International Journal of Cardiology 130 (2008) e14 e16 www.elsevier.

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Letter to the Editor

Return to work after acute myocardial infarction Listen to your doctor!

Jerneja Farka a,, Katja erne a , Mitja Lainak b,c , Irena Keber a
c

Department of Vascular Diseases, University Medical Center, Zaloska 7, SI-1000 Ljubljana, Slovenia b Department of Internal Medicine, General Hospital Murska Sobota, Murska Sobota, Slovenia Division of Applied Cachexia Research, Department of Cardiology, Campus Virchow Clinic, Charit Universittsmedizin Berlin, Germany Received 24 May 2007; accepted 1 July 2007 Available online 1 October 2007

Abstract Predictors of return to work after an acute myocardial infarction (AMI) are not fully established. In multivariate analysis adjusted for sex, age and type of intervention, only doctor's advice remained associated with return to work (HR 47.6, 95% CI 4.7500). This suggests that doctor's advice is a comprehensive integration of patient interview, clinical examination, evidence based medicine and clinical experience, and thus the key predictor of return to work after AMI. 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Acute myocardial infarction; Return to work; Physical factors; Socio-demographic factors; Psychological factors

1. Introduction Return to work is an important part of complete recovery and successful social reintegration after acute myocardial infarction (AMI) [1]. Due to the complex interplay of physical [1,2], socio-demographic [1,3,4], and psychological factors [1,5,6] the identification of eligible patients for return to work still presents a difficult challenge for the attending physician. To date, no universal indicators of return to work after AMI were identified. The purpose of this study was to assess the effect of different physical, socio-demographic, and psychological factors, and doctor's advice on return to work after AMI in patients attending multidisciplinary out-patient rehabilitation programme. 2. Methods In retrospective study we reviewed 247 out-patient rehabilitation programme medical records from period between 1999 and 2002. A structured questionnaire asses-

sing the physical, socio-demographic, and psychological factors was sent to 161 patients, who were younger than 60 years and full time employed prior to AMI, and alive 12 months after AMI. Socio-demographic factors included educational level, marital status, partner's employment status, social support, and, specifically, doctor's advice about return to work. Psychological factors included patient's wish to return to work, their mood after AMI, and working place stress. The National Ethics Committee approved the study protocol and all patients gave written informed consent. Data are presented as mean values ( SD) or proportion of patients. Student's t-test for independent samples, chi-square test, Pearson's correlation test, and multiple logistic regression analysis adjusted for sex, age, and type of intervention were applied as appropriate. We used SPSS 12.0 software package and p value of b 0.05 was considered statistically significant. 3. Results Seventy-four patients (46%) returned complete questionnaire and were included to the final analysis. Respondents and non-respondents did not differ in demographic characteristics, risk factors, pharmacological treatment, and

Corresponding author. Tel.: +386 41522123; fax: +386 15228020. E-mail address: jnfarkas@volja.net (J. Farka). 0167-5273/$ - see front matter 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.07.041

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return to work (70% vs. 67%). Respondents were split according to the return to work (52 vs. 22 patients) and were comparable for demographic characteristics. Table 1 summarizes response for physical, sociodemographic, and psychological factors. The groups differed in specific doctor's advice to return to work (73% vs. 5%, p b 0.001). Thirty-eight out of 39 patients (positive predictive value 0.97) who reported to receive doctor's advice to return to work actually returned to work, while 21 of the remaining 35 (negative predictive value 0.6) did not continue employment. Table 2 summarizes the results of univariate analysis. In multivariate analysis, adjustment for sex, age and type of
Table 1 Physical, socio-demographic, and psychological factors in patients with acute myocardial infarction Return to work (N = 52) Physical factors Exercise testing Able to perform heavy exercise Able to climb N 2 lifts of stairs Able to walk N 1500 m Recurrent angina pectoris Socio-demographic factors Married Partner employed Secondary school or less Doctor's advice to return to work Social support Partner Family Friends Co-workers Doctor Psychological factors Wished to return to work Mood 12 months after AMI Nervous most/all the time Depressed most/all the time Joyful most/all the time Melancholic most/all the time Working place prior to AMI Work was very stressful Stress associated with illness Work was important 8.6 ( 2.4) MET 32 (61%) 48 (92%) 38 (73%) 14 (27%) No return to work (N = 22) 7.3 (1.8) MET 6 (28%) 18 (82%) 11 (50%) 9 (41%) p

Table 2 Predictors of return to work univariate analysis Correlation coefficient Doctor's advice to return to work Performed heavy physical activity Wished to return to work Received support by co-workers Received support by friends Exercise testing in MET's 0.674 0.331 0.275 0.268 0.260 0.255 p b 0.001 0.004 0.018 0.021 0.025 0.029

intervention, only doctor's advice remained associated with return to work (HR 47.6, 95% CI 4.7500). 4. Discussion The reemployment rate in our study is consistent with previous reports of 62%92% [1]. We did not observe any association with age, sex, educational level or marital status as reported previously [1]. Irrespective to return to work, most patients reported receiving support by their family members. Friends and co-workers support, however, was significantly more frequent in patients who returned to work. Positive attitude and support by co-workers, a common finding in similar studies, seems to be of importance in reemployment after AMI [4]. In univariate analysis the doctor's advice was strongly associated with return to work and remained the only predictor in the multivariate model. Thus, it appears doctor's advice encompasses several physical, socio-demographic, and psychological factors. This finding is novel and as such it was not reported before. Yet, it is in line with previous reports and confirms the reported importance of doctor's advice to return to work in patients after AMI or coronary artery bypass surgery [1]. These observations imply that doctor's advice is and will probably always remain the best predictor of reemployment after AMI. The retrospective design and average response rate resulted in relatively small sample size. However, there were no differences between the respondents and nonrespondents. Another caveat is the self-assessment questionnaire, answered by the patients at home. Nevertheless, the questionnaire bias cannot be avoided, irrespective of the assessment type used in the study. In conclusion, doctor's advice predicted the return to work in patients after AMI. It appears that this advice comprehensively summarized the doctor's findings with the complex interplay of different physical, socio-demographic, and psychological factors. Our data add to the cumulating body of evidence stressing the superiority of the doctor's advice over individual factors. Prospective studies with larger sample size and also in the patients not receiving outpatient rehabilitation are needed to further investigate these observations. References

0.03 0.004 ns ns ns

46 (88%) 46 (88%) 34 (65%) 38 (73%)

17 (77%) 17 (77%) 18 (82%) 1 (5%)

ns ns ns b 0.001

46 (88%) 47 (90%) 45 (87%) 34 (65%) 49 (94%) 47 (90%)

21 (95%) 20 (91%) 14 (64%) 8 (36%) 21 (95%) 15 (68%)

ns ns 0.03 0.02 ns 0.02

11 (21%) 3 (6%) 28 (52%) 4 (8%)

8 (36%) 3 (14%) 11 (50%) 3 (14%)

ns ns ns ns

27 (52%) 24 (56%) 40 (77%)

16 (73%) 14 (64%) 19 (86%)

ns ns ns

Values are means (standard deviation) or number (percent of patients). AMI acute myocardial infarction.

[1] Shanfield SB. Return to work after an acute myocardial infarction: a review. Heart Lung 1990;19:10917.

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[2] Soejima Y, Steptoe A, Nozoe S, Tei C. Psychological and clinical factors predicting resumption of work following acute myocardial infarction in Japanese men. Int J Cardiol 1999;72:3947. [3] Myrtek M, Kaiser A, Rauch B, Jansen G. Factors associated with work resumption: a 5 year follow-up with cardiac patients. Int J Cardiol 1997;59:2917. [4] Boudrez H, De Backer G, Comhaire B. Return to work after myocardial infarction: results of a longitudinal population based study. Eur Heart J 1994;15:326.