Return to work after first myocardial infarction

Interventions to support return to work for people with coronary heart disease

BACKGROUND

People with coronary heart disease (CHD) often require prolonged absences from work to convalesce after acute disease events like myocardial infarctions (MI) or revascularisation procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Reduced functional capacity and anxiety due to CHD may further delay or prevent return to work.

OBJECTIVES

To assess the effects of person- and work-directed interventions aimed at enhancing return to work in patients with coronary heart disease compared to usual care or no intervention.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and LILACS through 11 October 2018. We also searched the US National Library of Medicine registry, clinicaltrials.gov, to identify ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) examining return to work among people with CHD who were provided either an intervention or usual care. Selected studies included only people treated for MI or who had undergone either a CABG or PCI. At least 80% of the study population should have been working prior to the CHD and not at the time of the trial, or study authors had to have considered a return-to-work subgroup. We included studies in all languages. Two review authors independently selected the studies and consulted a third review author to resolve disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and independently assessed the risk of bias. We conducted meta-analyses of rates of return to work and time until return to work. We considered the secondary outcomes, health-related quality of life and adverse events among studies where at least 80% of study participants were eligible to return to work.

MAIN RESULTS

We found 39 RCTs (including one cluster- and four three-armed RCTs). We included the return-to-work results of 34 studies in the meta-analyses.Person-directed, psychological counselling versus usual careWe included 11 studies considering return to work following psychological interventions among a subgroup of 615 participants in the meta-analysis. Most interventions used some form of counselling to address participants' disease-related anxieties and provided information on the causes and course of CHD to dispel misconceptions. We do not know if these interventions increase return to work up to six months (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.84 to 1.40; six studies; very low-certainty evidence) or at six to 12 months (RR 1.24, 95% CI 0.95 to 1.63; seven studies; very low-certainty evidence). We also do not know if psychological interventions shorten the time until return to work. Psychological interventions may have little or no effect on the proportion of participants working between one and five years (RR 1.09, 95% CI 0.88 to 1.34; three studies; low-certainty evidence).Person-directed, work-directed counselling versus usual careFour studies examined work-directed counselling. These counselling interventions included advising patients when to return to work based on treadmill testing or extended counselling to include co-workers' fears and misconceptions regarding CHD. Work-directed counselling may result in little to no difference in the mean difference (MD) in days until return to work (MD -7.52 days, 95% CI -20.07 to 5.03 days; four studies; low-certainty evidence). Work-directed counselling probably results in little to no difference in cardiac deaths (RR 1.00, 95% CI 0.19 to 5.39; two studies; moderate-certainty evidence).Person-directed, physical conditioning interventions versus usual careNine studies examined the impact of exercise programmes. Compared to usual care, we do not know if physical interventions increase return to work up to six months (RR 1.17, 95% CI 0.97 to 1.41; four studies; very low-certainty evidence). Physical conditioning interventions may result in little to no difference in return-to-work rates at six to 12 months (RR 1.09, 95% CI 0.99 to 1.20; five studies; low-certainty evidence), and may also result in little to no difference on the rates of patients working after one year (RR 1.04, 95% CI 0.82 to 1.30; two studies; low-certainty evidence). Physical conditioning interventions may result in little to no difference in the time needed to return to work (MD -7.86 days, 95% CI -29.46 to 13.74 days; four studies; low-certainty evidence). Physical conditioning interventions probably do not increase cardiac death rates (RR 1.00, 95% CI 0.35 to 2.80; two studies; moderate-certainty evidence).Person-directed, combined interventions versus usual careWe included 13 studies considering return to work following combined interventions in the meta-analysis. Combined cardiac rehabilitation programmes may have increased return to work up to six months (RR 1.56, 95% CI 1.23 to 1.98; number needed to treat for an additional beneficial outcome (NNTB) 5; four studies; low-certainty evidence), and may have little to no difference on return-to-work rates at six to 12 months' follow-up (RR 1.06, 95% CI 1.00 to 1.13; 10 studies; low-certainty evidence). We do not know if combined interventions increased the proportions of participants working between one and five years (RR 1.14, 95% CI 0.96 to 1.37; six studies; very low-certainty evidence) or at five years (RR 1.09, 95% CI 0.86 to 1.38; four studies; very low-certainty evidence). Combined interventions probably shortened the time needed until return to work (MD -40.77, 95% CI -67.19 to -14.35; two studies; moderate-certainty evidence). Combining interventions probably results in little to no difference in reinfarctions (RR 0.56, 95% CI 0.23 to 1.40; three studies; moderate-certainty evidence).Work-directed, interventionsWe found no studies exclusively examining strictly work-directed interventions at the workplace.

AUTHORS' CONCLUSIONS

Combined interventions may increase return to work up to six months and probably reduce the time away from work. Otherwise, we found no evidence of either a beneficial or harmful effect of person-directed interventions. The certainty of the evidence for the various interventions and outcomes ranged from very low to moderate. Return to work was typically a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Adhering to RCT reporting guidelines could greatly improve the evidence of future research. A research gap exists regarding controlled trials of work-directed interventions, health-related quality of life within the return-to-work process, and adverse effects.

A survey to assess the educational-level interference on self-evaluation of acute pain

OBJECTIVE

The present study aimed to evaluate whether patient education level interferes in the percentage of pain relief or increase using visual analogue scale (VAS) and subjective pain perception.

PATIENTS AND METHODS

Ninety-five patients presenting acute shoulder pain due to enthesitis were evaluated. They were asked to quantify the pain using VAS before steroid articular infiltration. One week later, patients reevaluated the pain using VAS and orally stated the percentage of perceived pain increase or relief. The information gathered was then compared among three patient educational levels (elementary, high school, and university).

RESULTS

Percentages of improvement stated orally and utilizing VAS presented no statistically significant differences among the three educational status levels (p = 0.804).

CONCLUSION

Patient educational status caused no impact in the results of acute pain self-assessment with VAS and oral evaluation.

The effect of streptokinase on return to work 18 months after a first myocardial infarction

In order to assess the impact of thrombolytic therapy on return to work eighteen months after a first myocardial infarction, 32 patients treated with streptokinase were compared with 30 patients not treated with streptokinase. The study was designed as a historical cohort study. The patients in both groups had continuous chest pain of less than six hours prior to admission and electrocardiographic changes consistent with acute myocardial infarction (MI). The two groups were comparable with respect to medical variables related to their myocardial infarction and to educational level. A total of 17 patients (53%) in the streptokinase group and 16 (53%) among controls had stopped working eighteen months after their MI. An association between the treatment and the working status could not be found (relative risk = 1.0) nor could it be found if the figures were corrected for deaths and retirements because of age. In conclusion, this study could not demonstrate any beneficial effect of thrombolytic therapy on the return to work eighteen months after an initial myocardial infarction.

Comparison of long-term outcome after acute myocardial infarction in patients never graduated from high school with that in more educated patients. Multicenter Investigation of the Limitation of Infarct Size (MILIS)

The clinical course of 363 patients with acute myocardial infarction who did not complete high school education was compared with that of 453 who completed at least high school. Both the in-hospital and 4-year mortality rates were markedly greater for the less educated than for the more educated patients (13 vs 5% [p < 0.001], and 36 vs 17% [p < 0.001]). Adverse baseline characteristics were partially responsible for the increased in-hospital (p = 0.059 after adjustment) and long-term (p = 0.024 after adjustment) mortality. The less educated patients were not as likely to quit smoking after acute myocardial infarction as were the more educated ones (38 vs 49%; p < 0.05). Patients who continued smoking had a greater mortality than did those who quit (24 vs 15% [p < 0.05] for less educated, and 10 vs 4% [p < 0.05] for better educated). Therefore, greater effort should be directed to smoking cessation among the high-risk group of less educated patients. However, the smoking continuation was responsible for only a small portion of the mortality difference, suggesting unidentified causes of mortality, such as lack of compliance with therapy and possible social isolation. Despite the high-risk status of the less educated patients, cardiac catheterization tended not to be performed as frequently as in the more educated patients after discharge from the hospital (16 vs 21%; p < 0.06 at 6 months).

Factors influencing return to work following hospitalization for traumatic injury

This paper describes the employment experience of 266 individuals one year after traumatic injury severe enough to require hospitalization. Of those working full-time prior to their injury, 56 per cent were employed full-time at one year; an additional 5 per cent were working part-time. Those sustaining a severe head or spinal cord injury were at highest risk of not returning to work (only 43 per cent and 21 per cent, respectively, had returned within the year). Low one-year employment rates (58 per cent) were also noted for individuals whose most severe injury was to one or more extremities. The extent and rate of return to work was examined in relation to selected socioeconomic and personal characteristics. Findings indicate that after controlling for type and severity of injury, personal income, and educational level of the injured person, as well as the identification of a strong social network as defined by the presence of one or more confidants, were important correlates of post-injury employment status.

Return to work after a myocardial infarction: the influence of background factors, work characteristics and illness severity

The relationship between return to work (RTW) within 6 months after a myocardial infarction (MI) and selected demographic factors, characteristics of prior work situation, pre-MI health status, and clinical severity of the MI has been studied in 249 patients below 67 years of age living in urban and rural areas of Western Norway. At the follow-up 8 out of 10 urban patients and 6 out of 10 rural patients were back at work. The RTW rate for the total sample was 73%. Age below 51 years, high educational and income level, working in tertiary industries, and in a job characterized by low physical activity and little psychosocial stress were all factors associated with a favourable work resumption. Multivariate analyses showed that socioeconomic or work-related factors could not fully explain the urban-rural differences in RTW. Stepwise discriminant analysis identified the following factors as important and independent predictors for RTW: Place of residence, age, education, perceived job stress, and clinical complications during hospitalization. Failure to return to work after a MI can be explained by a number of individual and social factors and only to a limited degree by the medical status of the patient. More knowledge is needed concerning the socio-cultural differences among both patients and attending physicians in attitudes towards work resumption after a MI.

Coping with myocardial infarction: a model with clinical applications, a literature review

Following a myocardial infarction any residual symptoms are likely to remind the patient of a possible fatal outcome and be detrimental to successful rehabilitation. Negative psychological attitudes need to be identified early. Intervention to improve the mental state should be introduced to restore self-confidence.

Prognosis after initial myocardial infarction: the Framingham study

During 20 years of follow-up of 5,127 men and women initially free of coronary heart disease in the Framingham cohort, 193 men and 53 women had one or more recognized, symptomatic myocardial infarctions. An additional 45 men and 28 women had unrecognized myocardial infarctions. Subsequent mortality and morbidity including angina, reinfarction, congestive failure and sudden death were ascertained. One in five men who had a first myocardial infarction died within 1 year, a mortality rate 14 times that of those free of coronary heart disease. In men who survived the 1st year, a recognized myocardial infarction increased risk of death over the next 5 years to 23 percent, four times that of the general population. The next 5 years carried a 25 percent mortality (three times that of the general population). The prognosis was distinctly worse in women than in men chiefly because of a higher (45 percent) early mortality rate in women. Patients with recognized and unrecognized myocardial infarctions had similar survival rates after 3 years. A second myocardial infarction occurred in 13 percent of the men and in 40 percent of the women within 5 years of the first infarction. Thus, women were more prone to death and reinfarction than men. Congestive heart failure occurred as commonly as reinfarction, affliction 14 percent of the men within 5 years of the initial infarction. Once congestive failure ensued, half of the affected patients were dead within 5 years. Angina developed in one third of the patients within 5 years of their first infarction.

Cardiovascular responses to dynamic and static effort soon after myocardial infarction. Application to occupational work assessment

Static and dynamic work involving the arms and the legs was performed by 40 men seven weeks after myocardial infarction. Leg ergometry produced a significantly higher peak work load, systolic blood pressure (BPs), heart rate (HR), and HR X BPs X 10(-2) product (DP) than did arm ergometry: 842 +/- 178 vs 546 +/- 135 kg-m/min, 176 +/- 24 vs 154 +/- 19 mm Hg and 256 +/- 54 vs 219 +/- 48 (SD). Peak heart rates were 145 and 142. Endpoints were primarily muscular and generalized fatigue and dyspnea. Ischemic abnormalities and ventricular ectopy were more frequent with leg ergometry. Sustained forearm lifting elicited higher HR, PBs and DP responses than sustained handgrip contraction: 95 +/- 16 vs 91 +/- 16 beats/min, 162 +/- 18 vs 152 +/- 17 mm Hg and 154 +/- 33 vs 139 +/- 33 (SD). Ischemic ST segment depression and significant ventricuar arrhythmias were infrequent with static effort. Dynamic leg testing is superior to dynamic or static arm testing in assessing the capacity of patients to perform physical work tasks after myocardial infarction.

Group education after myocardial infarction: Is it effective?

An analysis of the results of a study of a group of post-infarction patients who had received group instruction concerning the nature of myocardial infarction, compared with patients not so instructed, is presented. Contrary to expectation, anxiety levels as measured by the Catel IPTA Anxiety Scale were significantly higher in patients who experienced group education. Regardless of this finding, patients were subjectively appreciative of education.

Studies of correlation between progression of coronary artery disease, as assessed by coronary arteriography, left ventricular end-diastolic pressure, ejection fraction, and employability

The occupational status of a group of 100 male patients, 35 to 68 years of age, with chronic ischaemic heart disease was studied, and related to the severity and distribution of coronary artery stenosis seen on the arteriograms and to left ventricular function. In this series of patients 31 per cent were working, 31 per cent were recorded as temporarily sick, and 38 per cent as permanently disabled. It appears that while the type of previous occupation and physical activity associated with the job were of importance, there was no correlation between employability on the one hand and severity and distribution of coronary artery disease on the other. 'Blue-collar' workers had a higher rate of unemployment than those in 'white collar' occupations, but this could not be explained by differences in severity of coronary artery disease.

Myocardial infarction in car assembly workers

The incidence of myocardial infarction and the return to work for survivors were studied among the employees of an English car assembly plant by analysing 12 811 medical records of persons employed during the seven years between January 1966 and December 1972. The standardized morbidity ratio of myocardial infarction found in this study calculated on the basis of incidence rates reported by Kinlen )1973) for the Oxford community in which the factory was situated was 90. The standardized morbidity ratio from production line workers only was 66 and that for the monthly paid staff 272. Of the production line workers who survived the attack 22 (90%) returned to their previous jobs without undue difficulty and with two exceptions within four months of the onset of their illness; there was no relation between length of absence and age at the time of attack. These findings suggest that workers in mass production jobs such as car assembly are not special risk from myocardial infarction, and most of those who survive a heart attack are able to return to their former work. Taken with Kinlen's (1973) study and that of Armstrong et al. (1972) in Edinburgh, they also bear out mortality data by indicating that in Oxfordshire the incidence of coronary heart disease is lower than the British average.