary additional testing. This case study illustrates a common pitfall associated with using only a computer-generated exercise ECG for risk assessment of a life insurance applicant.     

Nonsustained wide QRS tachycardia during an exercise ECG stress test

The evaluation of a nonsustained wide QRS tachycardia in a life insurance applicant's exercise test presents a special challenge to the medical director because of the unpredictable and potentially lethal nature of these arrhythmias. Ventricular tachycardia accounts for up to 80% of wide QRS tachycardias in unselected populations and more than 95% of cases with a prior myocardial infarction. Malignant ventricular arrhythmias usually occur in the presence of significant structural heart disease. In this setting, ventricular arrhythmias carry a high risk of sudden cardiac death. Less commonly, ventricular tachycardia occurs in hearts that appear normal. In many such cases, however, the heart is in fact not normal, but rather has less visible abnormalities including derangements of cardiac ion channels or structural proteins. In these individuals, ventricular arrhythmias also carry a high risk of sudden cardiac death. There are, however, some ventricular tachycardia syndromes which occur in normal hearts that have a more benign prognosis.     

Diastolic dysfunction of the left ventricle. A review of the physiology, causes, diagnosis, treatment and implications

Diastolic dysfunction of the left ventricle frequently occurs in people with left ventricular hypertrophy and coronary artery disease. It is a common cause of congestive heart failure, especially in the elderly. The mechanism of diastolic dysfunction, its causes, diagnosis and treatment, are reviewed. These are important factors to a Medical Director who must assess the results of non-invasive studies. Alerted by the possibility of diastolic dysfunction, the Medical Director can be more sensitive to other signs and symptoms that may represent early signs of congestive heart failure or ischemia.     

Frequent premature ventricular contractions

Premature ventricular contractions (PVCs) are considered normal in many circumstances but can act as markers to other cardiac disease such as cardiomyopathy and ischemic heart disease. This case is presented to illustrate frequent PVCs as a marker for serious heart disease.     

Update on coronary artery calcium imaging

This update of coronary calcium imaging discusses methods of detecting and measuring coronary artery calcium and their correlation to coronary artery disease risk. The value of EBCT to traditional non-invasive cardiovascular tests is compared. A negative EBCT test makes the presence of atherosclerotic plaque, including unstable plaque, very unlikely. Negative EBCT may be consistent with low risk of a cardiovascular event over the next 2-5 years. Conversely, positive EBCT confirms the presence of a coronary plaque. The greater the amount of calcium, the greater the likelihood of occlusive disease, but there is a not a 1:1 relationship and findings may not be site specific. A high calcium score may be consistent with moderate to high risk of cardiovascular event within the next 2-5 years. Limitations and cautions concerning the general use of EBCT for screening are discussed.     

Markedly elevated gamma-glutamyltransferase

Gamma-glutamyltransferase (GGT) is a highly sensitive but poorly specific liver enzyme commonly used to detect hepatobiliary disease and possible alcohol abuse. Isolated elevations of this enzyme may be due to biochemical anomalies rather than the presence of pathology.     

Utilizing NT-proBNP in the selection of risks for life insurance

Brain natriuretic peptide (BNP) is a counter-regulatory hormone produced mainly by ventricular myocardium. Early research studies were performed to ascertain its value in the diagnosis of congestive heart failure in acute care settings. Subsequent studies have explored its utility in screening for asymptomatic left ventricular dysfunction in the community, determining prognosis in coronary artery disease, appropriate timing of surgery in valve disorders, and in evaluating many other cardiac diseases. This review summarizes the current status of medical literature, introduces a new test to the insurance industry.     

中国食品与非食品间的价格传导机制：理论和实证分析

本文对食品价格向非食品价格传导机制进行了理论上的分析,提出了成本推动、结构性推动和通胀预期三种传导途径,并建立了一个以食品通胀率和非食品通胀率为变量的向量自回归模型和脉冲响应函数对二者间的传导途径进行实证检验。结果显示：食品价格与非食品价格的传递作用是存在的,食品价格的上涨会对非食品价格造成同向的冲击．并且这种冲击具有稳定的持续效应。另外．我国食品通胀率比非食品通胀率波动性强,如果二者之间传导机制通畅．食品领域的通胀会对非食品领域的通胀水平带来巨大冲击,引发全面通胀的风险。因此,货币政策的制定不应剔除食品价格因素,我国CPI指数中的食品权重应谨慎下调。     

Low amplitude P, QRS and T wave pattern in lead I--the "isoelectric lead I sign"

An applicant's electrocardiogram contains a low amplitude P, QRS and T wave pattern in lead I. The diagnostic and prognostic implications of this ECG pattern are discussed.     

人民币汇率变动对我国物价传导效应的分析

本文对汇率传导理论及其效应进行了简要回顾,并在国内外学者研究的基础上,对2005年汇改以来汇率变动对我国价格的传递效应进行实证分析。实证结果表明,汇率变动对国内价格指数存在一定的传递效应,但作用较小,以人民币升值对抗物价上涨并不可行。     

"Flat line" in a limb lead

A life insurance applicant's electrocardiogram shows a flat line in one of the standard leads and new Q waves in the inferior leads. The clinical and risk assessment implications are reviewed.