From the Guidelines
For a return to offshore work after post-viral cardiomyopathy with an ejection fraction (EF) below 20% two months ago, I would not recommend clearance for offshore duty at this time. The patient's recent history of severe left ventricular dysfunction, as indicated by an EF below 20%, suggests a high-risk profile for adverse cardiac events, including sudden cardiac death, as highlighted in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1.
Given the clinical scenario, a comprehensive assessment is necessary, including a detailed history, physical examination, and investigations such as a repeat echocardiogram to evaluate current cardiac function. Significant improvement in EF, ideally to above 40%, is crucial before considering a return to offshore work, as outcomes improve with recovery of LVEF to >40% in the setting of prior heart failure with reduced ejection fraction (HFrEF) 1.
Key components of the assessment and management plan should include:
- A cardiology consultation to evaluate the need for guideline-directed medical therapy (GDMT) and to assess the risk of arrhythmias and sudden cardiac death.
- Stress testing to evaluate exercise capacity and arrhythmia risk.
- Optimization of heart failure therapy, which may include an ACE inhibitor or ARB, a beta-blocker, and possibly an aldosterone antagonist.
- Consideration for device therapy, such as an implantable cardioverter-defibrillator (ICD), if the EF remains severely reduced, as indicated for patients with persistently reduced LVEF ≤35% despite GDMT for ≥3 months 1.
Return to offshore work should only be considered after demonstrated stability on medication for at least 3-6 months, absence of symptoms like shortness of breath or chest pain, and documented improvement in cardiac function. The risk of sudden cardiac death and the challenges of managing cardiac emergencies in offshore environments necessitate a cautious approach, prioritizing the patient's safety and well-being above the desire to return to work.
From the Research
Components of Return to Work Assessment
For a patient with post-viral cardiomyopathy 2 months ago with an ejection fraction (EF) below 20, the components of a return to work assessment at an offshore medical evaluation may include:
- A thorough medical history (hx) to identify any underlying conditions that may have contributed to the development of cardiomyopathy 2
- A physical examination to assess the patient's current cardiovascular health and identify any signs of heart failure or other complications 3
- Investigations such as:
- Electrocardiogram (ECG) to assess the patient's heart rhythm and identify any abnormalities 4
- Echocardiography to evaluate the patient's left ventricular function and assess for any signs of cardiomyopathy 3
- Cardiac magnetic resonance imaging (CMR) to provide a more detailed assessment of the patient's cardiac function and structure 2, 4
- Inflammatory markers to assess for any ongoing inflammation or infection 2
- Endomyocardial biopsy to confirm the diagnosis of myocarditis and assess for any ongoing inflammation or scarring 2, 5
Considerations for Return to Work
When assessing a patient's fitness for return to work after a diagnosis of post-viral cardiomyopathy, the following considerations should be taken into account:
- The patient's current symptoms and functional capacity 3
- The results of any investigations, such as ECG, echocardiography, and CMR 3, 4
- The patient's risk of sudden cardiac death or other complications 6
- The patient's ability to perform their job duties safely and without risking their health or the health of others 3