One of the main goals of a cardiac rehabilitation (CR) program is to support the patient in return- ing to work: strong economic and quality of life arguments exist. It has been stated that patients after an acute myocardial infarction (MI) without complications such as left ventricular dysfunction or exercise-induced myocardial ischemia may safely resume their previous work: for light office work 2 weeks of sickness absence are recom- mended, for average manual work 3 weeks, and for strenuous physical work 6 weeks. Thus, a major- ity of MI patients may well return to work (RTW) within the first month after discharge from hospi- tal, as almost all industrial and other jobs require significantly less effort than the average maximum work capacity of a healthy population: only 25%
is generally demanded for the modern workplace.
Yet few patients resume work early: the median time is 50 days in most countries but and there are considerable differences between individual countries. In Europe and the United States between 60% and 93% rates of RTW have been reported in surveys. This may well be an overesti- mate as less than 70% remain at work one year after MI, less than 50% after 4 years.
Is there an explanation for the discrepancy between the chance of an early RTW and the actual praxis? Can, or should, CR programs play a role? The answer is yes. Inability to work after MI is determined by medical, psychosocial, and eco- nomic or job-related factors. Among the medical and patient factors, the main determinants are age, sex, education, previous MI, severity of MI, residual angina pectoris, poor left ventricular function, and a low exercise capacity. The psy-
chosocial factors include anxiety and depression post-MI, stress at the workplace, motivation to resume work, and the patient’s own perception of the severity of the disease. Among the economic and job-related factors, health insurance benefits and other financial incentives, employment rates, physical and mental workload demands are important prognostic factors.
It has been shown that the medical factors only play a minor role, with the other factors dominating the prognosis of RTW. Here the role of a CR team to support a patient to return to work is a truly multi- disciplinary task. Knowledge of the patient’s expec- tations and physical limitations must be translated into individually adapted exercise training. Psy- chosocial needs must be addressed carefully and the economic benefits of an early RTW must be weighed against the possible risks for work-related recurrence of cardiac events. Therefore, at the onset of CR an individual strategy for a successful and lasting return to work should be created. This strat- egy builds upon elements from three phase: the period before, during, and after the MI.
Relevant Factors from the Period Before MI
The CR team has a variety of pre-MI factors to con- sider when planning the road back to work: elderly and female patients, persons with a low level of edu- cation,and those living far away from the workplace all tend to resume work to a lesser degree. Surveys have shown that these are the populations that have poor access to CR, low participation rates, and a
38
Returning to Work after Myocardial Infarction
Joep Perk
317
considerable drop-out. They are clearly in need of special CR efforts, an adapted program design.
An analysis of the work environment and demands is mandatory including the degree of job satisfaction and economic reward, the physical burden and any perceived employment stress, and the presence of conflicts at the workplace. What is the role of the labor market, is there a threat of unemployment? Has the patient noted symptoms of angina pectoris during work or does he or she believe the disease is caused by the work environ- ment? Have there been any thoughts of an early retirement or a change of job/profession? Any notable financial consequences or a loss of social status? The summary of this individual job analy- sis should be available for the CR team at the beginning of the program.
Relevant Factors from the Hospital Phase
In several programs cardiac rehabilitation does not start until the patient is referred to the CR center. This causes an unwanted delay in the recovery process. Over the years the average duration of the hospital admission has shortened;
after an uncomplicated MI patients may remain 3–4 days before discharge, which gives the CR team ample time to inform and engage the patient in the aftercare. This unsatisfactory situation may even be aggravated if the acute care hospital lacks resources for cardiac rehabilitation and the patient may have to wait weeks before being enrolled in a comprehensive program. Acute care and the following rehabilitation should be a streamlined service in order to be effective.
The information from the acute phase is highly relevant for the tailoring of the post-MI care:
Which acute interventions were performed? Were there any serious complications? Has the patient developed signs of heart failure or is there a risk of malignant arrhythmia? Is there any residual ischemia that can or will not be treated with further coronary intervention?
Is drug treatment considered to be optimal or is there a need for adaptation during the period after discharge and have there been any significant side-effects? Has smoking cessation been successful and were there signs of severe
anxiety or depression that need attention? Which information has the patient and the family received during the hospital stay and at discharge?
As from the pre-MI period, a complete inventory of the acute phase should be available for the mul- tidisciplinary CR team at the start of rehabilitation.
Relevant Factors from the Post-MI Period
Information from the patient’s physical and mental recovery, from the social environment and from the workplace should be added to the infor- mation from the pre- and acute MI phase when preparing for an early return to work or for a deci- sion to advise a change of job or even a perma- nent withdrawal from working life. For the CR team the following questions need answers: Has the patient regained the desired physical work capacity or is there a persisting disability? Is the patient motivated to resume work, or is he or she limited by poor self-confidence? Is there an exag- gerated perception of disability with the onset of psychosomatic complaints, as tends to occur after 2–3 months of sickness absence?
Is the attitude of family and friends supportive and is there understanding and encouragement from the employer, supervisor, and colleagues? Is the employer willing to contribute to a change in the patient’s work environment if needed?
Who decides formally about sick leave, the family doctor, factory health service, health insur- ance physicians, the cardiologist, others? Are gen- erous sick leave benefits an obstacle for RTW? The answers to these questions may form the base of an action plan in which possible limiting factors are attended to. Thus, combining data from all three phases gives the information needed for the planning of an optimal RTW strategy. This may be expected to enhance an early and lasting RTW, but is this assumption evidence-based?
Survey of the Literature on RTW (Table 38-1)
The answer may be found in a recent review: four- teen studies from the past 25 years were assessed to be of sufficient quality according to the
standard used by the Swedish Council on Tech- nology Assessment in Health Care.1 Two studies describe outcomes during the first year post-MI, six studies present predictors for RTW, and six studies describe the outcome of interventions aimed at limiting sickness absence.
RTW Post-MI
Herlitz et al.2in a prospective cohort study inves- tigated all patients <65 years with MI and who were employed part-time or full-time prior to infarction: 37% had returned to full-time work and 12% to part-time work one year post-MI.
Higher age and larger infarctions influenced the outcome negatively. Boudrez et al.,3in the city of Gent, Belgium, found that of all men <60 years who had experienced MI only a few were on long-term sick leave due to heart disease. During the course of the first year 85% had returned to work.
Predictors for RTW
Maeland et al.4,5 followed 249 MI patients <67 years for half a year post-MI: 25% were still on sick leave. Social and psychological factors nega- tively influenced the possibility of return to work:
high age, low education, residence (worse in rural areas), stress at the workplace and anxiety, depres- sion, and poor self-confidence.
Wiklund et al.,6 in a cohort study of 201 male MI patients <60 years at work prior to MI, showed that the motivation to return to work was the main predictive factor. Patients with physically demanding jobs returned to work to a lesser degree than patients with lighter jobs.
More recently, similar findings have been reported: a study of first-MI patients from New Zealand found that 58% of the patients were working after half a year.7The patients’ perception that the disease was an obstacle for returning to work predicted longer sick leave. Soejima et al.8 showed that 83% of male Japanese MI patients were back at work after 8 months. The prevalence of depression and worry concerning one’s own health were predictive of lower RTW. Smith and O’Rourke9found in a study from the US that indi- viduals with higher socioeconomic status had a greater chance of returning to work: 72% of all
patients returned to work, a higher number in those with high socioeconomic status.
Interventions to Improve RTW
Dennis et al.10showed that advice from a cardiol- ogist to the patient’s family physician could shorten sickness absence. The intervention group reported a shorter sick leave duration (51 vs.
75 days). This could not be reproduced when advice was provided by a non-hospital-based cardiologist.11
Bengtsson12could not show a reduction in sick- ness absence in the study group. Hedbäck and Perk13did not find any effect after the first year in comparison with a study group and a control group (62% vs. 57%), even though regular contact was made with the workplace to reduce the dura- tion of sick leave. However, increasingly more individuals in the control group were sick-listed, and at 5-year follow-up significantly more were still at work among the CR participants (52% vs.
to 27%). Froelicher et al.14offered three alterna- tives for aftercare: participation in an exercise group, exercise including counseling, or only stan- dard aftercare. In this study from the US only a few were sick-listed, and 94% were at work after 6 months regardless of the design of aftercare.
Nursing-based psychosocial intervention as part of CR did not influence RTW, as shown by Burgess et al.15
In summary, the review has shown that at least half of the patients following MI return to work within the first year. Regarding the outcome of aftercare and CR programs several improvements in program design, access, and application are rec- ommended below:
The Role of Cardiac Rehabilitation:
Physical Training
The physical capacity of patients early post-MI is diminished due to physical deconditioning, a pos- sible loss of cardiac reserve and the effect of drug treatment. Exercise training influences VO2max, blood lipid levels, platelet aggregation, and fibrinolysis, and protects against malignant arrhythmia. Exercise-related dyspnea, fatigue, and angina may be alleviated.
TABLE38-1.Return to work after myocardial infarction Author, publication year,reference number andMeanage% return- countryAimFocus of studyndistributionType of sick leave dataInterventionto-workResults Herlitz,Outcome of morbidityAll patients admitted to a92172,16–98Percentage RTW ofStandard medical49%Under 65:37% full-time, 1994,2Swedenand RTW 1 year post-specific hospitaltotal groups and oftreatment12% part-time.Age and MIfor MIgroups <65yinfarction size predicts RTW Boudrez,1994,3RTW after MIMales ≤60 years29557.5 yearsData via mailed60% participated85%69% of all subjects RTW, Belgiumin a regionalsurvey 1991.Onlyin a rehabilitation85% of those who worked infarction registerRTWprogrambefore MI.Few cases of remaining sick leave Maeland,1986,4RTW 6 months post-Consecutive group 249<67RTW and sick leaveStandard medical72.7%See below.Residence,age, NorwayMI in relation to jobpatients after MI6 months post-MItreatmenteducation,stress at work before,demographic<67 yearsand with complications factors,and diseasepredict RTW severity Maeland,1987,5RTW 6 months post-Consecutive group 249<67RTW and sick leaveStandard medical72.7%73% RTW half a year post- NorwayMI vs.psychologicalpatients after MI 6 months post-MItreatmentMI,25% remained sick variables<67 yearslisted.Perception,anxiety, depression at hospital predictors for RTW Wiklund,1985,6Predictors of RTW 2Male patients <60 years,201<60Via mailedStandard medical75%Importance of psychological Swedenand 12 months post-MIworking before MIsurvey/telephone:treatmentfactors in RTW.Patients return-to-work 2 andindicated association 12 months post-MIbetween work and MI Petrie,1996,7RTW 6 months post-Consecutive group 14353.2 ±8.4RTW and sick leaveParticipation a58%40/105 RTW after 6wk,76 New ZealandMI in relation topatients after first MI 3 and 6 months post-combinedafter 6 months.Initial patient’s perception and<65 yearsMIrehabilitationperception of disease participation in cardiacprogramseverity determines the rehabilitationprognosis Soejima,1999,8RTW 8 months post-First-time MI,men ≤65 13454.3Via mailedStandard medical82.9%Age,depression,perception JapanMI in relation toyears,in full-time jobsurvey/telephone:treatmentof health,difficulty in psychological andpreviously.RTW on average 8managing stress but not clinical variablesmonths post-MIinfarction size determine RTW Smith,1988,9USRTW 1 year post-MIConsecutive group 15151.2 ±8Via mailedStandard medical72%Educational level,physical vs.work before,patients after first MI survey/telephone:treatmentdemands of job,perception demographic factors<70 yearsRTW 4 and 12of disease,and economic and degree of severitymonths post-MImotives mainly determine of the diseaseRTW
Dennis,RCT of targeted adviceMI patients (male)201:10249 andDetailed information onEarly stress test91% vs.Shorter sick leave with 1988,10USbased on cardiac stress≤60,withvs.9050 ±7time,degree,and type ofand targeted88%targeted advice:51 vs.75 test after uncomplicateduncomplicatedRTW 6 months post-MI.advice on sick-days post-MI.RTW:32% MIMI,workedleave duration toreduction which gave beforeprimary care$2102 as extra income in the study group Pilote,1992,11RCT of targeted adviceConsecutive187:9550 vs.Via mailedEarly stress test91% vs.No difference after 6 USbased on stress-ECG ingroup patientsvs.9251 ±6survey/telephone:RTWand targeted95%months.Patients without men after uncomplicatedafter MI ≤60vs.71,3 and 6 months post-MIadvice onresidual ischemia at work MI vs.standard careyears,workingsick-leave durationsooner 38 vs.65 days. before MIto primary care Bengtsson,The outcome of aInfarction patients <6587:44 39–65Number of sick-leaveCombined cardiac85%No significant difference in 1983,12rehabilitation programyearsvs.43days year 1,% RTWrehabilitationRTW between CR and Swedenafter MIprogramcontrol.Av.177 vs.172 full-time sick-leave days, 58 vs.98 part-time days Hedbäck,The outcome of aAll patients <65 years305:14857.3 vs.Return at 5 years post-MICombined cardiac51.8% vs.No difference after 1 year 1987,13rehabilitation programadmitted for acutevs.15757.2rehabilitation27.4%(61.5% vs.56.5%,but after Swedenpost-MI with standardMIprogram vs.2 years (64.9% vs.43.1%) treatmentstandard treatmentand after 5 years Froelicher,1994,14Two differentAll survivors ≤70258:8457.1 vs.RTW 12 and 24 weeksPhysical exercise,94%83% returned to work at 12 USinterventions post-MIyears with MIvs.88 55.6 vs.after dischargevs.physicalweeks post-MI,94% after with standard treatmentvs.8656.3exercise +24 weeks.No difference education vs.between groups standard treatment Burgess,1987,15RCT of psychosocialMI patients who180:8950.9 ±Numbers RTW 3–4 andNursing-based88% vs.10% still sick-listed after USrehabilitation post-MIworked at least 20vs.917.413 months after MI.psychosocial88%13 months,no effect from hours/week beforePercent moved to anotherinterventionintervention infarctionjob and sick-listed RCT:randomized controlled trial.
The benefits of physical training post-MI for RTW are a high degree of functional recovery, an improvement in psychological status, and enhanced self-confidence in the ability to perform physical work. In spite of this, conventional train- ing programs appear to have a limited effect on RTW when compared to patients who have not participated in CR. Therefore CR training pro- grams should adapt to the actual work conditions of the patient: even though the physiological effect of training may be equally beneficial for each patient, an office clerk will have different work capacity needs than a forestry worker. This applies even to exercise testing: the conventional tread- mill or ergometer bicycle stress test has little resemblance to the average industrial job. Voca- tional exercise testing and training should simu- late the patient’s work environment. Based upon the medical information of the referring car- diologist and the background data from the workplace, the physiotherapist can choose the appropriate model of exercise training.
The Role of Cardiac Rehabilitation:
Psychological Support and Stress Management
Psychosocial factors play an important role in the prevalence and in the progression of coronary artery disease. This has consequences for the pro- vision of psychosocial support within the frame- work of a CR service. The psychological expertise within the CR team should advise the employer on means of limiting a stressful work environment in patients where mental stress or strain at the work- place has been reported. Patients may be helped by participating in stress management classes or in special cases through individual counseling by a psychologist. Overprotection by family and friends and the attitude of work colleagues and supervisors may extend sickness absence. Here clear and timely information from the CR team is invaluable! Anxiety and depression should be diagnosed early post-MI and treated if indicated with pharmacotherapy. Repeated mental rein- forcement within the CR program may help the patient to regain self-confidence and trust in the ability to face work demands.
The Role of Cardiac Rehabilitation:
Vocational Counseling
This area remains insufficiently developed in a majority of the programs around Europe. In general, physical training, dietary advice, smoking cessation, psychological support, and drug treat- ment are the core components. In some centers specialized occupational therapists have been engaged, in other centers cooperation with corpo- rate health services in larger industries has been organized, but a structured program for RTW is often missing. A specific function within the mul- tidisciplinary team is recommended (specialized nurse, occupational therapist, or physiotherapist) where relevant information from the patient, the social environment, and the workplace is gathered and an RTW plan is applied. The person perform- ing this function will act as communicator between the CR service and the workplace. The main items for this service are shown as a check- list in Table 38-2. Early post-MI information to the employer is of special practical relevance. Is there a need for a short-term or permanent replacement for the patient? Is there a recommendation to change the present job or are adaptations at the workplace needed? Can a relation between the work environment and the MI be suspected and does this have consequences for other workers?
Work task-adapted training programs and work- simulated exercise testing may be used. Interesting results have been reported from the use of Holter ECG monitoring during a test-run of 2 hours at the
TABLE38-2. Checklist
• Are there any relevant limitations for RTW in the pre-MI job: heavy physical or mental demands, conflicts?
• Is the patient motivated?
• Early post-MI contact with employer, factory health services and/or family doctor
• Create an RTW plan, including expected length of sick leave
• Inform employer about length and degree of sickness absence
• Encourage regular and early contact between patient and workplace (at least weekly visits)
• Adapt the training program to physical demands at work
• Consider the appropriate exercise test before RTW when needed
• Use low-intensity work during sick leave as a bridge for RTW
• Use part-time work as a bridge for RTW
• Maintain contact between patient and CR team during the first months after RTW
longitudinal population based study. Eur Heart J 1994;15:32–36.
4. Maeland JG, Havik OE. Psychological predictors for return to work after a myocardial infarction. J Psy- chosom Res 1987;4:471–481.
5. Maeland JG, Havik OE. Return to work after a myocardial infarction: the influence of background factors, work characteristics and illness severity.
Scand J Soc Med 1986;14:183–195.
6. Wiklund I, Sanne H, Vendin A, Wilhelmsson C.
Determinants of return to work after myocardial infarction. J Cardiac Rehabil 1985;5:62–72.
7. Petrie KJ, Weinman J, Sharpe N, Buckley J. Role of patients’ view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study. BMJ 1996;312:1191–
1194.
8. Soejima Y, Steptoe A, Nozoe S, Tei C. Psychosocial and clinical factors predicting resumption of work following acute myocardial infarction in Japanese men. Int J Cardiol 1999;72:39–47.
9. Smith R, O’Rourke DF. Return to work after a first myocardial infarction. JAMA 1988;259:1673–1677.
10. Dennis C, Houston-Miller N, Schwartz RG, et al.
Early return to work after uncomplicated myocar- dial infarction. Results of a randomized trial. JAMA 1988;260:214–220.
11. Pilote L, Thomas RJ, Dennis C, et al. Return to work after uncomplicated myocardial infarction: a trial of practice guidelines in the community.Ann Intern Med 1992;117:383–389.
12. Bengtsson K. Rehabilitation after myocardial infarction. Scand J Rehabil Med 1983;15:1–9.
13. Hedbäck B, Perk J. 5-year results of a comprehen- sive rehabilitation programme after myocardial infarction. Eur Heart J 1987;8:234–242.
14. Froehlicher ES, Kee LL, Newton KM, et al. Return to work, sexual activity, and other activities after acute myocardial infarction. Heart Lung 1994;23:423–435.
15. Burgess AW, Lerner DJ, D’Agostino RB, Vokonas PS, Hartman CR, Gaccione P. A randomized control trial of cardiac rehabilitation. Soc Sci Med 1987;
24:359–370.
patient’s workplace. In patients with physically or mentally strenuous work demands, a gradual increase of work hours from part-time to full-time is often a valuable bridge between post-MI disabil- ity and a normal productive life. During this transition period continued support and encour- agement from the CR team may be requested, even if the exercise training has been concluded.
Conclusion
Advances in emergency care, coronary interven- tion technique, and post-MI prevention have improved the medical prognosis, but the social prognosis, that is, the opportunity to return to work, appears to have remained unchanged over the past decades. It is time that the advances in medical care are translated into improvements in the socioeconomic sphere. Relevant medical, psychological, and socioeconomic information should be summarized in a concise definition of the needs and demands of the patient. A multi- disciplinary CR team well connected to the acute care hospital but also to workplaces in the local community will then be able to provide a tailor- made service contributing to a timely and lasting return to normal social life and work.
References
1. Perk J, Alexandersson K. Sick leave due to coronary artery disease or stroke. Scand J Public Health 2004;
suppl 63:181–206.
2. Herlitz J, Karlson BW, Sjolin M, et al. Prognosis during one year of follow-up after acute myocardial infarction with emphasis on morbidity. Clin Cardiol 1994;17:15–20.
3. Boudrez H, De Backer G, Comhaire B. Return to work after myocardial infarction: results of a
