Hypertension is common – 25 percent of adults in the world have it to some degree. About 90-95 percent is primary or “essential”, meaning the cause is not known or identifiable. This is usually what is seen in clinical practice and underwriting. The rest is secondary, and has a known cause, such as kidney or endocrine disease, sleep apnea, or pregnancy.
Hypertension is more common in men and at older ages, as well as in certain ethnic groups, geographic locations, and socioeconomic levels. Overall the prevalence in this country is increasing, from 24 percent in 1995 to 34 percent in 2006. The clinical ranges that define hypertension have evolved as researchers continue to find that even small sustained elevations of BP can cause problems in the long term.
Many people have hypertension and do not realize it. In fact, our insurance exam may be the first time it is detected. Hypertension can cause symptoms such as headaches, lightheadedness, and vertigo, but most of the time it is asymptomatic, giving rise to the moniker “The Silent Killer”. The evaluation of hypertension usually involves a history and physical exam, routine labs, urinalysis, electrocardiogram, and chest X-ray or echocardiogram. Serial monitoring and recording of BP is essential, because it is persistently elevated readings over time that defines this disorder. An isolated BP elevation is not diagnostic of hypertension, and does not necessarily warrant treatment.
Why is high blood pressure such a concern? Think of it as a condition putting undue stress and strain on the heart and the blood vessel walls. Over time, this causes injury to the heart, the arteries, and the organs they supply. Sustained high blood pressure is associated with the following complications:
The treatment of hypertension involves lifestyle changes, including weight loss, dietary modifications, smoking cessation, alcohol reduction, exercise, and stress management. But often these are not sufficient, and medication is required. Although drug treatment is very effective, more than one drug may be required to maintain satisfactory control of the blood pressure. Apart from age, BP is one of the most powerful predictors of mortality. Both systolic and diastolic BPs are independent risk factors. Even mild hypertension can shorten life expectancy, while proper control of BP can improve survival. The positive relationship between BP and mortality is a continuum, with higher readings conferring higher risk. In assessing the BP, several key factors are considered:
Applicant 1 is a healthy 48-year old executive who had her insurance exam performed towards the end of an usually busy day. Her BP was noted to be elevated at 150/100. Follow-up with her physician showed a repeat BP of 116/72, consistent with other BP measurements on multiple prior office visits. This applicant can be Preferred Plus.
Applicant 2 is a 56-year old truck driver who has been treated for hypertension for the past 10 years. His BP on exam was 154/94. Review of his medical records indicated that this BP was consistent with those checked by his physician on a semi-annual basis for the past several years. Compliance with medication has not always been ideal, but the applicant has never smoked nor been treated for any other medical conditions. This applicant would be a Standard risk.
Applicant 3 is a 62-year old retiree who smokes one pack of cigarettes per day. She has not seen a physician in many years, but her exam notes that she has been treated for hypertension and a stroke in the remote past. Her exam BP was 180/120, her ekg showed left ventricular hypertrophy, and her insurance labs revealed elevated blood glucose, HGA1C, cholesterol, creatinine, and nt-proBNP levels. This applicant would be declined.