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Case Clinic:
Pulmonary Hypertension

Munich Re’s medical experts respond to challenging underwriting scenarios

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    August 2024

    This series presents individual medical cases that feature challenging conditions, uncommon diseases, or an unusual presentation of symptoms. Below, we summarize a case, explain our research and analysis, and suggest an underwriting recommendation. Munich Re’s team of global medical directors routinely conducts rigorous analyses of the latest medical advances so that primary insurers and society alike can benefit from evidence-informed risk assessments. It is our hope that exploring compelling cases will foster a greater understanding of medical research and awareness of new medical innovations and emerging risks while ultimately expanding insurability.

    Case: Pulmonary Hypertension with Obstructive Sleep Apnea

    The Munich Re medical team investigated the insurability of a 50-year-old applicant with obesity who, two years prior to application, was evaluated for complaints of lethargy and a possible heart murmur. An echocardiogram reported mildly elevated pulmonary artery pressure. A subsequent sleep study documented severe obstructive sleep apnea (OSA), for which continuous positive airway pressure (CPAP) was prescribed. A follow-up sleep study showed an excellent response to CPAP. Clinical records noted that lethargy had diminished and compliance with CPAP was good. A repeat echocardiogram showed a return of pulmonary artery pressure to normal levels.

    Munich Re medical's response

    What is pulmonary hypertension?

    • Pulmonary hypertension (PH) refers to elevation of pressure in the  pulmonary arteries. Etiology is typically divided into primary and secondary causes. Primary PH is rare and the prognosis is generally poor. Secondary PH is much more common, and presents as a complication of many different disorders, such as chronic lung disease (e.g., COPD), heart disease (e.g., left heart failure), or hypoxic pulmonary vasoconstriction (e.g., OSA). 

    How common is pulmonary hypertension, and what are some mortality and morbidity concerns?

    • Primary pulmonary hypertension is rare, and the prognosis is poor.
    • The prevalence of secondary pulmonary hypertension is difficult to assess because confirmatory testing is not always performed in patients with predisposing conditions. However, it is estimated that it may be present in up to 30% of those with moderate to severe OSA[1]
    • Morbidity and mortality will vary, depending on the underlying cause of secondary PH. For example, drowsiness and accidents may complicate OSA, whereas right sided heart failure may develop if an underlying cause cannot be treated effectively, e.g., progressive pulmonary fibrosis.
    • Pulmonary hypertension in the setting of OSA may be improved after successful treatment. In this instance, there is no extra mortality or morbidity.

    Final recommendation

    The Munich Re medical team was satisfied that the diagnosis of secondary pulmonary hypertension was explained by OSA. Follow-up showed good compliance with CPAP, improvement in clinical symptoms, and resolution of pulmonary hypertension. Because of this favorable profile, we were able to make a standard offer.
    Contact the author
    John F. White III
    Dr. John F. White III
    2nd VP & Medical Director
    Munich Re Life US
    Email
    jwhite2@munichre.com
    Gina Guzman
    Dr. Gina Guzman
    Vice President & Chief Medical Director
    Munich Re Life US
    Email
    gguzman@munichre.com
    Bradley Heltemes
    Dr. Bradley Heltemes
    Vice President & Medical Director of R&D
    Munich Re Life US
    Email
    bheltemes@munichre.com
    Tim Meagher
    Dr. Tim Meagher
    Vice President & Medical Director
    Munich Re, Canada (Life)
    Email
    tmeagher@munichre.ca
    The information provided herein is for general information purposes only and should not be relied upon as professional advice. Munich Re, and its employees, directors, officers, and representatives do not warrant, represent or guarantee the accuracy, completeness, or currency of any of the information provided herein and accept no liability whatsoever arising in any way from the use of or reliance on such information, including liability for direct, indirect, special, incidental or consequential damages. © 2024 Munich American Reassurance Company. All rights reserved.
    References
    1. UpToDate; Chapter: Pulmonary hypertension due to lung disease and/or hypoxemia (group 3 pulmonary hypertension): Treatment and prognosis; authors Robert P Frantz, MD, Hilary M DuBrock, MD; updated Jan 16, 2024