Who returns to work after heart attack? Linked health and tax registry evidence from Estonia

Background Acute myocardial infarction (AMI) affects not only survival and health, but also labour market participation. Return to work may differ by socioeconomic position, comorbidity and pre-event job characteristics. Estonia offers a unique opportunity to study these equity aspects by linking health insurance data with monthly tax registry data on wages, occupation and sector. Methods We linked Estonian Health Insurance Fund records with Estonian Tax and Customs Board employment data. The study included men born in 1934–1984 with a first AMI in 2015–2024. Health records from 2005–2014 were used to exclude previous AMI cases. The analysis was restricted to men with positive wage income one or two months before AMI. Employment after AMI was defined as positive wage income and measured among those alive at 12, 24, 36 and 48 months. Logistic regression models were estimated separately for each follow-up month, including age, education, language, Charlson comorbidity index, occupation and economic sector before AMI. Results The cohort included 4,623 previously employed men. Mortality increased from 5.3% at diagnosis month to 13.4% at 48 months. Among survivors, employment declined from 74.5% after 12 months to 64.6% at 40 months, respectively. Return to work showed clear socioeconomic gradients. Compared with primary education, higher education was associated with higher odds of employment: OR 1.68 at 12 months, OR 1.66 at 24 months and OR 1.59 at 48 months. Compared with Charlson index 0, index 3 or higher was associated with lower odds of employment at 48 months, OR 0.49. Sector and occupation before AMI also mattered: men working in education, retail and health sectors, and in ISCO groups 1 and 4, had higher probabilities of return to work. Conclusions Labour market recovery after AMI among previously employed Estonian men is strongly patterned by education, comorbidity and pre-event labour market position. Key messages • Linked health and tax registry data allow recovery after adverse health effects to be analysed as both a health and equity issue. • Return to work after AMI differs substantially by socioeconomic and job-related characteristics.