Mark Preston examines heart valve diseases and outlines how they can affect applications for life and critical illness cover
There are four valves in the heart, two on the left side, which are known as the mitral valve and aortic valve and two on the right called the ricuspid valve and pulmonary valve. Valvular heart disease can be described as any fault or abnormality of one or more of the valves and is characterised by stenosis, which is the narrowing of the valve, and regurgitation whereby blood flows in the wrong direction between chambers. The majority of valvular heart disease affects the aortic and mitral valves.
Mitral valve prolapse
Mitral valve prolapse is found in between 6% and 20% of healthy people. Picture a set of saloon doors swinging open ' if one of the doors started to become larger or if the hinges of the doors were damaged the doors would not close properly.
This situation is similar to mitral valve prolapse. The mitral valve has its own set of 'gates' or 'flaps' that open to let blood flow from the upper left chamber to the lower left chamber. The flaps should then neatly close again. However, if a mitral valve prolapse occurs the two flaps cannot close properly and, as a result, blood can leak back towards the upper chamber and this is called mitral regurgitation.
Symptoms and investigations
Mitral valve prolapse is generally asymptomatic and symptoms may include dyspnoea, palpitations, fatigue, chest pain and panic attacks.
A physical examination is the first step towards making a diagnosis. The physician listens to the patient's heartbeat and mitral valve prolapse is detected by a distinctive heart murmur just after the ventricles contract.
The next diagnostic step is an electrocardiogram (ECG) which measures the heart's electrical activity. Where a physical examination and ECG indicate mitral valve prolapses, an echocardiogram is usually carried out to verify the diagnosis. This uses soundwaves to track the function and structure of the heart and can provide detailed information regarding the extent of the valve abnormality.
Prognosis
Most cases run a benign and often asymptomatic course, however, there may be progression to mitral regurgitation. It can lead to infective endocarditis and occasionally sudden death from ventricular arrhythmia, although this only occurs in less than 1% of cases.
Medical evidence
All cases require a GP's report. All hospital reports will also be requested by the underwriter, as this indicates the degree of valve abnormality. A medical examination is not a routine requirement, but there may well be instances where a mitral valve prolapse can be identified in a patient who is otherwise asymptomatic.
Ratings
l Life cover: if there are normal dimensions and no more than slight mitral regurgitation then the case is accepted at standard rates. If there is more than slight mitral regurgitation then the ratings are based on those for mitral regurgitation.
l Critical illness (CI): if dimensions are normal and there is no mitral regurgitation, then the case can be issued on standard terms. With slight regurgitation the age of the applicant is significant. If the client is younger than 30 the rating would be in the region of +100%, between 31-50 the rating is +50% and over 50 years of age standard rates can be considered. If heart valve/structural surgery is an insured condition it may well be necessary to exclude it for CI cover.
Mitral regurgitation
Description
This is also known as mitral incompetency or mitral insufficiency and, as stated above, it occurs if the flaps in the mitral valve do not close properly and blood leaks back towards the upper chamber.
Symptoms and investigations
Mitral regurgatation often asymptomatic even when severe. Symptoms include fatigue, dyspnoea and palpitations. The gold standard non-invasive test to diagnose the condition is an echocardiogram as this establishes the nature and severity of the diseased valve.
Prognosis
Slight mitral regurgitation will usually warrant little treatment except for taking antibiotics for dental, medical or surgical procedures.
Surgical repair or replacement of the valve is usually carried out once the disease has progressed. Survival after the valve replacement is variable and strongly related to the heart's functional condition at the time of surgery.
There are a number of possible complications following heart valve replacement, including heart failure-infarction. Compared with mitral replacement, the repair of the valve tissue (valvotomy) may offer a better prognosis.
Medical evidence
As for mitral valve prolapse the evidence required is a GP's report and a sight of all hospital reports so that the extent of the valve disease can be identified.
Ratings
l Life cover: If there has been no surgery and there is only light regurgitation, with no progression and structurally normal valves, underwriters will consider standard rates. For mild to moderate regurgitation, ratings can range from +50% to +300% with younger lives attracting higher ratings.
If there is severe regurgitation the application will be declined. Within six months of an operation, the application will be postponed. If the applicant has a valvotomy, underwriting would be as for mild mitral regurgitation. Or if there has been a valve replacement terms will range from +100% to 450%, again the younger clients attract the higher ratings. However, where there are complications, whether with or without surgery, then the ratings can be increased.
l Critical illness: terms for CI are only available if there has been no surgery and the degree of regurgitation is classed as mild. Terms are also only available if the client is over age 40. Where heart valve and structural surgery is an insured condition, it is likely to be excluded from CI.
Aortic Stenosis
Description
Aortic stenosis occurs when scarring narrows or obstructs the flow of blood through the aortic valve. The left ventricle has to work harder to pump blood through a narrowed aortic valve. This increase in the pressure level results in left ventricular hypertrophy together with left ventricular dysfunction and failure.
Symptoms and investigations
Symptoms do not appear until late in the course of the disease. These include angina and dyspnoea on exertion although palpitations, fatigue and visual disturbance are sometimes present in severe cases. Once again, as with all valvular disorders, the investigations will follow a similar pattern, for example an ECG and echocardiogram. A chest x-ray may also be performed and studies used to classify the left ventricular function.
Cardiac catheterisation is also used to confirm the echocardiogram results and are important to determine the degree of any associated coronary artery disease.
Prognosis
Symptomatic aortic stenosis carries a much lower survival rate than any other aortic or mitral valve lesion. Once symptoms appear survival is commonly five years or less. Sudden death due to arrhythmia or ischaemia is not uncommon in symptomatic disease and to a much lesser degree, in asymptomatic disease.
Unoperated severe disease has a poor prognosis as surgery is the only proven treatment for aortic stenosis. Once the disease has progressed to a severe degree, aortic valve replacement is the best treatment.
Medical evidence
As for mitral valve prolapse and mitral regurgitation.
Ratings
l Life cover: on cases where there has been no surgery and there is only slight regurgitation and no outflow obstruction or complications, a loading of 50% is applied for mild to moderate regurgitation. Again, younger lives will attract the higher ratings. Severe regurgitation will be declined.
If surgery had taken place cover would be postponed for six months. But a valvotomy would usually be declined. For valve replacement, terms would range from +50% to 350%, again the younger client attracting the higher ratings. If there are any complications, whether with or without surgery, then the ratings can be increased.
l Critical illness: all cases would be declined.
It is fair to say that while valvular disorders are complex, the underwriting and assessment follows a straightforward pattern. Underwriters are reliant on the client's GP or consultant to provide the right level of detail in order to make an accurate assessment of the risk.
The majority of cases can be underwritten without the need for a medical examination or further investigations. However, if information is not up to date and the level of cover or premium supports it, the life office may arrange an echocardiogram which will provide up to date information regarding the extent of the valvular disease.
Where an adviser has a client with a known family history of heart valve disease it is recommended they take advantage of any underwriting helpline made available by a life office. These lines are normally manned by experienced underwriters who will be able to give an indication of the likely terms, based on the evidence presented. They will only be able to confirm terms once an application and medical evidence have been received.
