a) Long route truck driver with occult workplace hypertension, myocardial ischemia and complex arrhythmias
b) Clerical worker exposed to job strain and ERI, with chest pain, hyperlipidemia, glucose intolerance and positive exercise stress test
c) Post-myocardial infarction in a factory worker exposed to job strain--return to work issues.
Practical Exercise/Instruction:
Summary:
The three remaining clinical cases will be reviewed, using the interactive approach described for Session 6.
a) Long route truck driver with occult workplace hypertension, myocardial ischemia and complex arrhythmias
This case will exemplify threat-avoidant vigilant work, with numerous exacerbating stressors leading to a heavy additive burden among an occupational group at very high risk for hypertension and CVD. The use of ambulatory monitoring in surveillance, to detect occult work-related CV abnormalities and to inform physician recommendation of workplace modification as a possible therapeutic modality, is underscored. Trigger mechanisms of sudden cardiac death and considerations of public safety in relation to professional drivers are discussed.
b) Clerical worker exposed to job strain and ERI, with chest pain, hyperlipidemia, glucose intolerance and positive exercise stress test
The stressors that arise from the human-computer interaction, to which clerical workers are exposed, are reviewed as these create job strain and effort-reward imbalance in the contemporary workplace. We emphasize how these can impact upon metabolic pathways, and how, particularly among women, these processes may not be reflected in morphologic changes of the epicardial coronary arteries. The article by Hlatky and colleagues (1995) reporting a null relationship between exposure to job strain and coronary artery disease is critically reviewed in this context.
c) Post-myocardial infarction in a factory worker--return to work issues.
Psychosocial and physical factors fairly typical of the factory environment, together with lean production are reviewed as they can impact upon the occurrence of cardiac events at a young age. The participants are asked to decide whether or not this patient should return to the same working conditions as prior to the MI, and to justify their decision insofar as it deviates from usual clinical practice, drawing a parallel with the established approach to a patient with occupational lung disease, to strengthen their argument. We then present, for discussion, a new algorithm for return to work among stable post-MI patients, incorporating functional diagnostic laboratory evaluation as a pre-condition for ambulatory monitoring during work under precisely defined conditions.
Basic Readings:
Return to Work post-MI:
(1) Clinical issues: Return to work and public safety. In:
Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational
Medicine: State of the Art Review. The Workplace and Cardiovascular
Disease. 2000; 15 (1): 223-230.
(2) Theorell T, Perski A, Orth-Gomér K et al. The effects
of the strain of returning to work on the risk of death after
a first myocardial infarction before age of 45. Int J Cardiol.
1991; 30: 61-67.
Professional Drivers:
(1) Belkic K. Questions and answers concerning working life and health among truck drivers. The Job Stress Network website: Center for Social Epidemiology (www.workhealth.org), 2000.
(2) Belkic K, Emdad R, Theorell T. Occupational profile and cardiac risk: possible mechanisms and implications for professional drivers. International Journal of Occupational and Environmental Health. 1998; 11: 37-57.
Angina, Coronary Arteries and exposure to Job Strain and other Occupational Stressors:
(1) Hlatky MA, Lam LC, Lee KL, Clapp-Channing NE, Williams RB, Pryor DB, Califf RM, Mark DB. Job strain and the prevalence and outcome of coronary artery disease. Circulation 1995; 92: 327-333.
(2) Psychosocial factors: Review of the empirical data among men. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 24-40. (Read pp. 32-33)
(3) Kleiman NS. Angina pectoris in patients with normal coronary angiograms. In: Willerson JT, Cohn JN (eds.) Cardiovascular medicine. Churchill Livingstone, New York, 1995, pp. 375-389. (Read pp. 383-384)
(4) Landau C, Nordlander R, Nyquist O, Schenck K. Coronary artery spasm-A case with fatal outcome. Scand J Thor CV Surg 1979; 13: 129-132
Cardiovascular Metabolic Syndrome:
(1) The cardiovascular metabolic syndrome. In: Schnall PL, Belkic K, Landsbergis PA, Baker D (eds.) Occupational Medicine: State of the Art Review. The Workplace and Cardiovascular Disease. 2000; 15 (1): 146-150.