Resumption of Work after Acute Myocardial Infarction

Myocardial infarction in Malmö during the 10-year period 1963--1972

Myocardial infarctions in Malmö during the 10-year period 1963--1972 have been studied. The mortality from myocardial infarction decreased significantly among men during this period but not among women. The incidence of hospital-treated infarction increased significantly among men, mainly due to an increase in primary infarctions. The one-year survival in this hospital material did not improve during the period. The number of days of sick-leave during 12 months before primary infarction was significantly higher than expected. The duration of sick-leave during the year after primary infarction remained unchanged throughout the period. The mortality figures relate to all age groups, comprising 2 111 men and 1 409 women. The hospital incidence relates to men and women aged 65 years or below and comprises 1 323 men and 279 women during the period concerned. The reduced mortality and increased incidence of hospital-treated infarction are probaby explained by the fact that more men seek hospital treatment, leading to a better prognosis. The long duration of sick-leave after infarction is probably due to causes other than strictly medical factors.

Work-related outcomes after a myocardial infarction

STUDY OBJECTIVE

To evaluate work-related outcomes of patients at 7 months after a myocardial infarction and to identify patient, disease, and intervention characteristics associated with these outcomes.

DESIGN

Cross-sectional survey analysis.

SETTING

Large Midwestern academic health system.

PATIENTS

Eighty-nine patients with the discharge diagnosis of acute myocardial infarction during a 1-year index period.

INTERVENTION

Work performance questionnaire administered by telephone, and medical record review.

MEASUREMENTS AND MAIN RESULTS

Seven months after discharge, 232 patients were interviewed by telephone to determine work status before and after myocardial infarction, work-related outcomes (absenteeism and perceived work performance, assessed by the Work Performance Scale [WPS] of the Functional Status Questionnaire), and health-related quality of life. Univariate analyses were used to determine the association between individual characteristics and work-related outcomes. Of the 89 patients who had worked before the index myocardial infarction, 21 (23.6%) did not return to work. Variables associated with the outcome of not returning to work were past myocardial infarction (before the index myocardial infarction), coronary artery bypass graft surgery, heart failure, positive stress test, and low score on the Physical Component Summary (PCS-12) scale of the Short Form-12. Patients who did not return to work also tended to have more comorbidities and take more prescribed drugs than those who returned to work. Median WPS scores were higher for patients who had higher ejection fractions at discharge, had not experienced a myocardial infarction before the index event, underwent a percutaneous revascularization intervention at the time of hospitalization, and had not recently been absent from work. Workers reporting absences had lower PCS-12 scores than their counterparts or reported a rehospitalization before the survey.

CONCLUSION

Preexisting cardiac disease and poorer physical functioning were consistently related to worse work-related outcomes. This small study demonstrates the need for a larger, broader study that includes health beliefs, treatment, and other job and patient factors that may influence work-related outcomes.

Referral to occupational medicine clinics and resumption of employment after myocardial infarction

Rehabilitation after acute myocardial infarction (AMI) consists of education, exercise, and an encouragement to return to work (RTW). This study attempts to (1) determine whether the time interval between AMI and the visit at occupational medicine (OM) clinics predicts resumption of full employment, and (2) estimate the incidence of work-related recurrent AMI after RTW. We followed 216 consecutive AMI patients at a single OM clinic. The independent variables were clinical and personal data, physical workload and time between AMI, and first visit to the OM clinic. The outcome variables were full employment 24 months after the acute event and recurrent AMI during this period. Of all patients, 168 attempted RTW. Of these, 18 stopped working subsequently. Of the remaining 150 patients, 54 returned to part-time work and 96 were employed full-time after 2 years. Logistic regression indicated that a failure to resume full employment was independently associated with diabetes, older age, Q wave AMI, angina before AMI, heavy work, and a late visit to the OM clinic. For each month's delay in referral to the OM clinic, there was a 30% decrease in the chance for full employment 24 months after AMI. Six (4%) of the 150 patients who resumed employment sustained a recurrent AMI, two of them while at work. A delayed referral to the OM clinic was associated with work disability after AMI. Late referrals to OM clinics should receive a more intensive and sustained rehabilitation than early referrals. Whether an earlier referral to OM clinics will result in increased RTW rates is unknown. Patients who attempted to resume employment had a 1.2% risk of a recurrent ischemic event at their workplace.

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).

The importance of systematic inquiry in nursing research: An example; women and recovery from acute myocardial infarction

A review of the literature related to recovery from acute myocardial after discharge from the hospital revealed that very little is known about the recovery period in women. The recovery period has been studied in men with the major focus on cardiac rehabilitation, return to work, and sexual activity. In this descriptive exploratory study women were compared to men in these three areas of recovery within 3 to 9 months after discharge from the hospital. There were statistically significant differences in the following areas: marital status, more women were widowed or single; women had more responsibility for household duties after acute myocardial infarction, a decrease in frequency of sexual activity, and more reports of chest pain during sexual activity. Subjects reported little or no counselling by nurses with regard to cardiac rehabilitation, return to work or household duties, and resumption of sexual activity.

Myocardial infarction and patients' wives

When a patient has a myocardial infarction (MI), all aspects of marital function are affected. Soon after the MI, patients' wives experience psychological distress that decreases with time. Illness behaviors among the MI patients' wives increase, and aggressive and sexual impulses are often inhibited. Many families experience changes in members' work status after the husband has an MI, and wives are faced with increased chores. Marital interaction also changes. Dysfunctional marital relationships are associated with a poor psychosocial outcome. Additionally, spousal factors such as dependency are also likely to affect patients. Intervention strategies are best directed to wives at risk for problems.

A randomized control trial of cardiac rehabilitation

A randomized trial using controls tested whether psycho-social rehabilitation of acute myocardial infarction (MI) patients would improve significantly their return to work rate and assessed the importance of various psychological, social, occupational, socio-demographic, and medical factors in facilitating or impeding rapid return to work. Eighty-nine patients were assigned randomly to participate in an experimental cardiac rehabilitation program (rehab care), and 91 patients were controls who received conventional hospital rehabilitation (usual care). By the first follow-up interview at three months, patients assigned to experimental treatment were significantly less distressed psychologically and less dependent on family support than controls (P = 0.04 and P = 0.05, respectively). By the final follow-up interview at 13 months, there was a marginally significant difference in favor of the experimental group in the frequency of reported deterrents to work resumption (P = 0.07). However, the intervention did not result in a statistically significant difference in the return to work rate (P greater than 0.10). In each group, 88% were back at work by approximately the first year after infarction. In addition, the two groups were similar in the amount of time patients remained out of the workforce (median days rehab care = 75, usual care = 81; P greater than 0.10). A multi-stage data analysis procedure utilizing the Cox regression technique indicated that while several independent variables had significant univariate associations with the length of time patients convalesced, outcome was most influenced by the patient's initial cardiological status and clinical course, by the patterns of family support, and by the several variables measuring the presence of obstacles to resuming work. Our findings suggest that rehabilitation programs intervening on multiple levels (psychological, social, occupational, and physical) may best meet the needs of chronically ill cardiac patients. Results indicate that implementing measures addressing the patient's general psycho-social adjustment to MI may improve existing programs.

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.

Medical, psychological and social correlates of work disability among men with coronary artery disease

This study identifies the medical, psychologic and social factors that independently affect employment in patients with coronary artery disease (CAD). At coronary angiography, extensive clinical, psychological and social profiles were collected on 814 men younger than 60 years with documented CAD. Clinical factors studied included measures of symptom severity, prior myocardial infarction, coronary anatomy and left ventricular function. Psychosocial factors studied included the Minnesota Multiphasic Personality Inventory (MMPI), Zung Depression and Anxiety Scales, a type A structured interview, Jenkins Activity Survey and measures of education and social support. Multiple logistic regression analyses were used to assess the relative strength of the relation between these different factors and the patients' employment status. Many single factors differed between the 204 men (25%) who were disabled and the 610 (75%) who were not. Disabled men were less educated but no different in age, marital status or number of dependents. Disabled men had lower ejection fractions and higher indexes of angina, previous myocardial infarction and coexisting vascular disease. Disabled men also were more depressed and anxious and had lower ego strength and higher hypochondriasis scores on the MMPI, but were no different in type A behavior. By multivariable analysis, the most significant (p less than 0.01) independent predictors of work disability were, in decreasing order of importance, low education level, history of myocardial infarction, high levels of depression and high levels of hypochondriasis. It is concluded that psychological and social factors are strongly related to work status in patients with CAD, and may be more important than medical factors.

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.

Early discharge and return to work following myocardial infarction

Individuals who have experienced a myocardial infarction (MI) account for the largest component of all hospitalization costs and foregone earnings due to cardiac disease. Early return to full employment and premorbid activity level should be the focus of cost-effective rehabilitative programs. Yet the economic benefits of vocational rehabilitation have not been directly researched. Therefore, issues of import regarding activity after MI include the timing of ambulation, discharge and return to work. Studies of early mobilization and discharge are contrasted in terms of methodology and outcome. These cite economic, social and psychological advantages, yet these factors are examined in isolation of other variables. A review of the literature reveals that there is a reluctance by many health professionals to institute such practices based in part on the dilemma surrounding selection of specific indicators and risk factors. Yet analysis reveals that the contention surrounding these exclusion criteria is perhaps unfounded, as the variance is less than is commonly assumed. Recurrent themes likewise emerge regarding the multiplicity of variables associated with the timing of resumption of employment, which is considered to be the most precise index of recovery following an MI. Of these, only early intense rehabilitation, directed at attitudinal and behavioural change, is amenable to modification by health professionals. Related research endeavours have examined employment following aortocoronary bypass surgery, risk factors in the work environment and work stressors which occur following MI. Controversy arises regarding the correlation of age and personality factors with return to work. Discrepancies in research findings are attributed to the diverse approaches to data collection, obstacles encountered in measuring psychological states, lack of operational definitions, differences in degree of rehabilitation and length of follow-up and the absence of controlled trials. Clearly, experimental research focusing on the job-related economic and human cost impact of specific rehabilitation programs must be conducted.(ABSTRACT TRUNCATED AT 400 WORDS)