Return to work after coronary artery bypass operation

Surgical myocardial revascularization

In conclusion, surgical myocardial revascularization has utilized diverse methods to increase blood flow to the starving myocardium. These methods initially used the microcirculation as the portal to reach myocytes until angiography showed that the obstructions were macrovascular. This resulted in a 30-year era of direct attack on the coronary blockages by coronary bypass. Surgical conduits unfortunately have longevity considerably less than that of native arteries and are limited in number. Alternative conduits, both biologic and prosthetic, have not yet proved to have the same clinical results as the ITA. More patients are living long enough to have the extensiveness of their disease exhaust conventional therapies. Newer therapy, restricted thus far to untreatables, revisits the microcirculation by making laser channels. These many innovative procedures have benefited hundreds of thousands of patients. They emerged from the probity and innovation of many individual surgeons.

Psychosocial factors of coronary heart disease in women: a review

Although coronary heart disease is the leading cause of death in women in most industrialized countries, much less research has been carried out on this topic to date than in men. This article gives an overview of psychosocial factors of coronary heart disease in women, focussing on psychosocial risk factors for coronary heart disease in women such as socioeconomic status, employment status, chronic troubling emotions, social support and bereavement/widowhood. A second focus lies on psychosocial adjustment in women once coronary heart disease has become manifest, i.e. well-being, return to work, sexual activity and rehabilitation outcome after a myocardial infarction or coronary artery bypass grafting. Via a computerized literature research in Medline, Psychlit and Sociofile over the period 1980-1994 all studies on these topics were collected and reviewed. Comparatively more research has been undertaken on psychosocial risk factors for than on psychosocial adjustment to coronary heart disease in women. Low social class, low educational attainment, the double loads of work and family, chronic troubling emotions and lack of social support emerge as documented risk factors in women. Regarding psychosocial adjustment to coronary heart disease in women, there is a paucity of data, and studies including large samples of women and adjusting for gender are warranted. Psychosocial adjustment in women after a myocardial infarction seems to be worse than in men, whereas results on adjustment after coronary artery bypass grafting are inconclusive. Return to work rates after myocardial infarction or coronary artery bypass grafting are significantly lower in women than in men. Data on sexual activity of women after myocardial infarction or coronary artery bypass grafting are scarce, and there seems to be a complete lack of physician counseling on this topic. Studies on rehabilitation outcome report poorer programme uptake, poorer adherence and significantly higher drop-out rates for women than for men, yet those women who complete cardiac rehabilitation show the same or even greater functional improvements than men.

The relative importance of dispositional optimism and control appraisals in quality of life after coronary artery bypass surgery

Similar mechanisms have been proposed to explain the stress-buffering effects of both dispositional optimism and perceived control. Yet dispositional optimism as a personal resource should function independently of situational control appraisals. To evaluate the unique and additive contributions to adaptation of control appraisals and optimism, we followed 49 individuals scheduled for coronary artery bypass surgery. One month before surgery dispositional optimism was associated with neither health locus of control nor specific expectancies about the outcomes of surgery. Dispositional optimism, however, was associated with perceived control over the course of the illness and with quality of life appraisals. Although presurgery optimism predicted life quality 8 months after surgery, this was not the case when general and specific control appraisals and specific expectancies were included in the prediction. These findings are discussed as they relate to current conceptions of trait optimism.

Factors influencing return to work after aortocoronary bypass surgery

Factors influencing the effect on employment status were investigated in 250 patients (males: females 224:26) who underwent coronary artery bypass surgery between March 1983 and November 1985. The median age at operation was 57.9 (range 36.6-69.4) years and the median follow-up time 32 (19-52) months. Preoperatively 149 patients (59.6%) were receiving sick pay or disability pension because of their heart disease. Only 64 (25.6%) were gainfully employed, in contrast to 97 (38.8%) at follow-up. Of those who were working at the time of operation, all but eight returned to work postoperatively. At follow-up 183 (80.3%) were free from symptoms or much improved, with degree of improvement somewhat greater in those who were working postoperatively. The period of sick leave and the preoperative waiting time were significantly shorter for patients who were working postoperatively than for those who were awarded disability pension. Age, previous myocardial infarction, duration of preoperative angina and type of work were also found to influence postoperative employment status.

Effects of cardiac rehabilitation after coronary artery bypass grafting on readmissions, return to work, and physical fitness. A case-control study

In a case-control study 49 consecutive post-coronary artery bypass grafting (CABG) patients (10 f, 39 m) participating in a comprehensive rehabilitation programme were compared with 98 individually matched double control patients, receiving standard care. The rehabilitation programme, starting 6 weeks after surgery, consisted of follow-up at a coronary clinic, repeated health education, and physical training in out-patient groups. During the first year after CABG, fewer study group patients were readmitted to hospital (14% vs 32%, p less than 0.01) and on fewer occasions (1.1 vs 2.9, p less than 0.05). Fewer patients used anxiolytic drugs (0% vs 15%, p less than 0.01). At the one year post-CABG exercise test we found in the study group a tendency to a greater increase in work capacity, as compared with the values obtained at the preoperative exercise test (33 vs 25 W ns). There were no differences in the rates of returning to work (59% vs 64%). In a long-term follow-up study (av. 38 months post-CABG) the patients were asked to fill in a questionnaire evaluating perceived physical work capacity and training habits. The study group patients rated their physical work capacity higher, and more patients had continued with regular physical training (66% vs 46%, p = 0.05). There were fewer patients using anxiolytic drugs (9% vs 30%, p less than 0.01). Although the programme did not influence the return to work we conclude that it improved the quality of life of our patients as it entailed fewer readmissions and reduced the use of anxiolytic medication; in addition it promoted physical fitness and training habits.

Return to work after percutaneous transluminal coronary angioplasty

A prospective study of 82 patients employed in the 6-month period before percutaneous transluminal coronary angioplasty (PTCA) was performed to determine the patterns of lag time in work resumption and the factors associated with early return to work. One month after PTCA, 59% of patients had resumed work whereas 87% were employed 6 months after PTCA. Patients who had a myocardial infarction in the month before PTCA, as well as those with less than 12 years of education, blue collar jobs and low levels of self-efficacy (self-confidence) for return to work had a lower probability of work resumption at every point in the 24 weeks of follow-up. Cox proportional hazards analysis revealed the psychosocial construct, self-efficacy, to be the strongest predictor of return to work 1 month after PTCA, independent of having a recent myocardial infarction, disease severity, age, job classification, gender and physician advice (p = 0.0006). Kaplan-Meier analysis for return to work after PTCA confirmed that patients with high self-efficacy estimates obtained just before hospital discharge after PTCA resumed employment earlier than those with low self-efficacy levels (p = 0.0001). The same relation was observed in those patients with and without a myocardial infarction in the month before PTCA, p = 0.0022 and 0.0012 respectively. These findings suggest that although PTCA is considered relatively safe and minimally invasive by physicians, patients may still lack confidence in their ability to return to work even when physically capable of doing so.

Psychosomatic aspects of coronary artery bypass graft surgery. A prospective study of 101 male patients

101 consecutive male patients were examined by means of clinical interviews and depression, anxiety, personality, psychometric and life stress tests. The examinations took place preoperatively, on the 9th postoperative day (average) and 7.5 months after surgery. The mean age of the patients was 52.2 years and the mean duration of CHD was 6.7 years. Prior to surgery 77% had experienced myocardial infarction and 85% belonged to NYHA class III or IV. 74% had a 3-vessel disease. When the NYHA classification was used as criterion for rehabilitation the result was excellent. Postoperatively 80% belonged to NYHA class I or II. Hospital mortality rate was 4% and one patient died from myocardial infarction prior to the final follow-up. Preoperatively 17% of the study group were working. 87% of the patients experienced negative effects on work life, caused by CHD. Postoperatively 33% worked regularly. The postoperative work situation correlated with the duration of preoperative unemployment (p less than 0.0001), the patient's own opinion about work return (willingness/unwillingness to return to work) (p less than 0.01), as well as with the amount of negative life stress experienced preoperatively (p less than 0.01). Only 13% of the series experienced positive effects on work life, caused by CABG surgery. The majority of the patients had experienced negative effects on social and economic life (51%), as well as on sexual life (70%), caused by CHD. After surgery improvements were noted by 36% on social life and by 27% on sexual life. 15% experienced impairment of sexual life postoperatively. According to the Beck Depression Inventory 29% showed depression preoperatively, and 10% postoperatively. The difference is significant (p less than 0.0001). Clinically the figures tended to be higher. The same tendency holds for anxiety scores as measured by the Hamilton anxiety scale. The incidence of postoperative psychoses was 35%. Higher age (p less than 0.01) and/or absence of psychosomatic diseases (p less than 0.05) correlated with higher frequency of psychoses. Even though cardiological rehabilitation according to the NYHA classification was excellent, 22% of the series did not think their expectations were fulfilled. Psychic and social rehabilitation was in several aspects unsatisfactory, and the patients did not seem prepared for this. The importance to consider rehabilitation from a psychosomatic standpoint is clearly shown. To predict the result of rehabilitation preoperatively is not possible.

Quality of life variables in surgical trials

Clinical trials are commonly performed in surgery to assess the efficacy of one or more treatments. Many therapies result in only partial or temporary improvement, rather than cure. Others sharply affect the quality of patients' lives or of their deaths. For most interventions, it is important to document effects on quality of life as well as morbidity and mortality rates. yet, a review of the literature reveals that very few surgical trials consider quality of life variables as outcome measures. Surgical investigators in areas like cancer, inflammatory bowel disease, end stage renal disease, and cardiac disease have examined quality of life issues extensively using a variety of scales and indices. However, most studies on quality of life are hampered by poor design and inadequate methods of assessment. Failure to evaluate quality of life variables prevents the recognition and full use of potentially beneficial therapies and the rejection of potentially harmful ones.

Percutaneous transluminal coronary angioplasty: current status and future trends

Although originally percutaneous transluminal coronary angioplasty (PTCA) was used only in patients with well-preserved left ventricular function and single-vessel coronary disease, the criteria for selection of patients have enlarged as experience with the procedure has accumulated. Currently, patients with multivessel coronary disease, coronary occlusions, or myocardial infarction are also eligible to undergo PTCA. Technologic advances such as steerable guidewire systems have improved the success rates and have facilitated dilation of severe lesions even in tortuous vessels. Despite the increasing complexity of cases, the frequency of occurrence of complications (such as coronary dissection, occlusion, and infarction) has decreased while the success rates have improved substantially.

Return to work after coronary angioplasty: a report from the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry

Employment status was analyzed in 2,250 patients enrolled at 65 clinical centers in the NHLBI PTCA Registry. Patients were classified into 3 groups depending on the outcome of PTCA. In 63.6%, PTCA was successful without MI or CABG (Group A); in 25.3%, PTCA was unsuccessful and was followed by CABG (Group B); and in 11.1%, PTCA was unsuccessful and was followed by medical therapy alone (Group C). At entry, 68.3% of all patients were employed full- or part-time. The clinical characteristics of the 3 groups were different. Patients in Group C had a higher incidence of previous MI and previous CABG. In addition, patients in Group C had a significantly decreased baseline employment rate compared with those in Group A. At a mean follow-up of 1.5 years, there was a small but similar decrease in the percentage employed full- or part-time in all groups. Employment status also was analyzed in a subset of 1,150 patients working full- or part-time at baseline and aged 60 years or younger, who would be expected to have the highest return to work rates. At a mean follow-up of 1.4 years, 81 to 86% of patients remained working irrespective of the outcome of PTCA. However, patients with successful PTCA returned to work significantly sooner. The occurrence of chest pain during follow-up in these patients was an important predictor of return to work, irrespective of the outcome of dilatation. In patients with chest pain during follow-up, only 77% were working, compared with 90% of patients who had not had chest pain.

The effects of coronary bypass surgery on female sexual, psychological, and vocational adaptation

This paper reports the first study of female sexual, psychological, and vocational adaptation to coronary artery bypass surgery (CABG). Semistructured interviews were used to obtain data on 17 women undergoing CABG. Four time periods were examined: prior to and after the onset of cardiac symptoms; four months and one year after CABG. Female sexual response differs from what is known about male adaptation to CABG in three ways: 1) women did not demonstrate a significant and profound decline in frequency of intercourse one year after surgery; 2) the component most vulnerable to disruption in women is desire, in men it is arousal; 3) women do not harbor the sexual fears commonly seen in men such as sudden death during intercourse or performance anxiety. Psychologically, women fared better than men, but were less likely to return to work. This indicates that more attention should be directed toward vocational counseling of working women undergoing CABG.

Employment and recreation patterns in patients treated by percutaneous transluminal coronary angioplasty: a multicenter study

Employment and recreational patterns were analyzed in 279 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) for treatment of symptomatic coronary artery disease. PTCA was successful in 180 patients (65%). When it was unsuccessful, coronary artery bypass graft surgery was usually performed (80%). Return-to-work rates were high irrespective of the outcome of PTCA. Of patients employed full-time or part-time before treatment, 98.5% of those who had successful PTCA alone and 97% of those whose PTCA was unsuccessful but who underwent uncomplicated coronary artery bypass surgery maintained or improved their work status. In a subgroup of men who had been employed in occupations requiring physical labor, 85% of the men whose PTCA was successful returned to work, compared with 68% of those whose PTCA was unsuccessful. The interval from attempted PTCA to return to work was significantly shorter in the successfully treated group; in patients with successful PTCA, the median time to return to work was 14 days, compared with 60 days in patients in whom PTCA was unsuccessful (p less than 0.001). During follow-up, patients with successful PTCA had less angina and were more active in recreational activities than patients who required alternative treatments.

Cardiac rehabilitation following coronary artery bypass surgery

Early expectations of coronary revascularization prolonging life and reducing coronary events have been modified by 15 years' experience to mostly initial palliation of ischemic symptoms. Bypass surgery represents only a single therapeutic aspect for coronary atherosclerosis. Technically successful operations often fail miserably without overall risk factor alteration and functional capacity optimization which progressive exercise initiates during the postoperative period. Regular activity program participation improves physical conditioning, raises the symptom-limited exertional level, lessens post surgical musculoskeletal discomfort, and improves morale. Yet exercise alone without comprehensive secondary prevention and risk factor modification will be no more successful at arresting atherosclerosis than any other single measure. Both operative intervention and vigorous exertion are valuable components of coronary artery disease therapy, but must be part of an all-embracing effort. Whether regular exertion combined with overall risk factor modification will prolong life and reduce future cardiac events or beneficially alter the process of atherogenesis remain areas of avid investigation.

The rehabilitation of coronary surgical patients

Coronary revascularization has been reported to have failed to effectively rehabilitate working-age patients. This study of 565 patients demonstrates that motivation to return to work is strongly influences by age and educational level. Patients under age 55 are more likely to return to work than are patients over that age, but preoperative job classification does not influence rehabilitation. Although preoperative disability was associated with a slightly lower return-to-work rate (90%) than was the case with patients working preoperatively (97%) preoperative retirement was a strongly negative influence on rehabilitation. In this study, 80% of the patients worked to or beyond retirement age, and duration of work was not influenced by preoperative disability. The salary produced by those patients who were rehabilitated by surgery was four and a half times greater than the total cost of care and disability payments for the entire patient population. The factors which seemed to be the most important in effective rehabilitation were the psychological preparation of patients and their families and the attitude toward rehabilitation expressed by physicians and employers.

Employment patterns in males before and after myocardial revascularization surgery. A study of 2229 consecutive male patients followed for as long as 10 years

Loss of productivity is a major concern among patients with heart disease. To assess the effect of surgery on this factor, we surveyed every living male patient of the surgeon authors operated on from January 1968 through March 1978 (96% follow-up) and compared their pre- and postoperative work status with the U.S. population as reported by the U.S. Bureau of Labor Statistics (USBLS). Comparisons were made on an age-for-age basis and adjustments were made for changes in national employment patterns from 1968-1978. Preoperatively, our younger patients had a 10% lower employment rate than the U.S. male population at large according to the USBLS. Postoperatively, many returned to work, but an equal number who worked preoperatively did not postoperatively. The ability to work full time with little or no limitation increased 20% after operation. The main reason for not working was physical disability, with doctor's advice a distance second. Older patients showed a trend of accelerated retirement after surgery. A few returned to work, but many more retired. The ability to work full-time without limitation increased 4%. Thirty percent of all older subjects cited a desire to relax as their main reason for not working. Compared with the early years of surgery, patients in later years were older and did not show as much preoperative disability. There was some evidence of a deterioration of the effects of surgery. Patients with severely impaired left ventricular function fared worse both pre- and postoperatively, but the improvement was the same as for patients with normal or moderately impaired left ventricular function.

Activity level and employment status after coronary bypass surgery

Questionnaires were sent to 1,100 postoperative coronary patients to evaluate their symptoms, activity level and employment status. Ninety percent considered themselves improved and more active since surgery. Many of the patients were approaching retirement age at the time of surgery, and 20 percent of the group entered retirement postoperatively. Disregarding those who were unemployed or disabled from noncardiac illness before surgery, 82 percent of the patients either retired or returned to work after coronary surgery. From an economic standpoint, the disabled patients who have been able to return to work by virtue of the operation will generate for the economy 34 percent more than the total cost of surgery for all the patients.

Cardiac surgery in a small community: an eight-year experience

Long-term results of 374 open-heart procedures performed over an eight-year period in a small community hospital are presented. Patients were followed up for an average of 49 months. The heart unit did not conform to the yearly volume of cases suggested by current national guidelines. Nonetheless, we obtained some interesting results. 1. The hospital mortality in nonemergency coronary artery bypass operations was 1.8%; in all types of bypass operation, 3.3%; and 5.1% for all types of cardiac operation. 2. The attrition rate was less than 1% per year for all types of patients with a total long-term survival of 92%. 3. Patients having coronary artery bypass had a yearly attrition rate of 0.66% and a total long-term survival of 94.2%. 4. The average hospital cost per patient having open-heart operation was $9,670 in 1978 and $11,073 in 1979. Case volume requirements for an open-heart-surgery unit in our area allowed an exception from the guidelines with emphasis on quality of results rather than quantity. This permitted comprehensive cardiac care especially for the poor and those with fixed incomes unable to afford the cost of traveling and associated expenses. Further similar reports may be valuable in the formulation of health policies for small communities that guarantee the health rights of all segments of the population.

Clinical follow-up of 106 patients five years after coronary bypass surgery for angina pectoris

One hundred and six consecutive survivors were re-examined five years after coronary bypass surgery for stable angina pectoris (88 patients) or unstable angina (18 patients). Ninety-two per cent had less symptoms than before operation, 70% were so improved that they were not restricted in daily life and 30% considered themselves free from angina. Excluding one patient, who experienced chest pain at the exercise test and three asymptomatic patients who had undergone repeat operations, only 26% were free from angina at the five-year evaluation. Patients without angina had significantly lower diastolic blood pressure than those with residual symptoms, whereas the type of angina, smoking habits, serum lipids and common risk factors did not differ significantly. Thirteen per cent were employed on admittance for surgery, 49% had been able to work after surgery and 36% of those, who did not have old-age pension or invalidity pension for non-cardiac causes, worked full-time five years after surgery. Patients with sedentary work returned more often (53%) than those with manual labour (22%) and patients with sick-leave less than six months before surgery more often (91%) than those with sick-leave more than two years (13%). Peri-operative infarction was recorded in 5% and a further 10% suffered late myocardial infarction.