Influence of a cardiac rehabilitation programme on the return to work of workers with ischaemic heart disease: Influence of a cardiac rehabilitation programme

Observational Study 1 Medicine® Influence of a cardiac rehabilitation programme on the return to work of workers with ischaemic heart disease Influence of a cardiac rehabilitation programme Manuel Delgado-Calderón, MD, MSca, Lara Estefanía Jiménez-Ortega, MD, MSca, María Ladisa, MD, PhDb, Juan Carlos Camacho-Vega, PhDc,d , Ángel Vilches-Arenas, PhDb,e , Luis Gabriel Luque-Romero, PhDe,f,g , Israel Macías-Toronjo, MSch, Javier Fagundo-Rivera, PhDi, Juan Gómez-Salgado, PhDj,k,* Abstract This study aimed to examine the employment status of patients who have experienced ischemic heart disease one year after undergoing cardiac rehabilitation. For this, a quasi-experimental pre-post study without a control group of active workers aged 18 to 65 years diagnosed with ischemic heart disease and included in a cardiac rehabilitation programme was conducted. Sociodemographic and occupational data, cardiovascular risk factors and clinical-therapeutic data on heart disease were collected. A total of 214 patients were included, of which 115 patients returned to work. Several clinical factors contributing to return to work were identified: preserved left-ventricular ejection fraction (≥55%), < 3 obstructed coronary vessels, and stent revascularisation. Socio-occupational factors that may positively influence return to work were identified: age < 50 years, absence of anxious-depressive symptoms, higher level of education, and occupations with low physical strain. Cardiac rehabilitation is effective in improving cardiac function and health-related quality of life in workers with ischemic heart disease. Return to work and duration of temporary incapacity were associated with clinical-therapeutic variables and psycho-socio-occupational factors, such as type of job, physical strain, anxiety and depression, and age of the worker. Abbreviations: AMI = Acute Myocardial Infarction, CRP = Cardiac Rehabilitation Programme, CVRF = Cardiovascular Risk Factors, HRQoL = Health-Related Quality of Life, LVEF = Left Ventricular Ejection Fraction, MET = Metabolic Equivalent of Task, THR = Training Heart Rate. Keywords: cardiac rehabilitation, health-related quality of life, ischaemic heart disease, return to work, social and occupational factors 1. Introduction Despite advances in the management of acute coronary syndrome that have significantly changed its prognosis, atherosclerotic cardiovascular disease remains the leading cause of death in Western countries.[1] Currently, the risk of a new cardiovascular event after a first myocardial infarction remains high, in part because of residual damage.[2] In this context, cardiac rehabilitation programmes are particularly indicated after the diagnosis of acute myocardial infarction (AMI), as they have been shown to be effective in improving functional capacity, controlling Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for publication. The authors have no funding and conflicts of interest to disclose. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. This study received a favorable opinion from the Research Ethics Committee of the Virgen Macarena and Virgen del Rocio University Hospitals (C.P.MDC01/C.I.1968-N-22). a Resident Internal Specialist Physician, Hospital Universitario Virgen Macarena, Sevilla, Spain, b Department of Preventive Medicine, Hospital Universitario Virgen Macarena, Sevilla, Spain, c Department of Building Construction II, Higher Technical School of Building Engineering, University of Seville, Sevilla, Spain, d Occupational Risk Prevention Unit, Hospital Universitario Virgen Macarena, Seville, Spain,e Department of Preventive Medicine and Public Health, University of Seville, Sevilla, Spain, f Unidad de Investigación, Distrito Sanitario Aljarafe- Sevilla Norte, Sevilla, España, g Instituto de Biomedicina de Sevilla (IBiS), Campus Hospital Universitario Virgen del Rocío, Sevilla, España, h Department of Rehabilitation, FREMAP Huelva, Huelva, Spain, i Centro Universitario de Enfermería Cruz Roja, University of Seville, Sevilla, Spain, j Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, Huelva, Spain, k Safety and Health Postgraduate Programme, Universidad Espíritu Santo, Guayaquil, Ecuador. * Correspondence: Juan Gómez-Salgado, Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva. Avda. Tres de Marzo, S/N, Huelva 21007, Spain, (e-mail: [email protected]; salgado@ uhu.es). Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. How to cite this article: Delgado-Calderón M, Jiménez-Ortega LE, Ladisa M, Camacho-Vega JC, Vilches-Arenas Á, Luque-Romero LG, Macías-Toronjo I, Fagundo-Rivera J, Gómez-Salgado J. Influence of a cardiac rehabilitation programme on the return to work of workers with ischaemic heart disease: Influence of a cardiac rehabilitation programme. Medicine 2024;103:47(e40452). Received: 16 July 2024 / Received in final form: 21 October 2024 / Accepted: 22 October 2024 http://dx.doi.org/10.1097/MD.0000000000040452 Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2024 2 Delgado-Calderón et al. • Medicine (2024) 103:47 Medicine coronary risk factors,[3–6] reducing symptoms, and improving psychological distress.[7] There is also evidence of cost-effective- ness benefits.[8,9] Its multidisciplinary structure (cardiologists, rehabilitation physicians, primary care physicians, nurses, physiotherapists, and psychologists) allows interventions in different areas (physical training, correction of cardiovascular risk factors, psychological support) to guarantee a complete functional recovery.[10] It must be noted that a cardiac patient’s recovery is not considered complete until they are able to return to their “normal activities,” including work, with as few restrictions as possible. In fact, patients who are deemed unable to work, or who “self-disable” from work for reasons beyond their functional capacity, have a poorer quality of life, a higher frequency of frequent anxious-depressive symptoms, and poorer control of their risk factors.[11] Numerous prospective studies have been conducted over the past 25 years that provide potentially robust data to assess factors that may influence return to work after ischemic heart disease.[12] Although most patients return to work after a first episode of myocardial infarction, about 1 in 4 do not return to their usual occupation, either because of dismissal, voluntary resignation, permanent incapacity (total/absolute), or job change.[13,14] Only 25% of patients who do not return to work following a myocardial infarction do so because of a cardiac problem.[15] In contrast, the variables that make it most difficult to return to work are usually not cardiac or specifically medical in origin, but psychological and social in nature, accounting for up to 75% of sick leaves and incapacity to work. Therefore, the so-called “return to work” will in most cases be conditioned by factors other than cardiac functional capacity,[16,17] such as psychological factors (feeling of incapacity, anxiety-depressive symptoms, pessimistic attitude), social factors (age, low social class, household economic situation), and occupational factors (hard work, job dissatisfaction, income). Understanding the factors that influence return to work after an acute cardiac event, such as an AMI, should help to promote return to work by addressing these factors where possible. Moreover, it is worth remembering that Spain is one of the countries in Europe with the lowest level of implementation of cardiac rehabilitation programmes (barely covering 5%-6% of patients with any type of cardiopathy that could benefit from rehabilitation treatment), sometimes for spurious reasons.[18,19] The purpose of the present study was to evaluate the impact of cardiac rehabilitation programmes on the process of returning to work after an ischemic cardiac event. 2. Methods 2.1. Design A quasi-experimental pre-post study without a control group study was designed. The first stage studied the baseline variables before the cardiac rehabilitation programme (CRP). The second phase, one year after the end of the CRP, analyzed the occupational variables of all the patients recruited, using a clinical interview with telephone data collection. 2.2. Population and sample Patients with ischemic heart disease (chronic angina, acute coronary syndrome, or any diagnosis in this category defined in the ICD-10 with codes I20 to I25) treated with percutaneous transluminal coronary angioplasty, bypass surgery, or conservative therapy, and who completed a CRP during the defined study period. During the study period, 396 patients received a CRP. Based on the total number of patients, purposive sampling was performed using the inclusion and exclusion criteria, excluding 182 subjects, thus leaving a final sample size of 214 patients. In the telephone follow-up, 10 cases refused to provide work data and were coded as missing data in the statistical analysis. 2.3. Study period From January 01, 2020 up to and including December 31, 2021. The follow-up of the workers’ clinical-occupational situation was analyzed one year after the end of the CRP. 2.4. Inclusion criteria • Age range between 18 and 65 years. • Being in active employment (self-employed and/or employed, and registered with social security) at the time of the ischemic heart event. • Patients included in the cardiac rehabilitation programme during the defined study period. • Having completed the cardiac rehabilitation programme within the specified study period. 2.5. Exclusion criteria • Being on unemployment benefit (contributory or not) at the time of the ischemic heart event. In the case of “not self-em- ployed,” exclusion criteria include being on unemployment benefit (contributory or not) or simply not actively working at the time of the cardiovascular event. • Not having completed the cardiac rehabilitation programme, with the following criteria defined as non-comple- tion: failure to attend the minimum number of scheduled sessions; failure to complete the follow-up questionnaires; failure to complete the final cardiac function tests (echocardiography and ergometry). 2.6. Study variables Cardiovascular risk factors (CVRF), clinical-therapeutic factors, employment status, cardiac functional capacity, and Health- Related Quality of Life (HRQoL) were assessed before and after completion of the CRP. • CVRF: Alcohol and smoking habits; personal and family history of heart disease; high blood pressure; lipid and glycaemic profile; physical activity; obesity; y abdominal circumference of risk (>94 cm in men and > 80 cm in women). • Socio-demographic: sex, cohabitation, level of education, and age at which the worker was assessed at the first Cardiac Rehabilitation appointment. • Clinical-therapeutic: type of heart disease; coronary vessels involved; cardiovascular risk group (3 cardiovascular risk groups (low, medium, and high) are defined according to the patient’s ergometry, left ventricular ejection fraction (LVEF), and CVRF assessment.); and therapeutic approach. • Work history (at the start of the CRP): usual occupation; work shift; length of service; physical strain (physical requirements of the job quantified in metabolic equivalent of task (METs): low effort (<4 METs), moderate effort (4–6.9 METs), and high effort (7 or more METs); history of incapacity and disability. • Cardiac functional capacity: LVEF; type of exercise test; METs achieved on exercise test; training heart rate; and functional class. • HRQoL: SF-36[20]; SHIM, the Sexual Health Inventory for Men[21]; Goldberg Anxiety and Depression Scale.[22] In addition, a clinical interview was specifically structured for the descriptive analysis of another set of employment Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2024 3 Delgado-Calderón et al. • Medicine (2024) 103:47 www.md-journal.com variables, which allowed the determination of the employment situation of the patients one year after the end of the CRP: • Job-related variables (1 year after the end of the CRP): duration of temporary incapacity; reason for not returning to work (unemployment, retirement, recognition of permanent incapacity or disability); perception of current work ability*; relapses and whether there was an assessment by a prevention service and the resulting occupational aptitude report. * perception of the physical and mental resources available to the individual to meet the requirements of the job. It should not be confused with “work capacity,” which indicates the capacity to carry out physical work. This variable was obtained with the telephone follow-up carried out twelve months after the end of the cardiac rehabilitation programme by asking the worker about their perception of their ability to return to work after the heart disease. 2.7. Procedures Participants attended a CRP on a scheduled basis. The schedule set up by the Cardiac Rehabilitation Unit of the Virgen Macarena University Hospital in Seville includes 2 sessions per week for 2 months (with a minimum of 12 training sessions out of the 20 scheduled), in addition to attending health education and psychosocial intervention sessions. The data on the cardiac rehabilitation programme recorded in the patient’s single digitized medical record in the Andalusian Health Service (Diraya) were used to collect these data, with the patients’ prior informed consent to access these data. Therefore, the report of the first cardiac rehabilitation consultation after discharge from the coronary care unit was used to record the baseline variables (CVRF, clinical-therapeu- tic, and cardiac functional capacity variables) and the results of the battery of questionnaires (SF-36, Mediterranean diet, Goldberg, and SHIM) before the programme, and these data were reassembled for analysis after the last cardiac rehabilitation session. Information on the worker’s clinical and employment situation was obtained by telephone, after obtaining informed consent, through a clinical interview with a series of specific questions during the follow-up 1 year after the end of the rehabilitation programme. The variables in the database were collected in an anonymous form. 2.8. Statistical analysis The Statistical Package for Social Sciences (SPSS) version 29.0 for Windows, licensed by the University of Seville, was used to process and analyze the data, and differences with a P value < .05 were considered statistically significant. Continuous variables with a normal distribution were expressed as mean (X) ± standard deviation (SD); when the distribution was not normal, the median (Me) ± interquartile range (IQR) was used. Categorical variables are presented as numbers and percentages. The Kolmogorov–Smirnov test was used to check the normal distribution of the variables, and Levene’s analysis was used to verify the equality of variances. When some of the samples were very small, the distribution was not normal and the Mann– Whitney U test or Kruskal–Wallis test was used. The correlation between two variables was measured using Sperman’s-Ro. The chi-squared test was used to compare qualitative independent variables. For paired qualitative data, the McNemar test was used for 2 × 2 square (tetrachoric) tables, and the McNemar-Bowker test was used for higher order tables. 2.9. Ethical and legal aspects The proposed study respects the fundamental principles of the Declaration of Helsinki and complies with current legislation regarding respect for patient autonomy (Law 41/2002, of 14 November, Basic Law regulating patient autonomy and rights and obligations regarding clinical information and documentation) and the protection of personal data (Organic Law 3/2018, of 5 December, on the protection of personal data and the guarantee of digital rights). The study also received a favorable opinion from the Research Ethics Committee of the Virgen Macarena and Virgen del Rocio University Hospitals (C.P.MDC01/C.I.1968-N-22). 3. Results A total of 214 subjects were analyzed in the present study, with a mean age of 54 years ± 6 years (SD), with a minimum of 28 years and a maximum of 65 years. Of the patients, 83.9% were male and 10.7% were female. 80.8% of the individuals were cohabiting in a couple relationship. Given the need to obtain specific data on the variables that would define the context of the workers’ return to work one year after completing the cardiac rehabilitation programme, a specific clinical interview was set up by telephone; after analyzing the responses, it was observed that 56.4% of the subjects (n = 115) had actively returned to work. More than half (59.1%) continued to work for the same company or organization, 25.2% worked for another company, and 15.7% were self-employed. Upon returning to work, the predominant shift was the day shift (97.5% of cases), with no workers having a fixed night shift; in addition, 21.7% of subjects had a reduced working day, with heart disease being the reason for this reduction in 80% of cases. Table 1 describes the data on the duration of temporary incapacity and the type of event. Table 2 describes the causes of non-return to work and the prevalence of permanent incapacity and of disability of cardiac origin. 43.6% of the subjects (n = 89) had not returned to work, of whom 39.3% were receiving a noncontributory benefit for not having contributed enough years of work. Among the workers with a permanent incapacity to work, the percentage of recognized disability had a mean value of 40% ± 7% standard deviation, with a minimum value of 33% and a maximum value of 66%. Of the 115 people who returned to work, three were found to have total permanent incapacity for the jobs of lorry driver, delivery driver, and security guard. All of them had changed companies, had different jobs, and had been assessed by an external prevention service. On the other hand, there were three cases of recognition of absolute permanent incapacity while working as a bricklayer, an agricultural laborer, and a mechanic. Relapses (stent restenosis, ischemia in a new location, etc.) were rare among those who had returned to work, and in most cases required a short period of temporary incapacity (<30 days). Table 3 shows, on the one hand, the frequency distribution of the bodies that carried out the health assessment of the workers who had returned to work and, on the other hand, the contrast in the perception of the work capacity of the group that had not returned to work. It should be taken into account that in the case of workers examined by doctors from the Andalusian Public Health Service (SSPA, for its acronym in Spanish), outside the field of occupational risk prevention, no report on fitness for work was issued. Table 3 shows that 81.7% of the workers who returned to work were assessed by a prevention service or a mutual insurance company collaborating with the social security. After this assessment, 47.87% continued in the same job, 23.40% required a job adaptation but without changes in their usual Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2024 4 Delgado-Calderón et al. • Medicine (2024) 103:47 Medicine tasks, and 22.35% worked in the same job but with changes in their functions and tasks. 6 cases (6.38%) required a change of job. All the patients followed up by the APHS (Andalusian Public Health System) physicians were in the same job. In terms of the type of occupation they performed, 69.23% of the group of workers who had returned to work were in administrative/intellectual occupations, compared to 23.33% of the group who performed elementary occupations. Half of the Table 1 Duration of temporary disability and type of event Duration of temporary disability No of patients (%) Time from completion of programme to discharge No of patients (%) N = 204 N = 115 Up to 6 months 22 (10.78) Occupational discharge during CRP 20 (17.4) 6–9 months 36 (18.64) Up to 2 months 26 (22.6) 9–12 months 24 (11.4) 2–4 months 25 (21.7) 365 days or more 122 (59.18) 4–6 months 36 (30.3) 6 months or more 8 (7) Occupational event N = 204 Type of occupational event Yes 8 (3.9) Occupational accident 8 (100) No 196 (96.1) Occupational illness 0 (0) CRP = cardiac rehabilitation programme. Table 2 Reasons for not returning to work. Permanent incapacity and disability Reason for not returning to work No of patients (%) Type of permanent incapacity No of patients (%) N = 89 N = 61 Recognition of permanent incapacity. 58 (65.17) Partial 0 (0) Unemployment 20 (22.47) Total 58 (95.08) Retirement 11 (12.36) Absolute 3 (4.92) Severe incapacity 0 (0) Permanent incapacity of cardiac origin N = 204 Noncontributory benefit N = 89 No 143 (70) No 54 (60.7) Yes 61 (30) Yes 35 (39.3) Cardiac impairment N = 204 Relapse N = 115 No 143 (70) No 102 (88.7) Yes 61 (30) Yes 13 (11.3) Table 3 Medical examination and perception of work capacity after cardiac rehabilitation programme Medical examination following return to work No of patients (%) Entity performing medical examination No of patients (%) N = 214 N = 115 Yes 115 (53.7) Third-party prevention services 66 (57.4) Not returning to work 89 (41.6) In-house prevention service 23 (20) Lost data 10 (4.7) Mutual Societies Collaborating with Social Security 5 (4.3) Andalusian Public Health Service Specialists (not Occupational Health Services) 21 (18.3) Current occupational perception (those NOT returning to work) N = 89 Current occupational perception (those returning to work) N = 115 I am not physically limited to work 3 (3.4) I am not physically limited to work 53 (46.1) I am able to work, but this does cause me symptoms 10 (11.2) I am able to work, but this does cause me symptoms 26 (22.5) I often vary my working rhythm and work patterns 21 (23.6) I often vary my working rhythm and work patterns 13 (11.3) I need to change job 25 (28.1) I need to change job 12 (10.8) I do not feel able to work 30 (33.6) I do not feel able to work 11 (9.3) Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2024 5 Delgado-Calderón et al. • Medicine (2024) 103:47 www.md-journal.com skilled installers/assemblers were able to return to work, as were 33.33% of the catering and security workers and 44.47% of the drivers and machine operators. Table 4 describes the results of the occupational aptitude report according to the job held after returning to work. The inferential analysis of the socio-demographic variables showed that sex was not a determining factor in the duration of temporary incapacity (OR: 0.972; CI 95% 0.640–1.476; P > .05), but there were significant differences in the median time elapsed from the end of CRP to the subject’s return to work (81 days for men vs 146 days for women). In terms of age, significant differences were found when the sample was grouped using the age of 55 as a reference (OR: 2.100; 95% CI 1.706–2.585; P < .05), with 73.6% of subjects in the group aged ≤ 55 years returning to work (vs 55.4% in the group aged > 55 years) and also with a shorter duration of temporary incapacity. A higher level of education also made a statistically significant contribution to return to work, with a 93.75% return to work rate and shorter duration of temporary incapacity time in the group with at least a higher education qualification or university studies (OR: 1.483; CI 95% 1.207–1.800; P < .05). Most of the CVRFs analyzed showed a statistically significant improvement, except for alcohol consumption, weight, body mass index, adherence to the Mediterranean diet, sexual dysfunction, and anxiety symptoms. Among those who had completed the CRP, mean blood LDL-cholesterol levels decreased (109 mg/dL vs 58 mg/dL) as well as median basal blood glucose levels (111 mg/dL vs 91 mg/dL). The level of leisure time physical activity increased, with no patient having a sedentary habit after the programme and 92.5% of patients engaged in moderate level exercise (P value .03). Abdominal circumference decreased, with 45% of the subjects with abdominal circumference of risk (vs 58% at baseline, P value .016), although weight improved in only 30.3% of the patients (P value .016). The number of patients with blood pressure greater than 140/90 mm Hg was reduced after the programme to 34.6% (vs 51.9% at baseline, P value .021), as was the proportion of active smokers (12.61% vs 53.3% at baseline, P value .014). There was also a statistically significant benefit for the full set of cardiac functional capacity variables, with 72% of patients having preserved LVEF, more than half of subjects (56.5%) achieving > 10 METs on the exercise test, and significant differences in improvement in resting heart rate (RHR) and exercise heart rate (EHR) at the end of the programme. Furthermore, EHR had an inverse and statistically significant relationship with the duration of temporary incapacity (correlation coefficient r = −0.371). When analyzing the duration of temporary incapacity, almost 60% of workers had achieved a duration of 12 months. This variable did not follow a normal distribution, with a median (Me) of 365 days and an interquartile range (IQR) of 119 days, a minimum of 38 days and a maximum of 365 days. The time from the date of discharge from the cardiac rehabilitation unit to the date of discharge from work was also quantified. The analysis of this quantitative variable showed a normal distribution with a mean (X) of 102 ± 57 days, a minimum of 14 days and a maximum of 299 days. Both the rate of return to work and the time off work were found to be associated with various clinical-therapeutic variables, cardiac function, and occupation. Table 5 lists the variables that had a statistically significant influence on return to work and those that had a statistically significant relationship with the duration of temporary incapacity. In terms of the type of work performed, a statistically significant relationship was found between the need for more job adaptations and the more physically demanding the job was for patients who had suffered a heart attack and had returned to work. Table 6 shows the change in the results of the HRQOL questionnaires at the end of the CRP,[20–22] with a statistically significant difference in the improvement of depressive symptoms and the SF-36 score. The variables that significantly influenced the duration of temporary incapacity are also shown. 4. Discussion The mean return to work rate in the present study (56.4%) differs significantly from that reported in publications from Table 4 Working capacity by type of job Same job position Adjusted job position without change in functions or tasks Adjusted job position with change in functions or tasks Change of job position Administrative or intellectual work N 30 2 1 0 % 66.7 9.1 4.8 0 Catering, security services, and vendors N 4 7 5 2 % 8.9 34 23.8 33.3 Installers and assemblers N 5 0 5 1 % 11.2 0 23.8 16.7 Drivers and operators of fixed or mobile machinery N 2 5 0 1 % 4.3 20.5 0 16.7 Elementary occupations N 4 8 10 2 % 8.9 36.4 47.6 33.3 Data refer to workers who returned to work and were assessed by a prevention service or a mutual insurance company collaborating with the Social Security. Table 5 Influence of the variables on return to work and duration of the temporary disability % return to work Days of temporary disability (P value < .05) Coronary vessels involved <3 vessels 76.7 0 ≥3 vessels 55.2 0 Therapeutic management PTCA 61.08 225 Bypass 42.3 316 Left-ventricular ejection fraction (%) <55 vs ≥ 55 40.3 vs 63.2 0 METs following CRP <7 vs ≥ 7 19.8 vs 67.08 342 vs 278 Type of occupation Administrative 76.9 281 Elemental 45.83 365 Physical strain of job position Low 74.3 273 Moderate-High 41.36 365 CRP = cardiac rehabilitation programme, PTCA = percutaneous transluminal coronary angioplasty. Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2024 6 Delgado-Calderón et al. • Medicine (2024) 103:47 Medicine other countries, which report return to work rates of 89% and 66.9%.[19,23] Focusing on the Spanish context, several studies show return to work rates ranging from 40% to 70%.17,24–27 These differences in return rates need to be considered in relative terms, and it is therefore advisable to acknowledge the heterogeneity of studies with very different sample sizes, study periods, populations, or selected follow-up. It is also important to consider the year of publication because of the current advances in endovascular treatment. In terms of socio-demographic variables, this study shows that a lower percentage of subjects return to work after the age of 55 and that age is a good predictor of return to work, with the most significant differences found in the 50 to 60 age group according to the majority of publications reviewed.[16,25,27–29] On the other hand, skilled workers with higher levels of responsibility return to work more often than unskilled workers,[11,26,30] as can be seen in the group of workers with university education. In this study, there was an 8:1 ratio in favor of the male sex, a figure that is similar to published studies in working-age AMI patients and that fluctuates between 80% and 95%.[18,27,31–33] In this sense, according to the literature, the female sex has a higher risk of not returning to work, as a worse recovery is described than that observed in men of a similar age.[30,34] However, in the present study, sex was not a determining factor for return to work, although a statistically significant association was found for a longer period of sick leave in women between the end of CRP and discharge from work. It would be interesting for future studies to assess whether these data are related to the type of job performed by the patient, the functional cardiac capacity, the psychophysical demands of the job or the overall job satisfaction (psychological and economic) by carrying out an analysis disaggregated by sex. The fact that 77.4% of workers returning to work in the present study were cohabiting partners is consistent with other publications suggesting that cohabitation promotes HRQoL and cardiovascular health for both partners through mutual support in adherence to diet, exercise, and treatments, which may be associated with a more successful and earlier return to work.[33,35,36] Several publications conclude that clinical-cardiological variables have less influence on the return rate than socio-economic and occupational variables.[37,38] However, there is a large body of literature showing a greater relevance of these clinical variables.[26,31,33,39] This study showed that the extent of myocardial damage as measured by LVEF, the number of vessels affected, and the treatment option chosen were significant factors in determining return to work. Of the group of workers who returned to work, none worked in night shifts. Shift work, especially at night, causes greater emotional stress due to increased physical and mental strain, sleep disturbance, and poor diet with increased consumption of caffeine, tobacco and alcohol, factors that are not particularly favorable in the development of ischemic heart disease and that increase the likelihood of relapse.[11,27,30,39] The type of occupation and the physical strain (quantified by METs) of the job showed an association with the duration of temporary incapacity and return to work. This was statistically more significant when comparing occupations with more highly qualified tasks (teachers, physicians, architects, lawyers, etc.) with elementary occupations (agricultural workers, bricklayers, warehouse workers, etc.). The results of the present study are in line with those observed in most of the literature, according to which workers in more physically demanding manual jobs return to work less frequently than those in more intellectual, less physically demanding jobs.[11,16,17,26,28,30,40] In the context of return to work, a safety margin must be established so that the physical effort required by the worker’s duties and functions does not exceed 80% of the METs obtained in the exercise test at the time of discharge, or 40% if the work involves continuous physical effort.[10,30,41] Workers must be made aware that the aim is not to restrict them, but to give them positive guidance on what they can do without risks, depending on their functional capacity, with the aim of reintegrating them into the labor market at any time. With regard to temporary incapacity to work, the mean duration in the present study remains high (305 days) and is also considerably longer than that published in previous studies, with mean durations of temporary incapacity to work ranging from 180 to 240 days.[17,26,27,29,39] In clinical practice and according to the National Social Security Institute’s Occupational Assessment Guide, a good approximation for jobs with heavy workloads would be a sick leave period of 4 months for patients revascularised with stents or 6 months for aorto-coronary bypass operations, but these periods are unjustifiably prolonged in many cases in Spain.[15] In line with the above observations, the literature reviewed also seems to confirm an excessive duration of temporary incapacity, even in patients with good functional capacity after rehabilitation, and that this phenomenon is caused by psychosocial factors not related to work.[7,10,19,40] Indeed, as noted in the present analysis, there are publications in which the psychological factors most associated with a lower likelihood of returning to work are the patient’s perceived health-illness status, an introverted personality, and the presence of depression and anxiety.[42–44] Thus, the benefits of the psychosocial interventions provided by these programmes in terms of successful return to work are clear. In relation to patients’ individual perceptions of their health, the SHIM showed that the presence of sexual dysfunction, even mild, at the end of the programme was significantly associated with an increase in the duration of the temporary incapacity. There is no consistent literature on this finding, only that erectile dysfunction has been shown to be a cardiovascular risk factor predictive of coronary heart disease, especially in men under the age of 60. This may be explained by the anxiety-de- pression component that may affect the coronary patient and their partner, who may fear that sexual intercourse will trigger a cardiovascular event, thus creating a vicious cycle that prevents normal sexual activity.[45,46] The present study allowed to describe, at no economic cost and in a quick and easy way, important factors for return to work, such as type of occupation, psychosocial factors, functional capacity, and whether there was a recognized disability or incapacity. Also, the inclusion of data on sex, toxic habits, sedentary lifestyle, or body mass index prevents these variables from acting as confounders. The sample size required for statistical power (and external validity) could not be calculated because the study covered the first two years of the SARS-CoV-2 pandemic, during which time Table 6 Health-related quality of life (HRQoL) variables following cardiac rehabilitation programme and influence on return to work Pre-CRP/ post-CRP Days of temporary incapacity (P value < .05) (Risk factor not present vs present risk factor) Mental status Anxiety 36.9%/30.44% 301 vs 365 Depression 56.10%/38.22% 291 vs 365 Sexual dysfunction (SHIM) 77.5%/61.44% 250 vs 348 SF-36 score 46.92/70.21 r = −0.398 In the 3rd column, the days of Temporary Incapacity without the presence of the risk factor are compared with the days of Temporary Incapacity if the risk factor were present. CRP = cardiac rehabilitation programme, SHIM = Sexual Health Inventory for Men. Downloaded from http://journals.lww.com/md-journal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/20/2024 7 Delgado-Calderón et al. • Medicine (2024) 103:47 www.md-journal.com far fewer appointments were scheduled in the hospital cardiac rehabilitation gym and many patients were referred to outpatient CRPs. For various reasons, some data were lost; for instance, patients close to 65 years of age who took early or permanent disability retirement did not provide information on the conditions of their return to work. Similarly, in patients under 45, work capacity may have been overestimated because they had a better organic functional reserve. In addition, if contact by telephone was not possible, or if the patient did not consent to telephone follow-up, no data on the patient’s current clinical and employment situation could be obtained. Approximately 40% of the references are in Spanish. It is important to compare these results with the results of cardiac rehabilitation programmes in a closer environment, so that the resources, planning, and outcome of CRP are more homogeneous than when comparing with other countries with greater availability of resources or other training plans. In fact, it would be useful for future studies to conduct a more exhaustive review of articles in English in order to strengthen the conclusions. Finally, it is worth noting that the fact that workers reported information about their return to work via a clinical telephone interview may have contributed to the appearance of non-re- sponse and conformity bias. 5. Conclusions In conclusion, CRP has a beneficial effect on the return to work of workers who have suffered an ischemic cardiac event, with several factors showing a statistically significant influence on return to work: socio-demographic (age and level of education); clinical-cardiological (LVEF, number of coronary vessels affected, and type of revascularisation); and occupational (type of occupation and physical strain). A statistically significant association was found between certain variables and the duration of temporary incapacity: socio-demographic (age and educational level); therapeutic (percutaneous transluminal coronary angioplasty vs bypass); functional (METs at discharge and exercise heart rate); occupational (type of occupation and physical strain); and health-re- lated quality of life (SF-36 score, anxious-depressive symptoms, and sexual dysfunction). Most of the CVRFs and cardiac functional capacity variables showed a statistically significant improvement following the CRP. In the group of subjects who had returned to work, a statistically significant relationship was found between the need for better job adjustment and the greater the physical demands of the functions and tasks required by the job. This group also had a better job perception than the group of participants who had not returned to work. Author contributions Conceptualization: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho- Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Data curation: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho- Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Formal analysis: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho- Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Investigation: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho- Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Methodology: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho- Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Project administration: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, Juan Gómez-Salgado. Resources: Manuel Delgado-Calderón, Lara Estefanía Jiménez- Ortega, María Ladisa, Juan Carlos Camacho-Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías- Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Software: Manuel Delgado-Calderón, Lara Estefanía Jiménez- Ortega, María Ladisa, Juan Carlos Camacho-Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías- Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Supervision: Manuel Delgado-Calderón, Lara Estefanía Jiménez- Ortega, María Ladisa, Juan Carlos Camacho-Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías- Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Validation: Manuel Delgado-Calderón, Lara Estefanía Jiménez- Ortega, María Ladisa, Juan Carlos Camacho-Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías- Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Visualization: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho- Vega, Ángel Vilches-Arenas, Luis Gabriel Luque-Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Writing – original draft: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho-Vega, Ángel Vilches-Arenas, Luis Gabriel Luque- Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. Writing – review & editing: Manuel Delgado-Calderón, Lara Estefanía Jiménez-Ortega, María Ladisa, Juan Carlos Camacho-Vega, Ángel Vilches-Arenas, Luis Gabriel Luque- Romero, Israel Macías-Toronjo, Javier Fagundo-Rivera, Juan Gómez-Salgado. References [1] Estadística de defunciones según la causa de muerte: Últimos datos . Instituto Nacional de Estadística (INE). [cited on 14 Nov. 2023]. https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736176780&menu=ultiDatos&idp=1254735573175. 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