Summary
Background
Previous studies have evaluated return to work after acute ST-segment elevation myocardial infarction (STEMI) treated medically, after bypass surgery or after percutaneous coronary intervention (PCI) for stable coronary artery disease. However, there are few data regarding return to work after acute STEMI treated by direct PCI.
Aims
To analyse the factors influencing return to work after STEMI treated by direct PCI.
Methods
Two hundred consecutive patients who underwent direct PCI for acute STEMI and who were employed at the time of their STEMI were studied. Stents were used in 94% of patients and glycoprotein IIb/IIIa inhibitors in 77%.
Results
Among the 200 patients, 152 (76%) patients returned to work and 48 (24%) did not. Patients who did not return to work did not differ from those who returned to work in terms of time from onset of chest pain to PCI, STEMI location, left ventricular function, extent of vessel disease, PCI technique and success, completeness of revascularization, duration of hospital stay, intrahospital complications and performance of cardiac rehabilitation. Multivariable analysis showed that older age, daytime onset of chest pain, manual labour, rapid call-out of the emergency medical team, unmarried status and a limited number of risk factors were independent predictors of non-return to work.
Conclusion
Age, sociopsychological and occupational factors appear to be the strongest predictors of return to work after STEMI treated by direct PCI. Clinical and procedural factors as well as cardiac rehabilitation appear to have no impact on return to work in this subset of patients.
Résumé
Contexte
Des études antérieures ont évalué la reprise du travail après infarctus du myocarde (IDM) traité médicalement ainsi que celle des patients coronarien stables après pontage ou angioplastie. Très peu de données sont en revanche disponibles chez les patients traités par angioplastie primaire pour IDM.
Objectif
Analyser les facteurs de reprise du travail chez les patients après IDM traités par angioplastie primaire.
Méthodes
Deux cent patients ayant bénéficié d’une angioplastie primaire pour IDM et ayant une activité professionnelle au moment de leur accident coronarien ont été inclus. Le taux de stenting était de 94 % et 77 % des patients ont reçu des antiGP IIb/IIIa.
Résultats
Parmi les 200 patients, 152 (76 %) ont repris le travail (RT+) et 48 (24 %) ne l’ont pas repris (RT). Le groupe RT− ne différait pas du groupe RT+ vis à vis du délai début de la douleur-angioplastie, du siège de l’IDM, de la fraction d’éjection, de l’étendue des lésions coronaires, de la technique et du succès de l’angioplastie, du degré plus ou moins complet de revascularisation, de la durée de séjour hospitalier, de la survenue de complications et de la réalisation d’un programme de rééducation. L’analyse multivariée a montré qu’un âge plus avancé, la survenue de l’IDM en période diurne, une activité professionnelle manuelle, un délai d’appel médical par le patient court, un statut de célibataire et un plus petit nombre de facteurs de risque étaient des facteurs indépendants de non-reprise du travail.
Conclusion
Ainsi, l’âge, les facteurs sociopsychologiques et professionnels apparaissent comme les facteurs prédictifs de reprise du travail les plus importants après IDM traité par angioplastie primaire. Les facteurs cliniques et ceux liés à la technique d’angioplastie ainsi que la réalisation d’un programme de rééducation paraissent ne pas avoir d’impact significatif sur la reprise du travail chez ce groupe de patients.
Background
Acute ST-segment elevation myocardial infarction (STEMI) is a severe cardiac event. The rate and timing of return to work after STEMI are important, as there are consequences in terms of the quality of life of the individual patient as well as economic consequences for both the individual and society . Previous studies have evaluated return to work after STEMI treated medically , as well as after bypass surgery and after percutaneous coronary intervention (PCI) for stable coronary artery disease . However, there are very few data regarding evaluation of return to work in patients with acute STEMI treated by direct PCI, which nowadays is recognized as the best reperfusion method . As direct PCI compared with other strategies has been shown to improve left ventricular function and clinical outcome in patients who have an acute STEMI , subsequent improvement in rate and timing of return to work can be expected. To our knowledge, only one study based on the analysis of the PAMI trial population recruited from 14 countries has recently evaluated the frequency of returning to work after direct PCI for acute STEMI . However, in this international study by Abbas et al. , only medical factors were analysed; socio-occupational factors and cardiac rehabilitation were excluded. Also, only half of the patients received stents, and platelet glycoprotein IIb/IIIa receptor inhibitors were used in only 5% of cases of the study by Abbas et al. . As a combination of both stents and glycoprotein IIb/IIIa receptor inhibitors has been demonstrated to improve the results of direct PCI for acute STEMI , it is reasonable to assume that this modern reperfusion strategy should provide the best medical conditions to promote return to work.
Thus, in this study, we analysed the impact of both medical and socio-occupational factors as well as cardiac rehabilitation on return to employment after acute STEMI in a large cohort of working patients who underwent modern reperfusion by direct PCI in a single institution, with extensive use of both stents and glycoprotein receptor inhibitors.
Methods
Study population
All 807 consecutive patients who were treated in our institution by direct PCI for an acute STEMI from January 2000 to December 2004 were considered for the study. Of these, 429 patients were aged 65 years or less and were screened retrospectively, as 65 years represents the official age for retirement in France. Fifteen of the 429 patients died during hospitalization and were excluded from the study. There were 27 patients who underwent rapidly programmed bypass surgery during hospitalization after initial recanalization of the culprit vessel using a minimalistic interventional approach and in whom multiple lesions were not suitable for PCI; these 27 patients were also excluded to avoid a confounding factor in the final analysis, as surgery is known to have a different impact on work resumption than PCI . As some of the data were obtained by direct telephone interview of the patients, the 12 patients who died during the follow-up before they were interviewed were also excluded from the study. Fourteen patients were lost at follow-up and could not be interviewed. Finally, among the 361 remaining patients, 161 were not employed prior to their STEMI. Therefore, the study population for final analysis consisted of 200 patients.
Data were obtained from medical records and by questionnaires and direct telephone interviews. To exclude the possibility of missing a later return to work in some patients, interviews regarding work resumption were performed some time after STEMI (median 42 months). As the mean time for return to work after STEMI in the pre-PCI era has been shown to be 5 ± 1 months in France , patients in our study who returned to work were subgrouped into those considered as returning relatively early (within 3 months after discharge) and those who returned later.
Statistical analysis
Statistical analysis was performed with the SPSS 10.0 statistical package (SPSS Inc., Chicago, IL, USA). Continuous variables are expressed as means ± standard deviations and categorical data as numbers and percentages. Analysis of variance was used for continuous variables and the χ 2 test or Fisher’s exact test was used for categorical variables, as appropriate. Multiple logistic regression analysis, with consideration of all variables with a p value < 0.20, was performed to identify independent variables associated with work resumption and independent predictors of late return to work. Statistical significance was defined as p < 0.05.
Results
Baseline characteristics of the total population are shown in Table 1 . Among the 200 patients, 152 (76%) returned to work (RTW group), with a mean return time of 134 days (range 7–990), and 48 did not return to work (NRTW group). Comparisons between the two groups are shown in Table 2 . Patients in the NRTW group had a slightly more severe degree of coronary artery disease than those in the RTW group (40% with multiple vessel disease vs 28%, respectively) but the difference was not statistically significant. The rate of return to work was not different between patients who underwent a cardiac rehabilitation programme and those who did not. Cardiac rehabilitation was ambulatory in 85% of our patients. In addition, among patients who returned to work, those who had undergone rehabilitation returned to work much later than those who did not (156 ± 142 days vs 69 ± 62 days, respectively; p < 0.001). When compared with those in the RTW group, patients in the NRTW group were significantly older, had fewer risk factors and were more often single. The time taken for the patient to call the prehospital medical team after chest pain onset was significantly shorter in the NRTW group than in the RTW group. The rate of returning to work was higher in men than in women (78 vs 50%, p = 0.02). A higher percentage of patients in the NRTW group than in the RTW group were manual workers before their STEMI. STEMI occurred more frequently during the daytime (between 07:00 and 19:00 hours) in the NRTW group (81%) than in the RTW group (60%, p = 0.011).
| Variable | |
|---|---|
| Age (years) | 48 ± 7 |
| Sex (male/female) | 184 (92)/16 (8) |
| Single person | 47 (24) |
| Smoker | 53 (27) |
| High cholesterol | 91 (46) |
| Hypertension | 53 (27) |
| Diabetes | 16 (8) |
| Cardiovascular family history | 92 (46) |
| Known coronary artery disease | 15 (7.5) |
| Manual labour | 116 (58) |
| Chest pain onset from 07:00 to 19:00 hours | 130 (65) |
| Time from chest pain to catheterization (min) | 211 ± 163 |
| Anterior infarction | 65 (33) |
| Multiple vessel disease (≥ two vessels) | 61 (31) |
| LV ejection fraction (%) | 56 ± 9 |
| Stenting | 187 (94) |
| GP IIb/IIIa receptor inhibitors | 153 (77) |
| Post-PCI TIMI 3 | 191 (96) |
| Complete revascularization | 165 (83) |
| Intrahospital MACE a | 10 (5) |
| Duration of hospitalization (days) | 7 ± 5 |
| Cardiac rehabilitation | 150 (75) |
| RTW group ( n = 152) | NRTW group ( n = 48) | p | |
|---|---|---|---|
| Age (years) | 47 ± 7 | 52 ± 7 | < 0.001 |
| Sex (male/female) | 144 (95)/8 (5) | 40 (83)/8 (17) | 0.025 |
| Manual labour | 81 (53) | 35 (73) | 0.025 |
| Number of risk factors | 2.2 ± 0.9 | 1.7 ± 0.8 | 0.002 |
| Chest pain onset from 07:00 to 19:00 hours | 91 (60) | 39 (81) | 0.011 |
| Time to call (min) | 107 ± 135 | 58 ± 53 | 0.016 |
| Single person | 31 (20) | 16 (33) | 0.10 |
| Duration of hospitalization (days) | 7.0 ± 5.2 | 8.2 ± 2.9 | 0.16 |
| Multiple vessel disease (≥ two vessels) | 42 (28) | 19 (40) | 0.17 |
| Cardiac rehabilitation | 118 (78) | 32 (67) | 0.18 |
| Time from chest pain to catheterization (min) | 218 ± 178 | 189 ± 104 | 0.30 |
| Complete revascularization | 128 (84) | 37 (77) | 0.36 |
| GP IIb/IIIa receptor inhibitors | 119 (78) | 34 (71) | 0.39 |
| Post-PCI TIMI 3 | 143 (94) | 47 (98) | 0.49 |
| LV ejection fraction (%) | 56 ± 9 | 56 ± 10 | 0.64 |
| Stenting | 141 (93) | 46 (96) | 0.68 |
| Number of stents | 1.3 ± 0.9 | 1.3 ± 0.7 | 0.75 |
| Intrahospital MACE a | 7 (4.6) | 3 (6.2) | 0.94 |
| Anterior infarction | 50 (33) | 15 (31) | 0.97 |
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