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Coronary Artery Disease: Advances Lead to Customized Underwriting

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One of the exciting new trends in risk selection is what could be called “customized underwriting,” the personalization of the risk appraisal process.

In customized underwriting, the attempt is, when possible, to make decisions based on the actual risk posed by the individual applicant rather than on broad, population-based guidelines.

One area where this type of underwriting is being increasingly used is in the evaluation of coronary artery disease.

Coronary disease has traditionally been viewed in black and white terms. Certain cholesterol levels were seen as good, while others were seen as bad. Arteriosclerosis was said to progress in a methodical way, gradually narrowing the coronary artery until it eventually became totally occluded. Lesions were not viewed as warranting concern until blood flow to the heart muscle was reduced. Diagnosis relied on demonstrating obstructive disease with the exercise stress test or cardiac catheterization.

In recent years, however, it has become clear is that the quality of the atherosclerotic coronary plaque is at least as important as the quantity of disease.

We now know that the severe blockages are not the ones that kill people. Rather, it is the innocent looking, minor obstruction–the so-called vulnerable plaque–that is the culprit. When this plaque ruptures, the artery is suddenly occluded by a blood clot and the individual has a heart attack.

This can happen even if the individual just passed a stress test with flying colors.

The task in underwriting is to find the individuals who are at higher risk of experiencing these types of events. With this in mind three key points have become clear.

First, the total amount of atherosclerotic plaque, not just the number of obstructive lesions, is important.

Second, inflammation is a key player in the cascade leading to a heart attack. Inflamed plaques are unstable and rupture at a greater rate.

Third, treatment of risk factors can stabilize vulnerable plaques and markedly reduce the risk of acute events.

Tests and therapies that address each of these areas have seen greater clinical use and are of increasing relevance to the risk selection process. These include electron beam CT (EBCT) scanning, highly sensitive C-reactive protein (hs CRP) measurement, and treatment with statin drugs.

EBCT, by detecting calcium deposition in the atherosclerotic plaque within the coronary vessel wall, provides the best available estimate of total disease burden. While it does not identify the vulnerable plaques specifically, it does seem to identify the vulnerable person, i.e., the ones at higher risk. It also helps personalize the risk factor assessment.

From a risk appraisal perspective, what is “high” for an individual in terms of cholesterol, for example, is a level that is producing more coronary plaque than normal. What is “high” in these terms may or may not correlate with thresholds drawn from population studies.

C-reactive protein is a non-specific indicator of inflammation, and its elevation has been consistently associated with increased event rates in individuals with coronary artery disease. While still investigational at this time, it appears likely that either this or some other measure of inflammation will play a key role subdividing the broad population of individuals with CAD into those at higher and lower risk for future events.

Finally, the use of the statin drugs to treat elevated lipid levels has clearly changed the course of the disease. Acute event rates can drop by 40% or more and do so within a few months of starting the medication. The effect appears to be due to stabilization of vulnerable plaques via a combination of both lipid lowering and reduction of inflammation. In response, underwriting guidelines are increasingly reflecting these findings and tailoring actions to likely outcomes.

In summary, insurers are beginning to heed the advice traditionally given to clinicians. That is, “dont treat the numbers, treat the patient.”

In this case, evidence-based advances in understanding of the mechanism of coronary disease are allowing a more customized approach to risk selection, one that ties actions more closely than ever before to factors specific to the applicant in question.

Cliff Titcomb, MD, is vice president and chief medical director for ING Re, a Fort Wayne, Ind., individual life and health, and group life, accident and health reinsurance business of ING North America Insurance Corporation and part of ING Group. His e-mail is [email protected].

Reproduced from National Underwriter Life & Health/Financial Services Edition, November 18, 2002. Copyright 2002 by The National Underwriter Company in the serial publication. All rights reserved.Copyright in this article as an independent work may be held by the author.


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