Be Still My Beating Heart

    Atrial fibrillation (AF) is the most common chronic arrhythmia, and its incidence rises over age. Nearly 10 percent of the population is affected by AF by the age of 80, and it presents with very severe cardiac conditions (heart failure) as well as reversible ones which have less permanent consequence (thyrotoxicosis).

    Atrial fibrillation is often declined by life insurers, but newer research and study shows that while not usually standard, many AF cases can be insured at moderate ratings.

    Atrial fibrillation is a condition in which the heart loses its dominant pacemaker. Instead of a steady paced rhythm, which speeds up or slows down at a regular rate, many pacemakers in the heart compete for primary status. As a result, the heart rate can become rapid and irregular. Blood that is not pumped forcefully from the heart can stand and coagulate in the chambers and, as a result, AF is one of the most common causes of stroke. In fact, 15 percent of strokes in the United States can be attributed to AF.

    There are many ways atrial fibrillation can cause problems. Blood pressure can drop suddenly and severely when pumping capacity of the heart is affected. So can myocardial ischemia (lack of oxygen to heart tissue); rapid heart rates causing cardiac dysfunction; and, of course, stroke. AF is associated with an increase in mortality from 1.3 to 2 times expected in those affected with it. How it is dealt with depends on the cause and the degree of control of the arrhythmia.

    When atrial fibrillation occurs as a new finding on an insurance exam, it may be postponed pending an evaluation of the cause. Heart pump failure is a particularly ominous sign. So are advanced pulmonary disease, congestive heart failure, and stroke or heart attack history. Some reversible causes are alcohol excess/bingeing (“holiday heart”), medication excess, and inflammation of the sac surrounding the heart by a virus (pericarditis). Once the cause is determined not to be life threatening in and of itself, attention is paid to the management of the arrhythmia and treatment of the underlying condition.

    Previously, it was thought that atrial fibrillation was a lethal rhythm that should be converted to normal sinus rhythm whenever possible. This often involved electrical shocks to the heart (cardioversion) or large doses of antiarrhythmic medications that often had significant side effects. However, newer studies show that control of the heart rate may be just as important and equally effective.

    Studies published in the New England Journal of Medicine comparing  rhythm control versus cardioversion showed no increase in mortality, no overall difference in quality of life, and no overall difference in stroke. Anticoagulation (keeping the blood thinner to avoid blood clot formation) was found to have a significant positive effect, however, in many subsets of patients.

    When atrial fibrillation has a one-time cause, such as thyroid disease, infection or mild alcohol use, and that problem is addressed, those who return to normal rhythm can be offered standard insurance. In those who have atrial fibrillation where cardiac disease is mild, there is no true alcohol criticism, and there is good physician follow-up, a mild to moderate rating can be considered. Those whose underlying conditions are cause for concern in and of themselves will likely be declined.

    A “restless” heart may not always be an uninsurable case.

    MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life.

    Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021.

    Goldstone can be reached by ­telephone at 949-943-2310. Emaill: