Stents, bypass surgery and ejection fraction in a heart file

A cardiology report can read like a foreign language: "LAD 70 percent stenosis, DES placed, LVEF 55 percent." Each of those fragments tells an underwriter something specific about how much of the heart's blood supply was affected, how it was fixed, and how well the heart pumps. If you have had a heart procedure, or if your records mention a measurement you do not understand, knowing the vocabulary helps you answer the application accurately and gather the right documents.

This post explains the terms in everyday language and describes why each one matters to a risk assessment. It is general information, not medical advice, and it does not predict any insurer's decision. Your cardiologist is the right person to explain what your own results mean for your health.

The basic picture: a pump and its pipes

The heart is a muscle that pumps blood. It has its own set of blood vessels, the coronary arteries, that feed the heart muscle. Over years, fatty deposits called plaque can narrow those arteries. This is coronary artery disease. When a narrowing limits blood flow, a person may feel chest pain or pressure with effort, called angina. If an artery becomes blocked suddenly, part of the heart muscle can be damaged. That event is a myocardial infarction, commonly called a heart attack.

Two separate questions run through almost every heart file. The first is about the pipes: how many arteries are narrowed, how severely, and how they were treated. The second is about the pump: how well the heart muscle contracts. Stents and bypass surgery address the pipes. Ejection fraction measures the pump. The underwriter needs both.

Procedures you may see in the records

Angiogram or catheterization

In a cardiac catheterization, a doctor threads a thin tube through an artery, often in the wrist or groin, to the heart and injects dye so X-ray images show the coronary arteries. The image set is an angiogram. The resulting report often lists each major artery, with a percentage of narrowing. It is the most direct picture of the pipes, so underwriters value the catheterization report highly.

Angioplasty and stents

If an artery is significantly narrowed, the doctor may open it with a small balloon (angioplasty) and leave behind a stent, a small mesh tube that props the artery open. Stents come in a few types. A bare metal stent is just the mesh. A drug-eluting stent is coated with medication that slows the artery from re-narrowing. A report may abbreviate them, and you may see "DES" and "BMS."

For underwriting, a stent is a marker that disease was significant enough to treat. The questions that follow are practical.

• How many stents, and in which arteries? One stent in one artery is a different story from several.
• Why was it placed: during a heart attack, for angina, or after an abnormal test? A stent placed during a heart attack is usually read in light of the damage the heart attack caused.
• How long ago? More time without symptoms or further procedures is generally viewed more favorably.
• Has the stented artery stayed open, and have other arteries stayed stable on follow-up?
• Is the person on the recommended medications and following up with the cardiologist?

Coronary artery bypass graft (CABG)

Bypass surgery reroutes blood around blocked arteries using healthy vessels taken from elsewhere in the body, often a leg vein or an artery from the chest or arm. Surgeons describe it by the number of grafts: single, double, triple or more. The number is shorthand for how many arteries needed bypassing and, indirectly, how extensive the disease was.

Underwriters read bypass surgery as a sign of more advanced coronary disease than a single stent. That is not a judgment about outcome. Many people do well for years after bypass. It reflects the typical risk level in a group of people with similar histories. Key questions are how many grafts, how long ago, whether the heart pumps normally afterward, whether symptoms have returned, and whether further testing since the surgery has been clean.

Other cardiac procedures that may appear

• Stress test: an exam in which the heart is monitored during exercise or a medication-induced workload to see whether blood flow falls short. A normal result is reassuring; an abnormal one often leads to a catheterization. Reports describe how long you exercised and whether symptoms or ECG changes occurred.
• Echocardiogram: an ultrasound of the heart, covered below because it often produces the ejection fraction.
• Coronary calcium scan: a CT scan that measures calcium in the coronary arteries and returns a score.
• ECG or EKG: a tracing of the heart's electrical activity.
• Valve procedures or heart rhythm treatments, which are separate topics from stents and bypass but can appear in the same file. The post on atrial fibrillation, blood thinners and life insurance applications addresses one rhythm condition.

Ejection fraction: the pump measurement

Ejection fraction (EF) is the percentage of blood the heart's main pumping chamber, the left ventricle, pushes out with each beat. The heart never empties completely, so the number is always below 100 percent. Roughly speaking, a higher EF means a stronger squeeze and a lower EF means a weaker one. In many clinics, the mid-50s or higher is described as normal, but each lab prints its own reference range on the report, and your doctor interprets the result in context.

EF is usually measured with an echocardiogram. It can also come from nuclear imaging, cardiac MRI or a catheterization. Different methods give slightly different values, and the same method can vary a little from day to day, so a single number is an estimate rather than a precise measurement.

Why it matters to underwriting: EF is among the strongest indicators in the file of how well the heart is working now. A reduced EF suggests the heart muscle has been weakened, whether by a prior heart attack or by another cause, and it is associated with higher risk of future problems such as heart failure. A normal EF after a stent or bypass is a favorable finding. An EF that has improved after treatment tells a hopeful story, and the underwriter will want the trend if more than one value exists.

The report may use terms like "LVEF" (left ventricular ejection fraction), "preserved" (generally normal), "mildly reduced," "moderately reduced" or "severely reduced." Keep the actual number and the date, and make sure you know which test produced it.

The terms side by side

How the pieces combine in practice

Underwriters rarely rely on any single item. They put together a picture, usually in these steps.

1. Establish the diagnosis and the event. Was there a heart attack, or were the stents placed for angina or an abnormal test?
2. Measure the extent. How many arteries, how severe, how many stents or grafts?
3. Check the pump. What is the EF now, and what was it earlier?
4. Look at the time and the course. How long since the last event, and has there been any new symptom, test or procedure?
5. Check the surrounding risk factors. Cholesterol, blood pressure, diabetes, weight and smoking are read alongside. The guides on life insurance with high cholesterol and life insurance with high blood pressure describe how those are viewed.
6. Check treatment and follow-up. Medications taken as prescribed and regular cardiology visits are positives.

Here is a hypothetical contrast. Carla, 58, had a single drug-eluting stent placed for angina six years ago. Her EF on the latest echocardiogram is in the normal range, she has had no symptoms since, her stress test two years ago was normal, her blood pressure and cholesterol are controlled, and she does not smoke. Dev, 58, had a heart attack and then triple bypass surgery four years ago. His EF is reduced, though it has improved since surgery, and he has had one episode of chest pain since. An underwriter will see two quite different files. Carla's may be considered for coverage with a rating or even closer to standard at some companies. Dev's may produce a more heavily rated offer, a postponement or a decline at some companies. Neither is a promise. The point is that "has a stent" and "has had bypass" are not the same as "uninsurable," and the details drive the outcome.

Decoding the opening fragment

Return to the invented line at the top: "LAD 70 percent stenosis, DES placed, LVEF 55 percent." Read slowly, it says the following.

• LAD is the left anterior descending artery, one of the main coronary arteries. Reports often abbreviate artery names, so ask your doctor's office for a key if an abbreviation is unfamiliar.
• 70 percent stenosis means the artery's channel was narrowed by about 70 percent at one spot.
• DES placed means a drug-eluting stent was put in that spot.
• LVEF 55 percent is the left ventricular ejection fraction, a pumping measure the reporting lab may describe as normal or near normal.

An underwriter reading those few words would still have unanswered questions: when was this, was it during a heart attack, are other arteries narrowed, and what do the follow-up tests show? That is why a file with a single line is rarely enough and why the records request often follows.

Medications that travel with a heart file

After a stent or bypass, most people are prescribed a group of medications: something to reduce clotting, often for a defined period after a stent; a cholesterol-lowering drug; a drug to control blood pressure or heart rate; and sometimes others. The underwriter sees these in the prescription history and in the doctor's notes. Their presence is expected and is not a mark against you. What the underwriter looks for is consistency: refills on schedule, and any stoppages explained. If a doctor stopped a drug, note the date and the reason. If you stopped one on your own, say so honestly, since the refill history will show it. The post on cholesterol, statins and life insurance: your questions answered covers one of these drugs in depth.

If you have had symptoms or a test but no procedure

Not every heart file includes a stent or bypass. Many people have a stress test or a scan that prompted a conversation and a medication plan but no procedure. Underwriters read those files too. A normal test is usually a favorable item. An abnormal test followed by medical management is read in light of how severe it was and how the person has done since. Do not assume that having no procedure means nothing needs to be reported. The application asks about tests, symptoms and diagnoses, not only procedures.

Documents to gather before you apply

Ask your cardiologist's office or your hospital's records department for copies of the following, and review them yourself before submitting an application.

• Cardiology office notes from the last two or three visits, including the current medication list.
• The catheterization or angiogram report, which names the arteries and the narrowing.
• The procedure or operative report for any stent placement or bypass.
• The discharge summary from any hospital stay for a heart event.
• The most recent echocardiogram report, with the ejection fraction and date, and earlier ones for comparison.
• The most recent stress test report, if one has been done.
• Recent lab work, including cholesterol and blood sugar, and blood pressure readings.
• A list of medications with start dates. The underwriter will compare it with the prescription history, as described in the guide on how life insurance underwriting works.

If your records are scattered, the post on build a medical history worksheet before you apply for life insurance provides a worksheet, and the post on recent surgery or a hospital stay: when to apply covers the first weeks after a procedure.

An underwriter who is missing a record will usually ask your doctor for an attending physician statement. Having the key reports yourself can shorten the process and lets you check for errors.

Questions you may be asked on the application

Expect questions along these lines, and answer them from your records rather than memory.

• Have you ever been diagnosed with or treated for coronary artery disease, heart attack, angina or heart failure?
• Have you had any heart procedure, such as angioplasty, stent placement or bypass surgery? When?
• Have you had an echocardiogram, stress test or catheterization in the last several years, and what were the results?
• Are you currently taking medication for your heart, blood pressure or cholesterol?
• Have you had chest pain, shortness of breath or fainting in the last several years?

If you do not know a result, say so and name the provider, instead of guessing that it was normal.

What happens next

After the underwriter reviews the file, possible outcomes include an offer at a standard or rated class, a postponement until more time has passed, or a decline. If you are turned down, the guide on Declined for life insurance? What to do next explains the next steps, including how to ask the reason and how to improve the file over time. A broker who works with heart conditions can compare companies' guidelines. For questions about your health, your cardiologist is the right source. For complaints about the handling of an application, your state insurance department can help.

Key takeaways

• Heart files answer two questions: the condition of the arteries (stents, bypass, angiogram findings) and the strength of the pump (ejection fraction).
• A stent and a bypass are different signals; the count, location, reason and time since the procedure matter more than the label.
• Ejection fraction is an estimate that varies by method; keep the actual number, date and test type, and the trend if there is more than one reading.
• Gather the catheterization report, procedure report, latest echocardiogram, stress test, office notes and medication list before you apply.
• If you do not know a result, say so and name the provider; never guess that a test was normal.