Do you remember the game Operations? You know the one where you carefully operate on Sam without setting off the buzzer? Remember the excitement of seeing all the ailments to cure, some easier than others. But that dare devil in you always went for the really hard ones! As you get close to saving your patient Sam, one of two things happen 1) SUCCESS you got the ailment, you cured Sam or 2) The failing sounds of the buzzer goes off (along with your dreams of being a surgeon).
Okay maybe that’s a bit dramatic, but as underwriters we have a similar experience when we first open a file. Every case is comparable to Sam on the operating table - it’s our job to identify ailments and some are always going to be harder than others. One of the more challenging diseases is definitely Coronary Artery Disease (CAD). Let’s just say in the world of Operations it would earn you 1000 points!
So how can you successfully identify CAD as an underwriter? Below I walk you through the key steps and to bring back some memories - I approach it like a game of Operations.
Before you start the game you need to have a general idea of how to play – so I’ll begin with an explanation of CAD. Coronary Artery Disease is the build-up of plaque formation within the arteries. This plaque builds up and eventually the blood flow is restricted. However, most people do not realize that CAD actually commences during the teenage years. It can either be chronic, slowly progressing over time leading to the limitation of blood supply. Or, it could be also be acute, with the rupture of a plaque formation of a thrombus or blood clot.
Read the instructions
Underwriting any cardiac history, including CAD, has its challenges. That’s why it’s so important to get familiar with the disease (think of it as reading the game instructions). So what are the rules when it comes to CAD. Here is my list of ‘must be aware of’ when dealing with CAD cases.
- The anatomy and physiology of the heart with specific reference to Coronary Artery Disease
- Diseases and disorders of the coronary arteries
- Treatment required to control the symptoms
- Understand how the disease progresses
- Know the potential complications of the disease which can worsen the mortality
- Be able to read and interpret an angiogram and the information required to classify the risk
- Evaluate all evidence and identify impact on mortality
I know it seems like a daunting list but don't stress I’m going to help you uncover the key pieces of evidence to look for when dealing with cardiac cases.
Set up the board game
You’ve read the instructions and are familiar with the game, now it is time to set up. Seeing the whole board game with all the ailments is like opening a case with a ton of medical history to review. It can definitely be overwhelming, especially with concerning cardiac history in the picture. But by taking one piece of evidence at a time and looking at the big picture you’ll become more and more confident with your underwriting decisions for these cases.
Understand the anatomy
In the case of CAD, you’ll be focusing on the anatomy of the heart. As we know there are two main coronary arteries: the Left Main Coronary Artery (LMCA) and the Right Coronary Artery (RCA). The LMCA directs oxygenated blood to the Left Anterior Descending (LAD) and Left circumflex arteries. These arteries then supply oxygenated blood to the ventricles and left atrium. The RCA supplies oxygenated blood to the walls of the ventricles and the right atrium. This information is key because knowing how the heart is supposed to function with help you identify abnormalities. Now it is time to start the game.
Let the game begin: Look for the dominant artery
The dominant artery in most people is the RCA. (No, the dominant artery does not refer to the size or even the importance of the artery). It refers to the artery that supplies the posterior diaphragmatic portion of the septum and the left ventricle.
Therefore, a red flag should go up for the underwriter when it is stated that the dominant artery is not the RCA.
Other key factors to keep in mind:
- When the oxygen supply is low, damage to the myocardium begins (ischemia)
- Ischemia can be symptomatic or asymptomatic
- Increase in heart rate, exercise, stress, hypertension all increase the oxygen demand
- The risk factors (discussed next) speed the progression of this disease
- The myocardium can recover with less severe ischemia. However, there can be permanent damage to the myocardium with severe ischemia
Now let’s explore the risk factors of Coronary Artery Disease
Think of this as figuring out when the buzzer is most and least likely to go off on the board game. The risk factors for CAD are:
- high LDL and low HDL
- sedentary lifestyle
- smoking and family history
Keep these in mind while looking at a case, especially the modifiable ones (smoking, sedentary lifestyle, lipids, build). Chances are their family physician has advised them to stop or modify these risk factors.
Congrats you are halfway through the game of Operations! You know how to play the game (what to look for with CAD cases) and you are well on your way to saving Sam (confidently underwriting CAD). So now that you know what to look for how can you actually identify CAD? That will come in part two of my series! Stay tuned for it!