Summary:

A large body of empirical evidence implicates workplace (particularly psychosocial) factors in the etiology of HTN and CVD. The theoretical constructs of how workplace factors affect the development of HTN and CVD, together with a rich store of mediating biological mechanisms by which social factors such as work stress are perceived and processed by the central nervous system, and can lead to cardio-deleterious changes, provide convergent validation that workplace stressors play an important role in the development of these CVD. However, unlike other sub-specialties, e.g. pulmonary medicine, in which knowledge about contributory occupational factors is well incorporated into clinical assessment and management, the field of cardiology has not yet incorporated knowledge about the role of workplace stressors on CVD. Clinicians have not been trained to take an occupational CV history, except as it relates to levels of physical exertion. Consequently, recognition is often lacking of the patient's exposure to a potentially adverse work environment (e.g. with high levels of job strain, effort reward imbalance, threat avoidant vigilance, shift work, long work hours, high noise levels, specific activities such as city mass transit- or long route truck driving). The importance of assessing CV function of these patients during work is not adequately appreciated. Thus, e.g. in contradistinction to well-known entities such as white-coat hypertension, the prognostically important finding of Occult Workplace Hypertension (elevated work AmBP with normal casual clinic BP) is just beginning to attract clinical attention. The potential for Holter monitoring to detect signs of autonomic imbalance, myocardial ischemia and cardiac electrical instability has not yet been integrated with an assessment of work activity. In particular, knowledge about circadian and septadian patterns of cardiac event occurrence could be better utilized to optimize work-schedules, together with medication regimen, for at-risk patients.
The clinician is often called upon to judge the CV work fitness of patients. Given the rising prevalence of working conditions that are potentially harmful to the CV system, this type of judgment will be ever more frequently sought, and ever more difficult to render. Furthermore, the very jobs in which public safety could be compromised with the occurrence of an acute cardiac event are often those in which exposure to workplace psychosocial risk factors is the greatest. In current clinical practice, once such patients have suffered cardiac events, one of two tragic scenarios often ensues: either premature disability retirement or return to the job with little or no change in work conditions, thus placing the patient, as well as society, at risk. The clinician's challenge is to offer the cardiac patient a style of life and of work that protects both his and her health and right to be productive. This requires understanding the work environment, in addition to a functional evaluation of the patient. Not only does the clinician need to be in a position to formulate protective measures at the workplace for his or her patients, but also to see these implemented in practice.

Occupational Cardiology can be envisaged as a link between primary cardiology and occupational and preventive medicine. It would represent a "paradigm shift" by making the workplace an integral consideration for cardiologic practice. Some areas that would need to be developed include:

· Further refining our knowledge of the role of workplace stressors in the etiology of hypertension and various manifestations of CVD, and dissemination of that information to clinicians

· Furthering clinical acumen in taking and interpreting an occupational history, as it relates to the cardiovascular system.

· Formulating, testing and validating algorithms and guidelines for the diagnosis and management of work-related hypertension and relevant cardiovascular diseases and pre-pathologic conditions,

· Promoting cooperation with other key participants such as occupational health psychologists and other occupational health specialists and epidemiologists, as well as labor and management,

· Further empowering the physician to formulate and implement changes to help create a "heart healthy" workplace, and

· Developing educational programs to integrate these skills and knowledge into specialty and continuing education training in cardiology.

· Providing needed legislative and policy support for these goals.

Overall, the further development of Occupational Cardiology is a vehicle for achieving the goal of moving from epidemiological evidence to prevention-oriented clinical practice.

Basic Readings :

(1) Belkic K, Schnall P, Occupational Cardiology, www.workhealth.org, 2000.

(2) Belkic K, Schnall P, Landsbergis P, Schwartz JE, Gerber LM, Baker D, Pickering TG. Hypertension at the Workplace-An occult disease? The need for work site surveillance. Theorell T (ed.) Biological Stress Mechanisms. Advances in Psychosomatic Medicine, Basel, Karger, 2001; 22: 116-138.

(3) Schnall PS, Pieper C, Schwartz JE, Karasek RA, Schlussel Y, Devereux RB, Ganau A, Alderman M, Warren K, Pickering T. The relationship between "job strain", workplace diastolic blood pressure, and left ventricular mass index. Results of a case-control study. JAMA. 1990; 263: 1929-1935