Cardiac Infarction-Sharland JRNAL MEDICAL JOUJRNAL that there has been a significant change in policy since 1936, when Levine recommended a period of six to eight weeks in bed, with an appropriate convalescent period. Alternatively, it is possible that there is an increasing occurrence or recognition of milder cases.While most would acknowledge the considerable psychological benefits which are seen in a patient who is able to resume work, there are very few data concerning the physical effects of resumption of work, and it is impossible to answer the oftput questions, " Will I do myself any harm if I go back to work? " or " Should I have another month's rest from work? " The data presented in this series do not provide an answer to these questions except with respect to the mortality (the crudest index) which compares favourably with that recorded in doctors (Morris, Heady, and Barley, 1952 ;McMichael and Parry, 1960)-the mortality at one year is 4.2 %, compared with 4% of the doctors (who survived the first month after infarction), and at three years is 14%, compared with 10% in the doctors' series.Cook, Tuttle, and Kodlin (1962) report from a cardiac workevaluation centre an attempt to establish whether work had any effects on the progress of heart disease. They graded the work capacity of their patients into five categories ranging from normal capacity to confinement to bed. By comparing their assessment at the initial visit with the actual work being carried out when the patients were seen at six-monthly intervals they were able to classify the men into those who complied with the original advice, those who did more than recommended, and those who did less. The mortality of patients suffering from "atherosclerotic heart disease" showed a gradient from 9 % in those who did excessive work, to 5 % in those who complied with advice, and to 3 % in those who did less work than advised. Further studies are needed to confirm if hard work has any adverse effect on those who have suffered from cardiac infarction.The possible role of psychological stresses has not been considered as it was not possible to measure them. Summary and ConclusionsThe return to work of 212 men under 60 years of age who have survived one episode of cardiac infarction showed that 55 % were back at work within three months and 82 % within six months.The major changes in employment " status " had generally been achieved within six months of the initial cardiac infarction, and the various employment subgroups at this stage were therefore studied more closely. (a) Part-time work was usually a temporary phase which was ultimately followed by a return to full-time work. (b) A change of job was more common in those in social classes IV and V and those normally undertaking active or heavy work. (c) A review of the social class, physical activity of work, and severity of initial infarction of the few men who were not at work at six months (and who had not suffered any further episodes of cardiac infarction) did not show any obvious distinguishing featu...

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Left ventricular function and volume changes during supine isotonic exercise were assessed in 32 patients with coronary artery disease (CAD) and 12 normal subjects by electrocardiographically gated blood pool cardiac scintigraphy. Ejection fraction (EF) in normal subjects was 49 +/- 10% at rest, 54 +/- 10% during intermediate exercise (P less than 0.05 vs. rest), and 62 +/- 14% during maximal exercise (P less than 0.01 vs. rest). In patients with CAD the resting EF was 42 +/- 14%, 43 +/- 23% at intermediate exercise (P = nonsignificant vs. rest) and 36 +/- 11% at maximal exercise (P less than 0.01 vs. rest). Changes of average and maximal ejection rates from rest to exercise were similar to those of EF but had a lesser degree of statistical significance. End-diastolic volume index (EDVI) in patients with CAD, at intermediate exercise was equal to that at rest, but it increased during maximal exercise (P less than 0.01). In normal subjects EDVI did not change with exercise. Thus, during supine exercise the Frank-Starling mechanism is apparent in patients with CAD but not in normal subjects. Analysis of EF response to exercise is a highly sensitive technique to detect CAD provided that adequate exercise is achieved.

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