Comparison of the mortality between ischemia and frequent premature ventricular contractions on an exercise test

Ischemia on an exercise test (ET) is a known risk factor for cardiovascular mortality. However, the magnitude of risk of frequent premature ventricular contractions (PVCs) on ET is often overlooked. This analysis reveals that the quantitative additional mortality risk on ET presented by frequent PVCs is similar to ischemia.     

"Complicated" right bundle branch block

Isolated right bundle branch block is generally regarded as a benign finding in the absence of underlying structural heart disease. The presence of "electrocardiographically-complicated" right bundle branch block should alert the medical director to occult heart disease, which might impact on long-term survival.     

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.     

Coronary heart disease and life insurance

Coronary heart disease morbidity and mortality are dynamic issues. Outcomes from medical and surgical treatments are having dramatic effects. For the life insurer it is vital to follow closely the changing history of the disease.     

Ankle/arm blood pressure index: an insurance perspective

Recent studies conclude that the ankle/arm blood pressure index (AAI) is a useful clinical tool for refining cardiovascular risk classification in the elderly. A reduction in the AAI to 0.9 or less is associated with increased risk for both coronary heart disease and total cardiovascular disease morbidity and mortality, as well as all-cause mortality. This relationship persists after adjusting for traditional risk factors and known cardiovascular disease. AAI will appear more common in attending physician's statements, prompting a need to educate underwriters about this technology. AAI may be of particular interest to insurers dealing in the elderly market, to those with strong physician examiner systems, and in markets where blood or urine tests are not commonly used in underwriting.     

Kawasaki disease

Kawasaki disease is currently the leading cause of acquired heart disease in children in the United States and Japan. The case of an 18-year-old insurance applicant is used to review the pathogenesis, complications, treatment and prognostic implications of this disorder.     

Modeling disease elimination

The effect of the elimination of mortality from heart disease and cancer was modelled mathematically to allow for the effect of other competing causes of death. The model allows for potential dependence between heart disease or cancer and other causes of death by using cupola functions, which analyse the individual risk itself and the dependence structure between causes of death by using correlation coefficients. As the strength of these risk associations is unknown, the study investigated both full positive and negative dependence and compared this with no dependence. Depending upon the degree and type of correlation assumed, positive or negative, the life expectancy at birth is increased by between 3 months and 6.5 years if cancer mortality was eliminated, and between 5 months and 7.5 years in the case of heart disease. In addition, estimates of these effects on life insurance premia can be made with the greatest reduction for women with the elimination of cancer mortality. These figures provide a range of improvements in life expectancy and the consequent effect on life insurance risk premium rates which elimination of either of these important diseases would produce.     

Ventricular septal defects in adults

Ventricular septal defects are one of the most common congenital cardiac malformations and can be associated with many types of congenital and acquired heart disease.     

Cardiac catheterization: beyond stenoses

Coronary angiography remains the gold standard for the clinical assessment of atherosclerotic heart disease. Findings other than percent stenosis can often enhance mortality risk determinations.     

Right-sided endocarditis

Right-sided endocarditis is uncommon and usually involves the tricuspid valve. It occurs primarily in intravenous drug uses, and patients having pacemakers, central lines, or congenital heart disease.     

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.     

Book reviews

Valid measures of how people view risks due to combinations of hazards are needed. 320 adult smokers responded to four vignettes in which hypothetical men were described as having high or low levels of (1) smoking and (2) either (a) blood cholesterol or (b) family history of CHD (coronary heart disease). Ratings of the risk of a heart attack were made using one of three different rating scales: (a) nine‐point, (b) 101‐point, and (c) unbounded. The nine‐point scale yielded a strong sub‐additive interaction, the 101‐point scale yielded a weak sub‐additive interaction, and the unbounded scale yielded a weak synergistic interaction. Although respondents preferred the nine‐point scale, evidence from this and other studies suggest that scales with nine points or fewer should not be used to assess perceptions of risks due to multiple hazards.     

How does managed care do it?

Integrating the health services and insurance industries, as health maintenance organizations (HMOs) do, could lower expenditure by reducing either the quantity of services or unit price or both. We compare the treatment of heart disease in HMOs and traditional insurance plans using two datasets from Massachusetts. The nature of these health problems should minimize selection. HMOs have 30% to 40% lower expenditures than traditional plans. Both actual treatments and health outcomes differ little; virtually all the difference in spending comes from lower unit prices. Managed care may yield substantial increases in measured productivity relative to traditional insurance.     

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.     

Enacting evidence into clinical practice: the case of coronary heart disease

NICE evidence and National Service Frameworks may be increasingly legitimate, according to our research on the implementation of evidence-based medicine within British cardiac services. However, different professional conceptions of evidence still limited its diffusion, implementation of evidence-based medicine needed to be locally negotiated, and coronary heart disease ‘collaborative’ networks played a limited role in our case study.     

The future of therapeutics in the north

Health-care systems occupy from 6% up to 15% of developed countries' GDPs. Therapeutics, particularly hospital care, occupy the bulk of these expenditures, despite their focus on dealing with disease after it arises. In the 21st century health-care systems will focus on health gains. Therapeutics will have broadened to encompass prevention and treatment, and will be focused on each individual's unique biological, psychological and social needs. Major killers, most particularly heart disease and cancer, will be far more preventable or curable, because of changes in therapeutic paradigms to more holistic approaches as well as important biomedical breakthroughs. There are a variety of negative possibilities, including continued preeminence of the medical model, growing costs, increased inequality in access, and greater poverty and social disintegration. The movement to therapeutics more focused on health gains will be accelerated by a variety of trends, particularly the development by communities in the USA and many other countries of shared visions that guide the evolution of health care in these directions.     

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.     

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.     

Mortality analysis of complete right and left bundle branch block in a selected community population

A twenty year follow up of a selected, community population with complete right and left bundle branch block is reviewed by comparative mortality analysis. In this population, where cases and controls were free of hypertension and heart disease at entry, the presence of complete right bundle branch block does not have excess mortality. Complete left bundle branch block exhibits excess total and cardiac mortality.     

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.