J. Soc. Occup. Med.
(1990) 40, 65-67
A Cardiovascular Study of Shift Workers with respect
to Coronary Artery Disease Risk Factor Prevalence
R.G. BURSEY
British Nuclear Fuels pic. Sellafield, Seascale. Cumbria CA20 I PC UK
Summary
Fifty-seven shift workers were matched for age, cigarette smoking and
blue-collar/white-collar status against day worker controls. The recog-
nised coronary heart disease risk factors, Wood pressure, body mass
index, random plasma cholesterol and resting electrocardiograms were
compared between both groups.\None of these investigations gave a
statistically significant difference between the two groups. The study
supports the conclusion of previous morbidity and mortality studies
which have failed to show any conclusive evidence of an adverse effect
of shift working on the cardiovascular system.
Introduction
Approximately one-fifth of the workforce in industrial
societies is employed in shift work. Comparatively few
studies have been conducted to determine whether shift
work has any effect on the cardiovascular system. The
studies which have been undertaken suggest that there is
no significant association between shift work and car-
diovascular disease (for reviews see1 and2).
As a departure from cohort mortality analysis, this
present study was designed as a cross-sectional inves-
tigation, doubling as an intervention and preventative
medicine exercise. The rationale was based upon the
belief that the increased incidence of gastro-intestinal
disorders seen in shift workers may be explained, in
part, by the different eating habits of shift workers.
These same dietary differences might influence certain
coronary risk factors by altering cholesterol levels and
the body mass index of shift workers compared to day
working counterparts. These, in turn, could influence
blood pressure and the incidence of electrocardiographic
(ECG) abnormalities
Sufficient evidence exists from the Framington study
and the Pooling Project3 to show that the foregoing
four factors are risk factors for coronary heart disease.
Similar work on other populations such as the Seven
Countries study4 has confirmed the significance of these
risk factors. There is evidence to suggest that of the four
risk factors (raised cholesterol, overweight, raised blood
pressure and ECG abnormalities), the cholesterol level
has the greatest predictive value as a coronary heart
disease mortality risk factor5.
Method and subjects
The subjects were drawn from a large factory population
employed in the North-West of England. The factory is
engaged in the manufacture of nuclear fuel elements and
is essentially a light engineering and chemical plant. A
three-cycle, eight hour shift system is employed.
Blood pressure, body mass index (weight in
kilogrammes divided by height squared in metres) and
© 1990 Butterworths for SOM
0301-0023/90/020065-03
random plasma cholesterol measurements were obtained
from the annual medical examination data. Such
examinations are conducted on all employees as a
Company policy.
The electrocardiograms (ECG's) were performed on a
voluntary basis during employees' work-breaks.. Letters
were sent to the appropriate factory site addresses in-
viting the selected individuals (B and C shifts were ar-
bitrarily used from the four possible shifts A, B, C and
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D). They were invited to attend the Occupational Health
Department for an ECG in their own time. The reason
and nature of the examination was explained in the let-
ter. There, was no significant difference between the num-
bers of shift and day workers who came forward, being
58 percent of the total contacted and requested to volun-
teer.
Only male workers over the age of 40 years were in-
cluded in the study. Their mean age was 50 years with
a standard deviation (s.d.) of 6 years. The mean dura-
tion of shift exposure was 17 years (s.d. 7-66 years). Of
the 57 subjects in each group, 47 (82-4 per cent) were
blue-collar workers and 10 (17-6 per cent) white-collar
workers. The incidence of current smoking was 31-5 per
cent, this being in accordance with UK national figures.
The shift subjects were excluded from the study if their
total exposure to shift working was less than 5 years.
This figure was rather an arbitrary limit but it has been
suggested by Thus-Evensen that this is about the time
taken for adaptation to shift work to occur; those poorly
tolerating shift work leaving for one reason or another
within this 5 year period. Only day controls who had
never worked shifts were used.
The cholesterol measurements were performed 'in-
house' by an experienced, qualified Medical Laboratory
Scientific Officer. A Kem-O-Mat 2 analyser (Coulter
Electronics Limited) was employed. Each run of tests
was checked against three standards and two quality
control samples. Blood samples were always obtained
during mornings, for shift and day workers alike.
Analysis of samples was performed on the day of blood
collection.
Blood pressures, height and weight were recorded
during mornings only for both groups. These measure-
ments were recorded by qualified nursing staff.
A MAC PC Cardiograph (Marquette Electronics Inc)
was used to record the ECG's. This is a micro-processor
equipped machine which produces a report for each
tracing. Apart from printing details of ECG abnor-
malities, each tracing is characterized as being normal,
borderline or abnormal, using criteria similar to that of
the Minnesota code used for the Pooling Project lon-
gitudinal study3.
66 OCCUPATIONAL MEDICINE (1990) VOL. 40/NO. 2

Table I. Differences in blood pressure, body mass index and random plasma cholesterol values between shift workers and day workers

Systolic blood Diastolic blood Body mass Random plasma

pressure pressure index choleslerol
(mmHg) (mm Hg) (mmol/l)

Mean s.d. Mean s.d. Mean s.d. Mean ' s.d.

Shift workers 1251 14-3 77-6 10-1 26-28 317 5-68 1-44
Day workers 124 12-8 78-7 10-7 25-67 2-8 6-19 1-62

Significance ,<0-6 ,<0, p<0-2 ,<«H

levels shift/day

Blood pressure, body mass index and the random
cholesterol means for both shift and day worker groups
were tested by Student's / test. Differences in the
incidence of ECG abnormalities between the two groups
were tested by the x 2 test.
shift work, the results indicated a higher risk for car-
diovascular disease among shift workers as compared to
day workers although the evidence could not be con-
sidered conclusive.
This study has concentrated upon a cross-sectional
examination of individuals who have been matched in an
attempt to exclude the confounding variables of age,

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Results
No significant difference was found for systolic or dias-
tolic blood pressure, body mass index or random plasma
cholesterol values. The results and P values for these
measurements are shown in Table I.
The differences in incidence of the categories of ECG
analyses are shown in Table II. The frequency of nor-
mal, borderline and abnormal ECG tracings in the two
groups gave a %2 value of 1-362 and, therefore, suggests
that there is no evidence of a difference in the incidence
of latent heart disease between the matched shift and day
workers. A comparison between the number of ECG ab-
normalities referred to general practitioners for the shift
and day workers yielded a / value of 1-32, which is not
significant.
Discussion
Studies into shift work and cardiovascular disorders are
relatively few. Harrington's review1 concluded that there
was no firm evidence that cardiovascular disease is more
prevalent in shift workers and that available evidence
supported the conclusion that shift work has no appreci-
able effect on cardiovascular morbidity or mortality.
The Akerstedt review2 suggested that many of the early
studies suffered from methodological flaws which ren-
dered them difficult to interpret. The interpretation of
this review was that in studies in which the incidence of
disease had been computed and related to exposure to
Table II. Differences between shift workers and day workers in the
incidence of categories of ECG analyses
ECO Category
Normal Borderline Abnormal Abnormal
not referred referred
Shift 39(68-4%) 9(15-8%) 4(70%) 5(8-8%)
workers
Day 35(61-4%) 8(14-0%) 10(17-6%) 4(7-0%)
workers
cigarette smoking and, to some extent, socio-economic
status. Each of these variables are known to play a part
in the multi-factorial aetiology of cardiovascular disease.
All of the subjects included in the study were interviewed
and this ensured that those in the day working group
had never been exposed to shift work. The number of
matched shift and day worker pairs was significantly
reduced for inclusion into the study because individuals
classified as day workers had often performed shift work
with other employers. Since the study was limited to men
over 40 years of age, a number of them had experienced
military service and had, for example, been exposed to
the four hours on, eight hours off, watch system used at
sea. It is possible that this bias is not always excluded
from shift studies.
Because of the difficulties in matching large numbers
of shift workers against day working counterparts, the
study groups are comparatively small. An examination
of manifest cardiovascular disease is unlikely to yield
sufficient information to make valid comparisons. This
can be illustrated from the subjects in this study. Of
the shift workers, two individuals had known ischaemic
heart disease and three had hypertension. The day con-
trol group contained one individual with ischaemic heart
disease, one with hypertension and one man had un-
dergone angioplasty for femoral artery block. For this
reason, covert evidence of cardiovascular disease was
sought, doubling the purpose of the study to contain a
health prevention element. Sufficient evidence exists to
suggest that elevated cholesterol levels, hypertension and
male obesity6 are all risk factors for coronary artery
disease.
Most of the ECG recordings reported as borderline
showed non-specific intraventricular conduction delays
or minimal voltage criteria only for left ventricular hy-
pertrophy. Abnormal ECG reports deemed worthy of
referral were those where there was evidence of a pos-
sible silent myocardial infarct or where potentially sig-
nificant ischaemia might exist such as with marked axis
deviation. Since the limitations of resting ECG's were
recognised, such ECG findings prompted referral for
stress testing and further investigations.
Although the difference in mean cholesterol levels be-

tween the shift and day workers failed to reach sig-
nificance level, the result was lower for shift workers. If
the cholesterol level is the strongest predictive risk factor
for coronary heart disease mortality, it is of interest that
this was the only factor which approached significance
and it was in favour of shift workers.
Shift working does influence eating habits, poor ap-
petite during night working often leading to a shift being
worked without eating or perhaps just a light snack
being taken. There is a possibility that shift workers are
physically more active at the expense of spending less
time asleep than day workers. Other factors which may
explain why cholesterol levels as a risk factor are, at
least, no worse than that of day workers, are higher
incomes for a given range of tasks and greater awareness
of health factors since shift workers will recognise the
'unnatural' nature of their lifestyle.
This study confirms the conclusion that shift working
has no adverse influence on coronary heart disease by
reference to major risk factors, particularly cholesterol
Requests for reprints should be addressed to: DV R. G. Bursey, Medical Officer, British Nuclear Fuels pic, Sellafield, Seascale, Cumbria CA20 1PG,
UK.
CORONARY ARTERY DISEASE RISK FACTOR PREVALENCE 67
level, known to influence the development of this multi-
factorial disease.
REFERENCES
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3. Pooling Project Research Group. Relationship of blood pressure,
serum cholesterol, smoking habit, relative weight and ECG ab-
normalities to incidence of major coronary events: final report.
1978. J. Chronic Diseases 31: 201-306.
4. Keys A. Coronary heart disease in seven countries. Circulation
1970; Supp! 1-211:41-2.
5. Rose G. Incubation period of coronary heart disease. Br MtdJ
1982; 284: 1600-1.
6. Tuomilehto J, Salmen JT, Marti B, Jalkanen L, Puska P, Nissinen
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