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ECGs should be replaced: a newer cardiac marker does the job much better.

For more than half a century, the electrocardiogram has been a routine screening tool in life underwriting. By all rights, it should now be teetering on the brink of extinction.

What is fueling the demise of the venerable ECG? Several years ago, a novel cardiac marker dubbed NT-proBNP became available for risk appraisal. In the interim, its use has increased faster than any risk marker since the HIV test in the mid-1980s. Today, more than 80% of life insurers deploy NT-proBNP on some basis.

Unlike the ECG, which misses 50% of cases with heart disorders, NT-proBNP is virtually a flawless indicator of risk-significant cardiac disease. Even before obstructed coronary arteries, mal functioning heart valves, congenital cardiac defects, longstanding hypertension and other major cardiovascular ailments give off telltale symptoms, NT-proBNP levels begin rising insidiously. This happens because increased pressure in the heart chambers, and especially the left ventricle, is an inevitable consequence of all of these disorders.

As a rule of thumb, the greater the magnitude of heart "damage, the higher the NT-proBNP level. The medical literature is now replete with studies showing strong correlations between elevated NT-proBNP and increased mortality from cardiac as well as other circulatory system diseases.

Impressed by the link between elevated NT-proBNP and premature death, experts in clinical cardiology are now advising their peers to use this test to triage patients with known or suspected heart conditions.

The acid test for measuring the value of any underwriting tool is its protective value. This is determined by a so-called "cost/benefit study." One such study by a major insurer revealed that the return on investment per dollar spent on NT-proBNP dwarfed the payoff associated with the ECG. In fact, this study showed that NT-proBNP has a higher ROI than any other screening test used ha life underwriting.

The thresholds at which ECG screening is initiated have increased steadily over the last decade. In people under age 50, it is seldom required unless the amount of coverage is at least seven figures.

Nevertheless, the electrocardiogram has lingered as a staple in the assessment of older applicants largely for two reasons: its relatively low cost and ready access via paramedicals.

Why then is NT-proBNP destined to replace the electrocardiogram?

First, two NT-proBNP tests can be done for the price of one ECG.

Second, NT-proBNP is done in conjunction with the routine blood profile, which in turn is required on all applications where ECGs are currently ordered.

Additionally, NT-proBNP is 100% objective, whereas ECG analysis is time consuming and, by its nature, highly subjective. The rigors of doing an ECG are distinctly customer-unfriendly. And there is growing concern about the quality of ECGs performed by paramedical technicians. They are often poorly done and thus rendered difficult, if not impossible, to interpret properly.

Normal NT-proBNP readings are so favorable to insurability that underwriters often use them to offset debits assessed for such things as high blood pressure and elevated cholesterol.

The age of the electrocardiogram has come to an end. Its successor has a bright future.

Best's Review contributor Hank George is the principal of consulting and training firm Hank George Inc. He may be reached at
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Title Annotation:Insight
Author:George, Hank
Publication:Best's Review
Date:Sep 1, 2013
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