Transcript All good things must come to an end.

NT-ProBNP – What It Means In Underwriting And
How A Normal Value Can Help You!!
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N-Terminal Pro Brain-Type Natriuretic Peptide
(NT-ProBNP)
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First discovered in the 1950’s and really began to be
studied closely in the1980’s. Insurance laboratories
made available as part of SMAC in 2005.
• A complex amino acid substance produced within the
muscle cells of the heart.
• “Stress and strain” on the heart cells increase
productions of BNP.
• Helps relax the muscle cells of the heart and vessels
to lower the workload of the heart.
• BNP increases circulation to the kidneys and allows
them to unload more salt and fluid from the body.
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Natriuretic Peptides (NP’s)
ANP: Atrial Natriuretic Peptide
BNP: The physiologically active portion
NT-ProBNP: Inactive but more stable and easier to
measure in the laboratory ~ longer half-life,
making it more stable for laboratory testing
(stable 18 times longer at room temperature).
ExamOne Normal Range: <125 pg/ml
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Used clinically to diagnose and follow up the treatment of
congestive heart failure (CHF).
But also can be elevated with:
• Unstable coronary disease or myocardial infarctions
(heart attacks)
• Excessive thickening of the heart muscle (hypertrophy)
• Cardiac arrhythmias (atrial fibrillation)
• Valvular heart disease
• Pulmonary hypertension and emboli (blood clots)
• Chronic renal failure
• Chronic obstructive lung disease (COPD)
• CHF
From the life insurance standpoint…it also helps predict
higher cardiac and all-cause mortality!
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Lincoln Benefit Life
We use NT-ProBNP because it is stable longer for the
laboratory and has the same predictive value as
BNP.
We began screening in August, 2008 at age 65 and
older, for face values of $100,000 and above.
We offer potential credits for favorable results!
We use age-adjusted levels and set the cut offs fairly
high to avoid those in the “gray zone”.
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We review NT-ProBNP results in-depth for our
business on a periodic basis:
• Prior to initiating NT-ProBNP screening as part of
a cost/benefit analysis
• Shortly after implementing or screening in
August, 2008
• And periodically since
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Each time the results were very similar:
• Over 1/3 of screenings would be eligible for credits if
needed!
• Less then 10% of screenings require any type of adverse
underwriting action based on our current policies.
- Approximately half of these already have known
ratable cardiac conditions.
- Approximately a third of these would require
declination.
- Average age 75, average face between $800k to
$1M
• 80% of BNP’s done “for cause” came back in the
favorable range!
- Average age 55 and face of $3.4M
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Tests that assess cardiac ventricular function and
enlargement, coronary artery status, heart valve function
and cardiac rhythms are used to evaluate many of the
conditions that BNP screens for:
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Echocardiograms
Nuclear stress tests or stress echocardiograms
Coronary angiograms with left ventriculogram
Cardiac CT, MRI and PET scans
Holter monitors
If the underwriter has this type of current information
available to them for review, it can be very helpful in
assessing the significance of an elevated screening BNP
level or in cases where the BNP requirement is not
available.
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Fun Facts!
• Does the time of collection matter? No, not at all.
• Does posture or heart rate at the time of collection
significantly affect levels? No.
• Is NT-ProBNP affected by any cardiovascular drugs? Yes.
ACE inhibitors can raise it and beta-blockers can lower it.
• Does NT-ProBNP increase with age? Yes, very gradual until
age 65 and over.
• Is NT-ProBNP higher in women than men? Yes, minimally,
though.
• Does NT-ProBNP elevate during an exercise stress test? No.
• Is NT-ProBNP affected by weight? Yes, it is generally higher
in non-obese as compared to obese individuals.
• Is the impact due to weight significant? No.
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NT- ProBNP ~ How a normal value can HELP
You! (Tell me how!)
• A favorable NT-ProBNP result may allow an
improved offer in those cases where there is a
ratable cardiac history .
• Excellent point of reference for the underwriter
when reviewing cardiac cases where recent
cardiac testing has not been completed.
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REAL LIFE CASES
Pertinent case information:
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Male age 66
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Quoted Standard
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Attorney - Income $200k
Medical history:
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Per application, only history is rotator cuff
surgery
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Medications include daily aspirin and
Cardizem
(note what this is for)
These are hypothetical cases developed for discussion purposes only. Any similarities to real cases
submitted to Lincoln Benefit Life is coincidental. Underwriting opinions and rating suggestions are
based on pertinent factors of each individual case and not necessarily applicable to similar cases.
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Exam
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6’ 0” 184 pounds BP 122/80, Pulse 70
Smokes 1 cigar per month while playing golf
Same history on the exam as on the
application, but states the Cardizem is
taken for prophylaxis
EKG showed atrial fibrillation
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APS review
History of CAD, 1992 coronary spasm with no
significant fixed CAD
• Mitral annular calcification
• Paroxsymal Atrial Fibrillation
• Deverticulosis
• Stable pulmonary nodules
Tentative T2 subject to review of labs.
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Labs Slide showing NT-ProBNP at 1,332!
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Recommendation was to decline due to the
elevation of the initial NT-ProBNP but was
later issued after a repeat NT-ProBNP came
back normal.
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Final case disposition:
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Case was issued and placed based on the
new NT-ProBNP result without any
additional cardiac workup completed.
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Applicant died 18 months later from a
CVA thought to be related to the atrial
fibrillation.
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Review of key points and lessons of the case:
• The NT-ProBNP result will go back to normal,
even to levels one might consider to be
exceptional, after a cardiac event.
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Positive Consequence
Recent Favorable BNP Case Examples
• Case #1: This is a 77 year old male applicant that had an
abnormality on this insurance EKG. No history of underlying cardiac
disease. A favorable NT-ProBNP level on his insurance lab allowed
the underwriter to go from a low substandard offer to a standard
offer.
• Case #2: This is a 75 year old female applicant who was at a low
substandard rating for a history of Parkinson’s disease and mildmoderate obstructive coronary disease. Her screening NT-ProBNP
returned favorably and allowed the underwriter to improve the offer.
• Case #3: A 69 year old male applicant with a history of glucose
intolerance, hypertension and hyperlipidemia. He was potentially
low substandard rating but with favorable Healthy Credits
considerations, and a favorable NT-ProBNP level he qualified for a
Standard offer.
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QUESTIONS?
2013 Allstate Insurance Company
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