Case study 2: Bus driver with chest pain

At the end of his working shift, a 47 year old bus driver was admitted to the accident and emergency department complaining of worsening severe chest pain and tightness and shortness of breath. He had a strong family history of ischaemic heart disease (both his father and uncle having had heart attacks before the age of fifty) and he admitted to having smoked since leaving school.On examination his pulse was 96/minute and he had frequent premature beats, while his blood pressure was 130/70 mm mercury. The electrocardiogram showed ST elevation in the anterior leads. Chest X ray showed slight cardiomegaly and a few fine horizontal linear shadows at the bases. Serum enzymes showed elevated creatine kinase and aspartate aminotransferase. A diagnosis of myocardial infarction was made and he was discharged after 12 days with medication to take home, as well as instructions to "take things easy" until review in the outpatient clinic.

Commentary

What would you consider to be the likely management of the patient?

• Antithrombotic therapy - thrombolysis in the acute stage, perhaps aspirin thereafter,
• Advice on stopping smoking,
• Advice on weight control if overweight; perhaps lipostatisc agents if indicated by his lipid profile,
• Other cardioprotective measures, e.g. beta blockers,
• Advice on graded exercises,
• Further investigations, e.g. angiography as a possible prelude to angioplasty, maybe…

But is this enough?

What else should be considered?

Think about this then move on…

This case history relates to a common presentation of a common disease. Unlike the other cases in this series the problem is not as specifically occupational or environmental in its causation. His family history, smoking habits and other lifestyle factors such as his diet were probably very important causal factors.

However other factors could have contributed to his ischaemic heart disease, and to that of many others like him, and other important considerations arise:

What about the evidence that this man's work/environment may have contributed to his ill health?  Contributory causes could include particulate products of combustion (PM10), i.e. smaller than 10 microns.

Epidemiologic research has shown that a 10 microgram per cubic metre increment in PM10 was associated with approximately a 5% increment in emergency hospital admissions for cardiovascular disease such as heart attacks, after adjusting for known confounders. Carbon monoxide and, clearly, tobacco smoke can be important sources of damage to his heart or vascular system.

Occupational stressors

Other researchers have shown associations, probably partly causal, between occupational stressors and adverse cardiovascular outcomes.

What about the consequences of his ill-health upon his work:

What information would be needed and what advice should the patient be given about his return to work?

Information about the patient's status, about the job requirements and how to link the two is essential. As regards his clinical status, one should check whether he has:

• Anginal symptoms and what provokes them,
• Arrhythmias,
• Hypertension,
• Heart failure.

Public Service Vehicle licences and Heavy Goods Vehicle licences have stringent fitness requirements and he would not be readily allowed to return to bus driving. In other words, fitness for driving his private car is not the same as fitness for vocational driving (e.g. PSV, HGV).

Linking his health status and his job, in summary he would need to be:

• Post surgery,
• AND angina free for at least 6 weeks,
• AND not hypertensive (BP < 180/100 mm Hg) nor having symptoms of heart failure,
• AND no dysrhythmia that has caused or is likely to cause incapacity for at least 3 months,
• AND probably also would have to fulfil other criteria, e.g. ejection fraction >0.4, satisfactory exercise test.

Further information and advice should be obtained for example from:

• DVLA - Medical Aspects of Fitness to Drive.
• Occupational Health Physician - bus companies should have one.

So what job could he do if he could not drive a bus any more?

Perhaps he could be rehabilitated and re-trained in some way? Maybe as a bus inspector?

Do you have any other thoughts on the management or implications of this case?