Cardiovascular Morbidity and Mortality in the Workforce

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Cardiovascular Morbidity and Mortality in the Workforce

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In the following article, the term cardiovascular diseases (CVDs) refers to organic and functional disorders of the heart and circu- latory system, including the resultant damage to other organ systems, which are classified under numbers 390 to 459 in the 9th revision of the International Classification of Diseases (ICD) (World Health Organization (WHO) 1975). Based essentially on international statistics assembled by the WHO and data collected in Germany, the article discusses the prevalence of CVDs, new disease rates, and frequency of deaths, morbidity and disability.

Definition and Prevalence in the Working-Age Population

Coronary artery disease (ICD 410-414) resulting in ischaemia of the myocardium is probably the most significant CVD in the working population, particularly in industrialized countries. This condition results from a constriction in the vascular system that supplies the heart muscle, a problem caused primarily by arteriosclerosis. It affects 0.9 to 1.5% of working-age men and 0.5 to 1.0% of women.

Inflammatory diseases (ICD 420-423) may involve the endo- cardium, the heart valves, the pericardium and/or the heart muscle (myocardium) itself. They are less common in industrialized countries, where their frequency is well below 0.01% of the adult population, but are seen more frequently in developing countries, perhaps reflecting the greater prevalence of nutritional disorders and infectious diseases.

Heart rhythm disorders (ICD 427) are relatively rare, although much media attention has been given to recent instances of disability and sudden death among prominent professional athletes. Although they can have a significant impact on the ability to work, they are often asymptomatic and transitory.

The myocardiopathies (ICD 424) are conditions which involve enlargement or thickening of the heart musculation, effectively narrowing the vessels and weakening the heart. They have attracted more attention in recent years, largely because of improved methods of diagnosis, although their pathogenesis is often obscure. They have been attributed to infections, metabolic diseases, immunologic disorders, inflammatory diseases involving the capillaries and, of particular importance in this volume, to toxic exposures in the workplace. They are divided into three types:

dilative—the most common form (5 to 15 cases per 100,000 people), which is associated with the functional weakening of the heart
hypertrophic—thickening and enlargement of the myocardium resulting in relative insufficiency of the coronary arteries
restrictive—a rare type in which myocardial contractions are limited.

Hypertension (ICD 401-405) (increased systolic and/or diastolic blood pressure) is the most common circulatory disease, being found among 15 to 20% of working people in industrialized countries. It is discussed in greater detail below.

Atherosclerotic changes in the major blood vessels (ICD 440), often associated with hypertension, cause disease in the organs they serve. Foremost among these is cerebrovascular disease (ICD 430-438), which may result in a stroke due to infarction and/or haemorrhage. This occurs in 0.3 to 1.0% of working people, most commonly among those aged 40 and older.

Atherosclerotic diseases, including coronary artery disease, stroke and hypertension, by far the most common cardiovascular diseases in the working population, are multifactorial in origin and have their onset early in life. They are of importance in the workplace because:

so large a proportion of the workforce has an asymptomatic or unrecognized form of cardiovascular disease
the development of that disease may be aggravated or acute symptomatic events precipitated by working conditions and job demands
the acute onset of a symptomatic phase of the cardiovascular disease is often attributed to the job and/or the workplace environment
most individuals with an established cardiovascular disease are capable of working productively, albeit, sometimes, only after effective rehabilitation and job retraining
the workplace is a uniquely propitious arena for primary and secondary preventive programmes.

Functional circulatory disorders in the extremities (ICD 443) include Raynaud’s disease, short-term pallor of the fingers, and are relatively rare. Some occupational conditions, such as frostbite, long-term exposure to vinyl chloride and hand-arm exposure to vibration can induce these disorders.

Varicosities in the leg veins (ICD 454), often improperly dismissed as a cosmetic problem, are frequent among women, especially during pregnancy. While a hereditary tendency to weakness of the vein walls may be a factor, they are usually associated with long periods of standing in one position without movement, during which the static pressure within the veins is increased. The result- ant discomfort and leg oedema often dictate change or modifi- cation of the job.

Annual incidence rates

Among the CVDs, hypertension has the highest annual new case rate among working people aged 35 to 64. New cases develop in approximately 1% of that population every year. Next in frequency are coronary heart disease (8 to 92 new cases of acute heart attack per 10,000 men per year, and 3 to 16 new cases per 10,000 women per year) and stroke (12 to 30 cases per 10,000 men per year, and 6 to 30 cases per 10,000 women per year). As demonstrated by global data collected by the WHO-Monica project (WHO-MONICA 1994; WHO-MONICA 1988), the lowest new incidence rates for heart attack were found among men in China and women in Spain, while the highest rates were found among both men and women in Scotland. The significance of these data is that in the population of working age, 40 to 60% of heart attack victims and 30 to 40% of stroke victims do not survive their initial episodes.

Mortality

Within the primary working ages of 15 to 64, only 8 to 18% of deaths from CVDs occur prior to age 45. Most occur after age 45, with the annual rate increasing with age. The rates, which have been changing, vary considerably from country to country (WHO 1994b).

Table 1 shows the death rates for men and for women aged 45 to 54 and 55 to 64 for some countries. Note that the death rates for men are consistently higher than those for women of corresponding ages. Table 2 compares the death rates for various CVDs among people aged 55 to 64 in five countries.

Table 1. Mortality from cardiovascular diseases in 1991 and 1990 in the age groups 45-54 and 55-64 for selected countries.

Country	Men				Women
	45-54 Years		55-64 Years		45-54 Years		55-64 Years
	Rate	%	Rate	%	Rate	%	Rate	%
Russia**	528	36	1,290	44	162	33	559	49
Poland**	480	38	1,193	45	134	31	430	42
Argentina*	317	40	847	44	131	33	339	39
Britain**	198	42	665	47	59	20	267	32
USA*	212	35	623	40	83	24	273	31
Germany**	181	29	597	38	55	18	213	30
Italy*	123	27	404	30	41	18	148	25
Mexico**	128	17	346	23	82	19	230	24
France**	102	17	311	22	30	12	94	18
Japan**	111	27	281	26	48	22	119	26

*1990. **1991. Rate=Deaths per 100,000 inhabitants. % is from all causes of death in the age group.

Table 2. Mortality rates from special cardiovascular diagnosis groups in the years 1991 and 1990 in the age group 55-64 for selected countries

Diagnosis group (ICD 9th Rev.)	Russia (1991)		USA (1990)		Germany (1991)		France (1991)		Japan (1991)
	M	F	M	F	M	F	M	F	M	F
393–398	16.8	21.9	3.3	4.6	3.6	4.4	2.2	2.3	1.2	1.9
401–405	22.2	18.5	23.0	14.6	16.9	9.7	9.4	4.4	4.0	1.6
410	160.2	48.9	216.4	79.9	245.2	61.3	100.7	20.5	45.9	13.7
411–414	586.3	189.9	159.0	59.5	99.2	31.8	35.8	6.8	15.2	4.2
415–429	60.9	24.0	140.4	64.7	112.8	49.2	73.2	27.0	98.7	40.9
430–438	385.0	228.5	54.4	42.2	84.1	43.8	59.1	26.7	107.3	53.6
440 441–448	{50.0}	{19.2}	4.4 18.4	2.1 6.7	11.8 15.5	3.8 4.2	1.5 23.4	0.3 3.8	0.3 3.8	0.1 2.6
Total 390–459	1,290	559	623	273	597	213	311	94	281	119

Deaths per 100,000 inhabitants; M=male; F=female.

Work Disability and Early Retirement

Diagnosis-related statistics on time lost from work represent an important perspective on the impact of morbidity on the working population, even though the diagnostic designations are usually less precise than in cases of early retirement because of disability. The case rates, usually expressed in cases per 10,000 employees, provide an index of the frequency of the disease categories, while the average number of days lost per case indicates the relative seriousness of particular diseases. Thus, according to statistics on 10 million workers in western Germany compiled by the Allgemeinen Ortskrankenkasse, CVDs accounted for 7.7% of the total disability in 1991-92, although the number of cases for that period was only 4.6% of the total (Table 3). In some countries, where early retirement is provided when work ability is reduced due to illness, the pattern of disability mirrors the rates for different categories of CVD.

Table 3. Rate of cardiovascular disease among early pensioners* due to reduced ability to work (N = 576,079) and diagnosis-related work disability in the western part of Germany, 1990-92

Diagnosis group (ICD 9th Rev.)	Main cause of illness	Access to early retirement; number per 100,000 early retirees		Average annual work disability 1990–92
				Cases per 100,000 employed		Duration (days) per case
		Men	Women	Men	Women	Men	Women
390–392	Acute rheumatic fever	16	24	49	60	28.1	32.8
393–398	Chronic rheumatic heart disease	604	605	24	20	67.5	64.5
401–405	Hypertension, high blood pressure diseases	4,158	4,709	982	1,166	24.5	21.6
410–414	Ischaemic heart diseases	9,635	2,981	1,176	529	51.2	35.4
410, 412	Acute and existing myocardial infarction	2,293	621	276	73	85.8	68.4
414	Coronary heart disease	6,932	2,183	337	135	50.8	37.4
415–417	Pulmonary circulatory diseases	248	124	23	26	58.5	44.8
420–429	Other non-rheumatic heart diseases	3,434	1,947	645	544	36.3	25.7
420–423	Inflammatory heart diseases	141	118	20	12	49.4	48.5
424	Heart valve disorders	108	119	22	18	45.6	38.5
425	Myocardiopathy	1,257	402	38	14	66.8	49.2
426	Stimulus performance disorder	86	55	12	7	39.6	45.0
427	Cardiac rhythm disorder	734	470	291	274	29.3	21.8
428	Cardiac insufficiency	981	722	82	61	62.4	42.5
430–438	Cerebrovascular diseases	4,415	2,592	172	120	75.6	58.9
440–448	Diseases of the arteries, arterioles and capillaries	3,785	1,540	238	90	59.9	44.5
440	Arteriosclerosis	2,453	1,090	27	10	71.7	47.6
443	Raynaud’s disease and other vascular diseases	107	53	63	25	50.6	33.5
444	Arterial embolism and thrombosis	219	72	113	34	63.3	49.5
451–456	Diseases of the veins	464	679	1,020	1,427	22.9	20.3
457	Noninfectious diseases of the lymph nodes	16	122	142	132	10.4	14.2
458	Hypotension	29	62	616	1,501	9.4	9.5
459	Other circulatory diseases	37	41	1,056	2,094	11.5	10.2
390–459	Total cardiovascular diseases	26,843	15,426	6,143	7,761	29.6	18.9

*Early pensioned: Statutory pensions insurance for former Federal Republic of Germany, work disability AOK-West.

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Cardiovascular Morbidity and Mortality in the Workforce

Contents

Cardiovascular System References