The evidence that stress is involved in the development of IHD is by no means conclusive.
There is reasonably good evidence that job stress in the form of having little control over one’s work environment is associated with cardiovascular disease mortality, but it is difficult to dissociate such phenomena from the confounding problems of socioeconomic class and habits such as smoking.
Low socioeconomic class may itself be taken as an indicator of stress per se and IHD is undoubtedly more common with lower socioeconomic class.
Acute stress is anecdotally associated with acute MI, but there is conflicting evidence from formal studies.
Recently, the so-called ‘takotsubo’ cardiomyopathy has been described. Patients with this condition present with what appears to be a sudden-onset acute MI with transient ballooning of the apical region of the left ventricle in the presence of normal coronary arteries.
This appears to be associated with stress, suggesting a possible aetiological link with high catecholamine levels.
Once a patient has developed overt CHD, the general advice should be to encourage exercise and a return to work. Patients who return to work after an acute MI have a better long-term prognosis than those who do not.
These general principles have to be modified for each patient.
A patient with a large anterior MI and overt heart failure should not go back to work as a scaffolder.
However, someone with stable chronic angina or who has recovered well from MI should be encouraged to return to work.
Dr Andrew Clark, reader and honorary consultant cardiologist, Castle Hill Hospital, Cottingham