Early repolarization ECG pattern--still a benign finding?

A life insurance applicant with an early repolarization pattern on his electrocardiogram (ECG) previously assessed as a standard risk, wishes to increase the amount of his coverage. The risk assessment implications of recent studies of early repolarization ECG patterns are reviewed.     

Giant negative T waves

Marked T wave inversion in a life insurance applicant's ECG may suggest high risk. Careful analysis of the ECG, an informative attending physician statement, and judicious use of additional testing allows the medical director to put this striking ECG abnormality in its proper context.     

Assessment for congenital long QT syndrome

A 29-year-old male presented for an evaluation of his risk for having congenital long QT syndrome. Despite being asymptomatic and having a normal QTc interval on the resting ECG, a suggestive family history was an indication for a thorough cardiac evaluation. A geneticist reviewed this workup and recommended against genetic testing. While up to 10% of affected carriers of a congenital long QT syndrome gene mutation can be asymptomatic with a normal QTc, consideration of all of the clinical factors allowed for further risk stratification. The evaluation of an ECG for the long QT syndrome includes calculating a corrected QT interval for the heart rate and assessing the T-waves for morphology associated with this syndrome.     

Myocardial infarction or technical artifact?

Misplacement of recording electrodes can generate misleading patterns on the standard 12-lead electrocardiogram (ECG). Some lead placement errors are easily recognizable, others are more difficult to detect and can be quite important in risk selection because the resulting changes in ECG morphology can mimic other conditions such as myocardial infarction. Therefore, identification of incorrectly performed ECGs is an important task for the medical director.     

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.     

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.     

Asymptomatic ST segment elevation

Asymptomatic ST segment elevation in a life insurance applicant's ECG raises several prognostically important possibilities such as myocardial infarction, pericarditis, Brugada syndrome and early repolarization. This ECG case study discusses the ECG features involved in the differential diagnosis.     

Are lending relationships beneficial or harmful for public credit guarantees? Evidence from Japan's Emergency Credit Guarantee Program

This paper examines the effectiveness of Japan's Emergency Credit Guarantee (ECG) Program set up during the financial turmoil following the failure of Lehman Brothers, in increasing credit availability and improving the ex-post performance of small businesses. In particular, using a unique firm–bank matched dataset, the paper examines whether lending relationships enhanced or dampened the effects of the ECG program. It is found that the ECG program significantly improved credit availability for firms using the program. However, when it was a relationship lender (main bank) that extended an ECG loan, the increased availability was partially, if not completely, offset by a decrease in non-ECG loans by the same bank. Further, propensity score matching estimations show that the ex-post performance of firms that received ECG loans from the main bank deteriorated more than that of firms that received non-ECG loans. We do not find such loan “substitution” or performance “deterioration” effects when a non-main bank extended ECG loans. Our findings suggest that close firm–bank relationships may have perverse effects on the efficacy of public credit guarantees.     

Poor R-wave progression

Poor R-wave progression is a common ECG pattern, which is often inconclusively interpreted by medical directors. Although this ECG pattern is commonly attributed to anterior myocardial infarction, it may also be caused by left bundle branch block, Wolff-Parkinson-White syndrome, right and left ventricular hypertrophy as well as by faulty ECG recording technique. Failure to make a definitive interpretation of this pattern may result in a delay or loss of business.     

Tall R wave in lead V1

Tall R waves in lead V1 present the life insurance company medical director with a diagnostic dilemma. This ECG pattern may be present in applicants with right bundle branch block, right ventricular hypertrophy, Wolff-Parkinson-White syndrome, posterior myocardial infarction, hypertrophic cardiomyopathy, muscular dystrophy, dextrocardia, misplaced precordial leads, as well as in normal individuals. This ECG case study discusses the ECG features involved in the differential diagnosis.     

Do small businesses adjust their capital structure? Evidence from the global financial crisis in Japan

We investigate the extent to which small businesses adjust their capital structures to target levels when their leverage increases substantially during a financial crisis. We examine Japan's Emergency Credit Guarantee (ECG) program during the 2008 global financial crisis. The increased leverage from the use of the ECG program during the crisis increased the probability of default. Additionally, small businesses adjusted their leverage ratios to the target range before the crisis. However, such adjustments were weak during and after the crisis, particularly for target firms in the ECG program.     

Left axis deviation

Left axis deviation is one of the most commonly encountered ECG abnormalities. Its presence should alert medical directors and underwriters to the possibility of underlying structural heart disease. Many of the causes of left axis deviation are apparent from the clinical findings. Left anterior fascicular block is one of the commonest causes of left axis deviation and has specific ECG criteria for its diagnosis.     

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.     

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.     

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.     

Does adding up of economic capital for market- and credit risk amount to conservative risk assessment?

There is a tradition in the banking industry of dividing risk into market risk and credit risk. Both categories are treated independently in the calculation of risk capital. But many financial positions depend simultaneously on both market risk and credit risk factors. In this case, an approximation of the portfolio value function separating value changes into a pure market risk plus pure credit risk component can result not only in an overestimation, but also in an underestimation of risk. We discuss this compounding effect in the context of foreign currency loans and argue that a separate calculation of economic capital for market risk and for credit risk may significantly underestimate true risk.     

基于风险-收益均衡控制的信用风险管理研究

风险—收益均衡是风险和收益同时实现最优的一个状态。风险优化是风险—收益均衡控制的具体过程。我国商业银行正处于财务目标和风险目标约束同时增强的风险管理制度转型阶段,制度转型的方向是改革单向风险管理制度,建立风险—收益均衡控制的信用风险管理制度。本文以《巴塞尔新资本协议》框架下的信用风险计量、经济资本和风险优化理论为指导,探讨在缺乏有效资本管理制度条件下,如何建立基于风险—收益均衡控制的过渡性信用风险管理模式,重点研究了RAROC风险管理思想和风险控制技术,并展开了实证分析。RAROC修正模型与过渡方案具有可行性,并有很强的信贷政策指向意义。     

Communication of risk assessment information to risk managers

This article describes the results of a two-phase study of risk communication between risk assessors and risk managers (including policy makers). The first phase consisted of telephone interviews with 30 air quality risk managers from all levels (18 from local, state, and regional offices, and 12 from national offices). The second phase involved a focus group with 11 senior EPA risk managers representing a broad range of EPA national offices and programmes. The two-hour focus group elicited responses from the risk managers to specific examples of videotaped risk information created by agency risk assessors. The risk managers indicated their interests in hearing both qualitative and quantitative information about risk and emphasized the importance of discussing other information about the decision context. Similar responses to the videotaped risk information were elicited from a class of students at the Harvard School of Public Health. This exploratory work suggests that to better inform risk managers, risk assessors must also appreciate and present the broader context of the decision, and they must convey how uncertainties and weaknesses in the assessment may influence stakeholder perceptions of risk and the effectiveness of different risk management options. Further research on how to communicate risk information to risk managers is recommended.     

Risk reporting: A study of risk disclosures in the annual reports of UK companies

The concepts of risk and risk management have received considerable attention lately, but this has yet to be reflected in empirical research examining firms’ risk reporting practices. This study seeks to address this gap in the literature and explores risk disclosures within a sample of 79 UK company annual reports using content analysis. A significant association is found between the number of risk disclosures and company size. Similarly a significant association is found between the number of risk disclosures and level of environmental risk as measured by Innovest EcoValue`21™ Ratings. However, no association is found between the number of risk disclosures and five other measures of risk: gearing ratio, asset cover, quiscore, book to market value of equity and beta factor. The paper also discusses the nature of the risk disclosures made by the sample companies specifically examining their time orientation, whether they are monetarily quantified and if good or bad risk news is disclosed. It was uncommon to find monetary assessments of risk information, but companies did exhibit a willingness to disclose forward-looking risk information. Overall the dominance of statements of general risk management policy and a lack of coherence in the risk narratives implies that a risk information gap exists and consequently stakeholders are unable to adequately assess the risk profile of a company.     

金融体系风险分担机制比较研究

金融体系风险分担机制分为金融市场的横向风险分担机制与银行中介的跨期风险分担机制。横向风险分担机制在规避非系统性风险方面占有优势,而跨期风险分担在规避系统性风险方面占有优势。两种风险分担机制是一种互补关系,适度结合才能更好地发挥金融体系的风险分担功能。在经济全球化的过程中,金融体系的两种风险分担机制都会受到损害,对经济稳定形成威胁,因此我们在金融改革和对外开放的过程中应该从风险分担的视角来进行金融体系设计,保持一个健全的风险分担机制。