Coronary Artery Disease (CAD)

Known CAD

Angina:

Any PSW with stable or unstable angina (current or by history) should be provided with work restrictions and referred for further evaluation and treatment.

Post-myocardial infarction:

The risk of a major cardiac event is greatest within the first few months after a myocardial infarction (MI). The PSW must be evaluated prior to returning to duty and annually thereafter. The PSW may be cleared up for full duty when they meet all the following criteria:5,6,7 

• Minimum recovery period to be decided by the agency’s medical provider in consultation with the treating cardiologist (See Table 1).a
• At baseline (i.e., when return to work is first considered) and annually:
  • no angina.
  • evaluation of modifiable CAD risk factors (total cholesterol, high- and low-density lipoprotein cholesterol, systolic BP, diabetes, and smoking).
  • normal left ventricular ejection fraction (LVEF).4
  • normal symptom-limited imaging exercise stress test as defined above.

LVEF values are dependent on the imaging technique used, method of analysis, and operator.4 While individual testing facilities have determined their own measures of “normal,” most use a value of greater than or equal to 50%.6

Post-Percutaneous Coronary Intervention (PCI):

The PSW who has undergone a PCI after sustaining an event causing myocardial damage should be evaluated according to the section on post-myocardial infarction above. The PSW who has undergone a PCI without myocardial damage must be evaluated prior to return to duty and annually thereafter. The PSW may be cleared for full duty when they meet all the following criteria:5,6,7

• Minimum recovery period to be decided by the agency’s medical provider in consultation with the treating cardiologist (See Table 1)
• Recovery of access site with no evidence of significant hematoma, pseudoaneurysm, or infection.
• At baseline (i.e., when return to work is first considered) and annually:
  • no angina.
  • evaluation of modifiable CAD risk factors (total cholesterol, high- and low-density lipoprotein cholesterol, systolic BP, diabetes, and smoking).
  • normal LVEF.
  • normal symptom-limited imaging exercise stress test as defined above.

LVEF values are dependent on the imaging technique used, the method of analysis, and the operator.4 While individual testing facilities have determined their own measures of “normal,” most use a value of greater than or equal to 50%.6

Post-Coronary Bypass Graft (CABG) Surgery:

The PSW who has undergone bypass graft surgery with or without myocardial damage must be evaluated prior to return to duty and annually thereafter. The PSW may be cleared for full duty when they meet all the following criteria:5,6,7

• Minimum recovery period to be decided by the agency’s medical provider in consultation with the treating cardiologist ^b (See table 1).
• Healed surgical sites (sternum and leg)

At baseline (i.e., when return to work is first considered) and annually:

• no angina
• evaluation of modifiable CAD risk factors (total cholesterol, high- and low-density lipoprotein cholesterol, systolic BP, diabetes, and smoking).

No less than 3 months post-surgery and annually thereafter:

• normal LVEF
• normal symptom-limited imaging exercise stress test as defined above.

LVEF values are dependent on the imaging technique used, method of analysis, and operator.4 While individual testing facilities have determined their own measures of “normal,” most use a value of greater than or equal to 50%.6

Coronary Artery Spasm

The PSW with treated coronary artery spasm may be cleared for full duty when they meet all the following criteria:6

• no recurrence of symptoms of coronary spasm.
• treatment with calcium channel blockers and/or long-acting nitrates (i.e., not sublingual).
• normal symptom-limited imaging exercise stress test as defined above.
• clearance by the treating cardiologist to participate in high exertion activities.

Coronary artery spasm is associated with increased risk of life-threatening arrhythmias and sudden cardiac death.8 The condition is diagnosed by the absence of identifiable atherosclerotic lesions by provocation studies, typically during dobutamine or adenosine EST.(9) When diagnosed and associated with symptoms of cardiac ischemia or life-threatening arrhythmias, the PSW should be restricted. PSWs with coronary spasm and treated with an implantable cardioverter defibrillator (ICD) should be restricted according to the section on ICDs.

Myocardial Bridging

The PSW with the treated myocardial bridge may be cleared for full duty when they meet all the following criteria:

• surgical resection of the bridge or stenting when recommended by the treating physician.
• recovery period of at least 6 months after surgical resection or stenting.6
• normal symptom-limited imaging exercise stress test as defined above.

Myocardial bridging is diagnosed when a portion of a major epicardial coronary artery is completely covered by myocardium. Myocardial bridging is commonly observed by angiography as coronary artery compression during systole. It is usually asymptomatic and of no clinical consequence. However, it has been associated with exercise-induced ischemia and exercise-related acute cardiac events, particularly in vessels whose tunnel length is long and deeper than 3 millimeters beneath the epicardium.6,10  

Coronary Vasculitis

Coronary vasculitis is rare and is associated with a variety of medical conditions including polyarteritis nodosa, Takayasu arteritis, and Buerger’s disease.11 PSWs with active coronary vasculitis should be restricted due to the increased risk of sudden incapacitating cardiac events.12, 13Once the vasculitis has been resolved, the PSW can return to full duty. However, there is no sensitive or specific test that can determine when the inflammatory process has resolved.

aRecommendations from various medical organizations regarding timeframes for returning to work after myocardial infarction.

bRecommendations from various medical organizations regarding timeframes for returning to work after myocardial infarction.