+ Return to Work (RTW) after Acute Coronary Syndrom (ACS) SFC - 2016 No Conflict of interest for this subject Dany Michel Marcadet Paris
Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Company Consulting Fees/Honoraria Novartis Bayer BMS
Economic considerations Cardiologists are frequently required to give their judgment about the cardiovascular status of patients recovering from ACS. However, specialists may easily take a passive, disinterested and even permissive position on the matter. Although the wellness of their patients is their first concern, cardiologists must also consider other factors 90 million working days are lost annually within the European Union because of CHD morbidity.* *Leal J, Luengo-Fernandez R, Gray A, Petersen S, Rayner M. Economic burden of cardiovascular diseases in the enlarged European Union. Eur Heart J 2006;27:1610 1619.
It is well established that RTW is not a simple function of clinical status, but is influenced by demographic, social, and psychological factors. Patients perceptions of their illness and disability appear to be important predictors. In this context, part of the responsibility that patients return to work as soon and in the best conditions possible fall on doctors in charge of judging their cardiac sequelae (1). Petrie KJ. BMJ 1996;312:1191 1194. Mittag O. Soc Sci Med 2001;52:1441 1450.
Role of cardiologists It is not the cardiologist s job to decide whether a patient can return to work or not, there are specialised doctors whose duty it is to do so : occupational physician Many factors related to the almost infinite peculiarities of job positions, to considerations such as age, motivation, satisfaction with previous position, salary, trade, unemployment rates, comorbidity, or even economic aspects - which in some studies have shown influential on return to work than clinical endpoints - are involved in that decision.
Role of cardiologists Evaluation by a cardiologist of the sequelae and functional status of the patient is irreplaceable The cardiologist surely has to deliver information regarding the patient s functional capacity to work and the possible risks a patient runs if cleared for work return.
Cardiac parameters to be measured Regarding the patient s functional capacity to work and the possible risks a patient runs if cleared for work return, we need: An echography to evaluate the EF An exercise test (if possible with VO2) to evaluate Ischemic level, arrhythmia and capacity. if revascularisation was performed or not
Cardiac parameters to be measured: Furthermore, only the physical component of work is covered, leaving out other aspects that could also be important in certain contexts : day/night shift, location, position, environment, stress, risks for third party and should remain the responsibility of occupational health doctors With those results it should be straightforward to provide a thorough expert report highlighting the sequelae and functional capacity for return to work.
Timing Lastly, an important aspect to be considered as well is regarding when return to work is advisable. Traditionally, return to work was advised within a wide timeframe, between 3 and 6 months after an acute coronary event or a coronary bypass surgery. This recommendation is now obsolete as it does not take into account the important improvements in acute therapies, preventive treatments and cardiac rehabilitation that have occurred in recent years. Modern guidelines have shortened this period to 1-3 months, but are not fully clear in this respect.
(HAS) Argumentaire HAS juillet 2011
+ RTW after revascularization (HAS) Argumentaire HAS juillet 2011
and Revascularization (HAS) RTW is to be adapted according : The age of the patient The criterion of severity of myocardial infarction (history of myocardial infarction or previous location), The extent of lesions found on the coronary angiography possible revascularization HAS juillet 2011
and Revascularization (HAS) The results of the examinations (ejection fraction, stress test, holter...) The severity of the residual symptoms, The socio-economic level, Psychological factors (anxiety, depression), The duration and conditions of transport. HAS juillet 2011
Implantation of a bipolar pacemaker or an ICD In most cases, employees can return to work after an implantation of a bipolar pacemaker or an ICD, based on an appropriate risk assessment. However, pacemakers with unipolar settings experienced a great deal of interference in identical fields. Electromagnetic interference with cardiac pacemakers and implantable cardioverterdefibrillators from lowfrequency electromagnetic fields in vivo. Maria Tiikkaja1*, Aapo L. Aro2and al. Europace (2013) 15, 388 394
Psychological and clinical predictors of return to work after acute coronary syndrome. MR. Bhattacharyya*, L Perkins-Porras, DL. Whitehead, and A Steptoe. European Heart Journal (2007) 28, 160 165
Depression Depressed mood measured soon after admission is a predictor of returning to work following ACS. The management of early depressed mood might promote the resumption of economic activity and enhance the quality of life of cardiac patients.
Reporting on coronary patients for return to work: an algorithm An article from the e-journal of the ESC Council for Cardiology Practice Vol. 10, N 20-23 Feb 2012 + Algorithm for cardiac assessment for return to work. (ESC) Acute coronary syndrom Revascularization performed YES NO FE 50% < 50% 50% < 50% Stress test - + - + - + - + Working capacity A M5 M5 I M5 M3 M3 I A - Cleared for any type of work I - Incapacity M5 - Can perform tasks requiring < 5 METs M3 - Can perform tasks requiring < 3 METs
Conclusion The role of cardiologist is irreplaceable to evaluate with noninvasives tests Sequelae of ACS and functional status Risks of RTW
+ references 1. Hämäläinen H, Mäki J, Virta L, Keskimäki I, Mähönen M, Moltchanov V, et al. Return to work after first myocardial infarction in 1991-1996 in Finland. Eur J Public Health. 2004;14:350-3. 2. Smith GR, O'Rourke DF. Return to work after a first myocardial infarction. A test of multiple hypotheses. JAMA. 1988;259:1673-7. 3. Mittag O, Schramm S, Böhmen S, Hüppe A, Meyer T, Raspe H. Medium-term effects of cardiac rehabilitation in Germany: systematic review and meta analysis of results from national and international trials. Eur J Cardiovasc Prev Rehabil. 2011;18:587-93. 4. Gutiérrez-Morlote J, Vacas M, Lobato A, Llorca J, Prieto JA, Domenech J, et al. The effect of myocardial infarct on the employment situation of patients. Rev Esp Cardiol. 1999;52:556-62. 5. Boudrez H, De Backer G. Recent findings on return to work after an acute myocardial infarction or coronary artery bypass grafting. Acta Cardiol. 2000;55:341-9. 6. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58:44-122. VolumeNumber:Vol10 N 20