39 Return to Work after Coronary Interventions

One of the objectives of coronary interventions is to enable patients to return to work. This is also one of the aims of the cardiac rehabilitation programs offered to these patients. The inability to resume professional activities after coronary interventions may constitute a stress (and there- fore a risk factor) for the patient due to a loss of self-esteem and earnings.

The most frequent coronary interventions currently in use are aorto-coronary bypass graft surgery (CABG) and percutaneous coronary angioplasty or intervention (PCI). Both are expen- sive and contribute to the high cost of treating coronary disease. The economic consequences are even more severe if the patient does not return to work afterwards.

In this context, we need to improve our under- standing of the factors increasing or decreasing the probability of a return to work, to make it possible to implement appropriate measures to facilitate the return to professional activity after coronary interventions.

Return to Work after Aorto-coronary Bypass Graft Surgery

Rate and Delay for Return to Work

Between 59%

and 100%

of patients who were working before surgery return to work after CABG (Tables 39-1, 39-3), with an average of about 75%. The mean delay to return to work is generally about 3 months, with a value of 3.2 ± 2.2 months reported in the prospective study

PERISCOP

and of 67 ± 58 days in the surgical arm of the study by Mark et al.

Medical Factors

Many studies have attempted to analyze the factors that have a significant effect on return to work after CABG.

Medical History

Diabetes may be predictive of failure to return to work.

However, many authors have reported that diabetes has no effect on the likelihood of returning to work.

A history of myocar- dial infarction has no significant effect on the likelihood of returning to work.

In contrast, Mark et al. reported that diffuse peripheral vascular damage is a negative factor for return to work.

Severity of Coronary Disease

Preserved left ventricular function is a positive factor for return to work.

In the study by Boudrez and De Backer,

mean left ventricular ejection fraction was 0.71 ± 0.12 in those who returned to work, and 0.62 ± 0.18 in those who did not (P < 0.01). Hlatky et al.

also reported that a good left ventricular function increased the prob- ability of return to work at the end of a 4-year follow-up period. Conversely, other studies have reported that a depressed left ventricular function decreases the likelihood of returning to work.

According to Mark et al.,

congestive cardiac

39

Return to Work after Coronary Interventions

Philippe Sellier

324

– Persistent dyspnea has also been reported to decrease the likelihood of returning to work after CABG.

Postoperative Physical Capacity

Good effort tolerance is a medical variable with a positive predictive value for return to work after CABG. In the PERISCOP study,

the duration of the exercise test was 543 ± 183 seconds in those who returned to work and 481 ± 168 seconds in those who did not (P = 0.00024). These results are consistent with those obtained by Engblom et al.

Other Factors Functional Class

Patients with a functional class I or II according to the New York Heart Association (NYHA) classification before surgery are more likely to return to work.

Psychological Factors

The degree to which the patient is motivated to return to work plays a positive role according to Boudrez and De Backer,

Engblom et al.,

and Hlatky et al.

The depression that may follow CABG decreases the likelihood of returning to work.

In the study by Stanton et al.,

56% of patients who were not depressed returned to work after surgery, versus only 16% of depressed patients.

Socio-Professional Factors

Many socio-professional factors have a significant effect on the likelihood of the patient returning to work after CABG.

Age

The older the patient, the less likely he or she is to return to work.

Speziale et al.

reported that age is a negative factor for return to work, with an odds ratio of 4.44 (95% CI: 1.3–15.0). In this study, 78.3% of patients below the age of 50 years returned to work compared to only 60.7% of patients over the age of 50.

failure also decreases the likelihood of returning to work, with an odds ratio of 0.20 (95% CI:

0.10–0.39; P < 0.0001).

The severity of coronary lesions also has a debatable effect. The number of coronary arteries affected has no significant effect on the likelihood of returning to work.

According to Boudrez and De Backer,

complete revascularization is a posi- tive factor for return to work. In the PERISCOP study,

complete revascularization was observed in 78.2% of patients who returned to work and in 75% of those who did not; this difference is not significant.

Cardiac arrhythmias,

detected by Holter recording carried out after the end of bypass surgery, have no significant effect on the likeli- hood of returning to work, regardless of whether these problems result from numerous premature ventricular contractions or from residual ventric- ular tachycardia.

Cardiac Symptoms

Cardiac symptoms also play an important role in determining the likelihood of returning to work after CABG:

– Persistent angina symptoms decrease the likelihood of returning to work.

According to Skinner et al.,

the absence of angina increases the likelihood of returning to work. However, it should be noted that a positive effort test, showing an ST-segment depression at peak exercise >1mm, has no significant effect

on the likelihood of returning to work. It therefore seems that only symptoms associated with myocardial ischemia are important.

TABLE 39-1. Studies on return to work after coronary artery bypass surgery

Period of Patients Average follow- % RTW (active

Authors study (n) up (months) patients)

Perk¹ 1980–1985 49 12 59

Monpère¹⁴ 1988 57 7 73

Speziale¹⁰ 1995 213 38 78.7

Skinner⁶ 1988–1989 353 12 84

Boudrez⁸ 1995-1998 136 12 81

PERISCOP³ 1998–1999 530 12 67.5

RTW: return to work.

In the PERISCOP study,

the mean age of the patients who had returned to work after CABG during the first year was 49.6 ± 5.7 years and the mean age of those who had not was 52.6 ± 5.4 years (P < 0.001).

The Patient’s Educational Level

Generally, the more educated the patient, the more likely he or she is to return to work after bypass surgery.

Socio-professional Category

Belonging to a high socio-professional category increases the chances of a patient returning to work after CABG.

Speziale et al.

reported that belonging to a low socio-professional category significantly decreased the likelihood of a patient returning to work, with an odds ratio of 0.65 (95%

CI: 0.16–0.95). In contrast, Engblom et al.

found that socio-professional category had no significant effect on the likelihood of returning to work.

Physical Activity Associated with Work

The probability of returning to work is lower if the patient’s former job involves intense physical activity. According to Boudrez and De Backer,

only 50% of patients with jobs involving heavy manual work returned to work, versus 80–88% of patients with moderately heavy or light jobs (P < 0.02). However, this difference did not remain significant in multivariate analysis.

Social Support

Boudrez and De Backer

found a relationship between the frequency of return to work and the presence of solid social support, particularly from the patient’s colleagues. This relationship was significant only in univariate analysis, disappear- ing in logistic regression models.

Previous Employment Status

The employment status of the patient before surgery (in active employment, unemployed, or on sick leave) plays a key role in determining whether the patient will return to work. Patients who were not working before surgery rarely return to

work.

According to Speziale et al.,

being in active employment before CABG is predictive of a return to work (odds ratio 4.20; 95% CI: 1.5–13.5).

Similarly, the longer the patient is on sick leave before surgery, the less likely the patient is to return to work after surgery.

Effect of Cardiac Rehabilitation after CABG on the Likelihood of Returning to Work

The effect of cardiac rehabilitation programs after CABG on the likelihood of returning to work is unclear. In a case-control study, Perk et al.

com- pared 49 patients following global rehabilitation programs after CABG with 98 patients who under- went surgery and then received the usual treat- ment. One year after bypass surgery, the rate of return to work was 59% for the group undergoing rehabilitation, and 64% for those on usual treat- ment (not significant). Other authors have also shown that cardiac rehabilitation programs have no significant effect.

In this last study, only the group of patients under the age of 55 years under- going cardiac rehabilitation had a rate of return to work higher than the control group (60% vs. 35%, P = 0.002). Monpère et al.

compared the results of two non-synchronous studies and demon- strated that occupational health physicians played a positive role in the return to work, increasing the rate of return to work from 51% to 78%.

Return to Work after Coronary Angioplasty

Rate and Delay for Return to Work

The rate of return to work after PCI at one year is similar to that for CABG (Table 39-2). In a study by Danchin et al.,

the rate of return to work was 73%. In the subgroups of patients undergoing

TABLE39-2. Return to work after coronary angioplasty Period of Average follow- % RTW (active Authors study Patients (n) up (months) patients)

Danchin¹⁵ 1980–1982 77 ? 73

Ben-Ari¹⁹ 1983–1984 175 18 74

Holmes¹⁷ 1984 2250 18 81–86

RTW: return to work.

Role of Rehabilitation in the Return to Work

Hoffman-Bang et al.

randomized 150 patients undergoing coronary angioplasty into an inter- vention group (cardiac rehabilitation program) and a control group. The rate of return to work at 12 and 24 months was 74% and 78%, respectively, in the intervention group and 68% and 61%, respectively, in the control group (not significant).

Ben-Ari et al.

found that the rate of return to work at 18 months was significantly higher for patients following cardiac rehabilitation pro- grams than for other patients (84% vs. 64%;

P < 0.01).

Comparison of Aorto-Coronary Bypass Surgery and Coronary Angioplasty

Many studies have shown that angioplasty only has a positive effect on delay to return to work, with the rates of return to work being similar at the end of follow-up for both therapeutic strategies.

Conclusions

Only 60–80% of patients working before surgery return to work after myocardial revascularization.

Patients return to work slightly sooner after PCI than after CABG, but the long-term results are similar for the two treatments.

angioplasty in comparative studies (mostly com- paring angioplasty with bypass surgery), the rates of return to work vary from 63% to 100% of the patients working before surgery (Table 39-3).

The delay to return to work is also highly variable and has decreased over time. In 1984, Danchin et al.

reported that patients returned to work an average of 4 months after surgery. In the

“PCI” arm of comparative studies, the median time to return to work was 27 days in the Mark et al. study,

4.9 weeks (2.7 to 10.9) in the BARI study

and almost 20 days in the RITA study in 1990.

Medical Factors

Several studies comparing the effects of PCI and CABG have investigated factors affecting the likelihood of returning to work, but none has identified the specific effect of each of these treatment strategies. However, certain factors making a return to work less likely have been identified. These factors are age,

the persis- tence of anginal pain,

and the result of angioplasty.

Socio-professional Factors

According to Laird-Meeter et al.,

not work- ing before angioplasty makes a return to work significantly less likely. However, the type of work done and job satisfaction have no significant effect on the likelihood of returning to work.

TABLE39-3. Comparative studies on return to work rate after coronary artery bypass surgery or angioplasty

Publication CABG PCI Mean follow- % RTW P

Authors (year) (n) (n) up (months) (CABG) % RTW (PCI) value

Jang²⁰ 1982 151 163 19 69 79 NS

Laird-Meeter⁹ 1989 125 94 12 63 76 NS

McGee² 1993 112 119 6–18 100 100 NS

Mark⁴ 1994 449 312 12 79 84 NS

RITA¹³ 1996 251 267 24 62 65 NS

BARI¹⁶ 1997 217 192 48 82 82 NS

% RTW: rate of work resumption after revascularization, only in patients working before. CABG: coronary artery bypass graft surgery; PCI: percutaneous coronary intervention.

artery bypass graft surgery. Q J Med 1999;92:87–

96.

7. Hlatky MA, Boothroyd D, Horine S, et al. Employ- ment after coronary angioplasty or coronary bypass surgery in patients employed at the time of revascu- larization. Ann Intern Med 1998;129:543–547.

8. Boudrez H, De Backer G. Recent findings on return to work after an acute myocardial infarction or coronary artery bypass grafting. Acta Cardiol 2000;55(6):341–349.

9. Laird-Meeter K, Erdman RAM, van Domburg R, et al. Probability of a return to work after either coro- nary balloon dilatation or coronary bypass surgery.

Eur Heart J 1989;10:917–922.

10. Speziale G, Bilotta F, Ruvolo G, et al. Return to work and quality of life measurement in coronary artery bypass grafting. Eur J Cardiothorac Surg 1996;10:852–858.

11. Engblom E, Hämäläinen H, Rönnemaa T, Vanttinen E, Kallio V, Knuts LR. Cardiac rehabilitation and return to work after coronary artery bypass surgery. Qual Life Res 1994;3:207–213.

12. Stanton SA, Jenkins CD, Denlinger P, et al. Predic- tion of employment status after cardiac surgery.

JAMA 1983;249:907–911.

13. Pocock SJ, Henderson RA, Seed P, et al. Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery.

3-year follow-up in the randomised intervention treatment of angina (RITA) trial. Circulation 1996;94:135–141.

14. Monpère C, François G, Rondeau du Noyer C, et al.

Return to work after rehabilitation in coronary bypass patients. Role of the occupational medicine specialist during rehabilitation. Eur Heart J 1988;

9(suppl L):48–53.

15. Danchin N, Cuilliere M, Mathieu P, et al. Socio- professional rehabilitation after transluminal coro- nary angioplasty.Arch Mal Coeur Vaiss. 1984;9:993–

997.

16. The writing group for the Bypass Angioplasty Revascularization Investigation (BARI) investiga- tors. Five-year clinical and functional outcome comparing bypass surgery and angioplasty in patients with multivessel coronary disease. JAMA 1997;277:715–721.

17. Holmes DR Jr, Van Raden MJ, Reeder GS, et al.

Return to work after coronary angioplasty: a report of the National Heart, Lung, and Blood Institute percutaneous transluminal coronary angioplasty Registry. Am J Cardiol 19984;53:

48C–51C.

18. Hoffman-Bang C, Lisspers J, Nordlander R, et al.

Two-year results of a controlled study of residential rehabilitation for patients treated with percuta-

The medical factors influencing return to work

are essentially the presence of symptoms, which has a negative effect, and ability to tolerate effort, which has a positive effect. The severity of coro- nary disease, in patients without symptoms, has only a slight effect.

As after myocardial infarction, social factors such as age, educational level, socio-professional category, and level of physical activity involved in the patient’s work play an important role in the likelihood of returning to work.

Cardiac rehabilitation, studied almost ex- clusively in patients undergoing CABG, has no significant demonstrated effect on the like- lihood of returning to work. The promising results obtained in a study of cardiac rehabilita- tion after angioplasty require confirmation.

However, specific interventions, particularly those of an occupational physician, facilitating the transfer of information to the company doctor and social reinsertion, are clearly of great value.

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