Coronary Artery Disease: Advances Lead to Customized Underwriting

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.