[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Views 395
Invited Commentary
November 21, 2018

Work and Cardiovascular Disease in China

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
  • 2Duke Clinical Research Institute, Durham, North Carolina
  • 3Verily Life Sciences, South San Francisco, California
JAMA Netw Open. 2018;1(7):e184815. doi:10.1001/jamanetworkopen.2018.4815

The article by Jiang et al1 offers essential insights into the factors associated with returning to work after a nonfatal acute myocardial infarction (AMI) among Chinese adults. Using data from the China Patient-centered Evaluative Assessment of Cardiac Events Prospective Study of Acute Myocardial Infarction registry, the investigators analyzed 1566 employed patients in 53 hospitals across 21 provinces, assessing how many of these patients resumed work within 12 months after the acute hospital phase of AMI. The study shows that, in China, AMI can be a major life-changing event because almost half (44.1%) of previously employed individuals, especially women, do not return to work within 12 months after AMI.

The high number of Chinese patients not returning to work after AMI is in stark contrast with those from higher-income countries. Recent analyses from the United States2 and Denmark3 showed that only 7% and 9%, respectively, were unable to return to work at 12 months after AMI, with only a minority of these individuals retiring from the workforce. Therefore, these data from China are eye opening and spur a call to arms, particularly with an increasing global burden of noncommunicable diseases. Deaths from ischemic heart disease, as a proportion of total deaths, have increased in the 5 most populous countries that are not members of the Organisation for Economic Co-operation and Development (OECD) from 2000 to 2016.4 Among these countries, China has seen the greatest increase. The study by Jiang et al1 demonstrates that, beyond increased risk of mortality, AMI can have a tremendous effect on personal well-being and finances for Chinese individuals. The “financial toxicity” of atherosclerotic cardiovascular disease has also been noted in a significant number of individuals in higher-income countries such as the United States.5 Diminished household income from job loss, by leading to difficulty affording medications and access to medical care, can initiate a vicious cycle that leads to poorer clinical outcomes.2 It is therefore critical for clinicians, researchers, and public health officials around the world to take note of these data and develop measures to mitigate the adverse effect of AMI among survivors. The study by Jiang et al1 reinforces the notion that the financial consequences of cardiovascular disease and treatments need to be studied as part of prospective studies. Metrics assessed could include involuntary job loss, given its association with lower quality of life.2

The study by Jiang et al1 emphasizes the need to focus on the health of AMI survivors. In-hospital complications were the only preventable factor associated with an inability to return to work, showing the need for high-quality AMI care to avert such complications. Control of cardiovascular risk factors is essential to both primary and secondary prevention of ischemic heart disease. In China, 28% of adults (52% of men and 3% of women) were current smokers in 2015, amounting to more than 316 million individals6; smoking cessation is low-hanging fruit for post–myocardial infarction risk optimization. Asian populations have much higher rates of hypertension and stroke; therefore, well-rounded intensive risk factor modification needs to be instituted to improve outcomes. Cardiac rehabilitation has been proven to improve patients’ functionality after AMI, yet access and uptake remain very low in China, with 1 study estimating that there were only, on average, 2 cardiac rehabilitation programs per 100 million inhabitants.7

The study by Jiang et al1 suggests that manual workers and those with a lower educational level may be most severely affected by the physical and psychological impairments of AMI. Countries around the world, however, are increasingly transitioning to being knowledge-based economies; the proportion of the labor force in agriculture is declining among the most populous non-OECD countries, China in particular. Nevertheless, as the Chinese workforce grew to about 787 million in 2017, these data indicate that countries across the economic spectrum need to place heightened emphasis on the health and wellness of their inhabitants to continue growing.8 Coupled with a rapidly aging population, the need to invest in preventive medicine is particularly important.

The study by Jiang et al1 also showed that women are less likely than men to return to work, even after adjustment for other factors. These findings mirror those of a prior analysis of 1680 young patients aged 18 to 55 years (57% women) in the United States and Spain, which showed that women were less likely than men to return to work, although this difference was not noted after adjustment for sociodemographic, psychosocial, and health measures.9 Although women accounted for only 8.3% of patients in the study by Jiang et al,1 limiting what can be assessed from this study, the reasons for more women not returning to work after AMI in China need to be further investigated.

The study does have some limitations. Generalizability of this registry to the broader Chinese population of 1.5 billion is unclear, particularly given the heterogeneous access to health care in the country. Like other health systems, significant geographic and socioeconomic disparities in access to health care and other essential services exist, with wealthy individuals able to access health care services on par with those in higher-income countries.10 Furthermore, future studies could provide deeper insight by obtaining more granular and qualitative information. For example, a significant number of patients opted for early retirement after AMI, considerably more than after AMI in North America.2 Future studies should examine whether such decisions were in line with cultural aspirations associated with earlier retirement or were involuntary owing to health reasons.

Finally, studies such as the one by Jiang et al1 emphasize the need to transform the generation of information that can shape policy and medical care. Traditional modes of generating clinical data such as registries and traditional clinical trials are resource intensive and have a significant lag from data collection to dissemination. The development of learning health systems that generate data in near real time, including embedded randomization to compare interventional strategies, is necessary such that local issues can be identified and then tailored solutions can be designed with rapid testing of the benefits and risks. The development of learning health systems is necessary to develop unique, timely, and actionable knowledge that highlights and addresses issues native to the health ecosystems of countries around the world.

Back to top
Article Information

Published: November 21, 2018. doi:10.1001/jamanetworkopen.2018.4815

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Warraich HJ et al. JAMA Network Open.

Corresponding Author: Haider J. Warraich, MD, Division of Cardiology, Department of Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710 (haider.warraich@duke.edu).

Conflict of Interest Disclosures: Dr Wang reported receiving research funding from AstraZeneca, Gilead, Lilly, The Medicines Company, the National Institutes of Health, and Canyon Pharmaceuticals; performing educational activities or lectures for AstraZeneca; and consulting (including continuing medical education) for Medco. Dr Califf reported receiving personal fees from Merck and being employed as a scientific advisor by Verily Life Sciences (Alphabet). No other disclosures were reported.

Jiang  Z, Dreyer  RP, Spertus  JA,  et al; China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Collaborative Group.  Factors associated with return to work after acute myocardial infarction in China.  JAMA Netw Open. 2018;1(7):e184831. doi:10.1001/jamanetworkopen.2018.4831Google Scholar
Warraich  HJ, Kaltenbach  LA, Fonarow  GC, Peterson  ED, Wang  TY.  Adverse change in employment status after acute myocardial infarction: analysis from the TRANSLATE-ACS Study.  Circ Cardiovasc Qual Outcomes. 2018;11(6):e004528. doi:10.1161/CIRCOUTCOMES.117.004528PubMedGoogle ScholarCrossref
Smedegaard  L, Numé  AK, Charlot  M, Kragholm  K, Gislason  G, Hansen  PR.  Return to work and risk of subsequent detachment from employment after myocardial infarction: insights from Danish nationwide registries.  J Am Heart Assoc. 2017;6(10):e006486. doi:10.1161/JAHA.117.006486PubMedGoogle ScholarCrossref
World Health Organization.  Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2016. Geneva, Switzerland: World Health Organization; 2018.
Khera  R, Valero-Elizondo  J, Okunrintemi  V,  et al.  Association of out-of-pocket annual health expenditures with financial hardship in low-income adults with atherosclerotic cardiovascular disease in the united states.  JAMA Cardiol. 2018;3(8):729-738. doi:10.1001/jamacardio.2018.1813PubMedGoogle ScholarCrossref
Li  S, Ma  C, Xi  B.  Tobacco control in China: still a long way to go.  Lancet. 2016;387(10026):1375-1376. doi:10.1016/S0140-6736(16)30080-0PubMedGoogle ScholarCrossref
Zhang  Z, Pack  Q, Squires  RW, Lopez-Jimenez  F, Yu  L, Thomas  RJ.  Availability and characteristics of cardiac rehabilitation programmes in China.  Heart Asia. 2016;8(2):9-12. doi:10.1136/heartasia-2016-010758PubMedGoogle ScholarCrossref
World Bank. Labor force, total. https://data.worldbank.org/indicator/SL.TLF.TOTL.IN. Accessed August 13, 2018.
Dreyer  RP, Xu  X, Zhang  W,  et al.  Return to work after acute myocardial infarction: comparison between young women and men.  Circ Cardiovasc Qual Outcomes. 2016;9(2)(suppl 1):S45-S52. doi:10.1161/CIRCOUTCOMES.115.002611PubMedGoogle ScholarCrossref
Wang  T, Zeng  R.  Addressing inequalities in China’s health service.  Lancet. 2015;386(10002):1441. doi:10.1016/S0140-6736(15)00402-XPubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Limit 140 characters
Limit 3600 characters or approximately 600 words