the rehabilitation cardiologist`s point of view.

JOINT SESSION SOCIETE FRANCAISE DE MEDECINE DU TRAVAIL/
SOCIETE FRANCAISE DE CARDIOLOGIE
JESFC 2016
Dr Catherine MONPERE
Centre de Prévention et de Réadaptation Cardiovasculaires « Bois Gibert »
TOURS (F).
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 :
AUCUN CONFLIT D’INTERET AVEC MA PRESENTATION).
Affiliation/Financial Relationship
 .
Company
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
 Is this question still relevant ??
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Reasons of non attendance for CR
Consecutive serie of 600 pts post ACS referred for
CR in « Bois- Gibert » from 01/2015 to 15/11/2015
66patients/600 (11%) did not attend « BoisGibert »:
- Unwilling to participate : 33%
- Referral to an other SSR Unit: 30%
- Professional and/or socio-economic reason: 24%.
- Medical reason: 13%.
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Estimation à +/- 0,3 point près du niveau du taux
de chômage et de son évolution
Champ : population des ménages, personnes de 15 ans ou plus
Source : Insee, enquête Emploi
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Cardiac
Unique Predictors
of Delayed Return
rehabilitation
to Work
favors RTW rates
but is a barrier to an Predictor
t
p
early return to work Attended cardiac
3.55
<.001
rehabilitation
??
Manual occupation
-Isaaz K et al
Arch.Cardiovascular
Disease (2010), 103:310-16
More days in
hospital
Physically active job
-Worcester M.U et al:
Heart Lung and
Circulation(2014)23:444-53
Dissatisfied with job
No confidante
3.43
.001
2.89
.004
2.91
.004
2.89
.004
2.29
.023
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
A changing socio -economical context ….
 Before 2008:
 Environmental context
 After 2008 :
 Environmental context
 Near full-employment rate.
 Economical development
 Good health-insurance coverage
 High unemployment rate.
 Economical crisis
 Decrease health insurance and sick leave
 Cardiac rehabilitation goals:
 To match physical and psychological
job- demands with clinical status and
functional capacities.
 To re-assure and motivate patients to
return to work
compensation.
 Less cardiac rehabilitation attendance:




Fear of loosing job during CR period
Social precarity
Vicious circle : unhealthy way of life,
increased psycho social stress at work
place … increased risk of recurrence :
 NEW PARADIGM….
 NEW CHALLENGE !!
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
FACTORS INFLUENCING RTW
CLINICAL AND
FUNCTIONAL
PARAMETERS
ENERGY REQUIREMENT OF
THE JOB
LEGAL CONSIDERATIONS
PSYCHO-SOCIAL
ASPECTS
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CLINICAL AND FUNCTIONNAL PARAMETERS
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CLINICAL AND FUNCTIONNAL PARAMETERS
 symptomatology (angina, dyspnea, fatigability, NYHA CLASS)
 évaluation :
 Ischemic risk (coronarography, stress test, stress
echography, scintigraphy..)
 Arythmic risk (holter, stress test)
 Left ventricular function (echocardiography,
cardiorespiratory stress test) and hemodynamic profile.
 Risk stratification
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CARDIO-PULMONARY
EXERCISE-TEST :
Objective evaluation of physical
capacities
Reproducibility
Assessment aerobic capacities,
however often different from real
work conditions (static efforts)
Parameters to consider:
- residual ischemia? rythm
disturbance ? BP profile
- peak workload ,peak VO2,
- 1st ventilatory threshold,
- chronotropic response.
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CR : AN OPPORTUNITY TO OPTIMISE PHYSICAL CAPACITIES
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CR : AN OPPORTUNITY TO
OPTIMISE PHYSICAL CAPACITIES
Combined training :
endurance + low resistance
 Does not induce deleterious
LV remodelling
 Higher results on sub max
performances,
 muscular strenght,
 QOL compared to endurance
training alone
Becker PJ. Eur Heart J 2008
Schmid JP. Eur J Cardiovasc Prev Rehabil
2010
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CR: AN OPPORTUNITY TO
OPTIMISE PHYSICAL CAPACITIES
Cardiopulmonary exercise testing is
predictive of return to work in cardiac
patients after multicomponent
rehabilitation.
Ex capacities and the VE/VCO2
slope are independant prognosis
factors for RTW.
A.Salzvedel et al
Clin Res Cardiol. 2015
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Paramètres cliniques et fonctionnels : niveau de risque
Recommandations SFC 2011
Faible
• évolution clinique hospitalière non compliquée (pas de récidive ischémique,
d'insuffisance cardiaque ou d'arythmie ventriculaire sévère)
• bonnes capacités fonctionnelles (> 6 Mets) à distance (3 semaines ou plus)
de la phase aiguë
• fonction ventriculaire gauche systolique conservée
• pas d'ischémie myocardique résiduelle au repos ou à l'effort
• pas d'arythmie ventriculaire sévère au repos ou à l'effort
Moyen
• capacités fonctionnelles moyennes (5-6 Mets) à distance (3 semaines ou
plus) de la phase aiguë ; seuil ischémique élevé
• fonction ventriculaire gauche systolique modérément altérée
• ischémie myocardique résiduelle modérée et/ou sous décalage du segment
ST inférieur à 2 mm au test d'effort ou ischémie myocardique réversible lors
des explorations isotopiques ou échocardiographiques
• arythmie ventriculaire peu sévère (classe I ou II de Lown) au repos ou à
l'effort
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Paramètres cliniques et fonctionnels : niveau de risque.
Recommandations SFC 2011
Elevé
•évolution clinique hospitalière compliquée (insuffisance cardiaque,
choc cardiogénique et/ou arythmie ventriculaire sévère)
•survivants de mort subite
•capacités fonctionnelles basses (< 5 Mets) à distance (3 semaines ou
plus) de la phase aiguë
•fonction ventriculaire gauche sévèrement altérée (fraction d'éjection
< 30 %)
•ischémie myocardique résiduelle sévère (angor d'effort invalidant,
seuil ischémique bas et/ou sous décalage du segment ST > 2 mm à
l'électrocardiogramme d'effort)
•arythmie ventriculaire complexe (classes III, IV et V de Lown) au repos
ou à l'effort
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
WORKPLACE CHARACTERISTICS
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
WORKPLACE CHARACTERISTICS
Parameters to consider:
Type of exercise encountered : dynamic, static, arm-shoulder
exercises

_
-
Thermal factors and / or acoustic factors, pollution
Transport time to the job site
Night time job
Deleterious effects of shift-work (3 x 8h) ++


modifications of circadian cycles (cortisol, mélatonine …)
 cholestérol, blood pressure
Economic status of the entreprise
Financial security
Socio-Cultural level
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
HOW TO MATCH ?
WORKPLACE
CHARACTERISTICS
CLINICAL AND
FUNCTIONAL
PARAMETERS
Evaluation of metabolic and cardiovascular demands)
Niveau
d'activité
Activités domestiques
et de loisir
TRES LEGER se laver
< 3 METS
se raser
s'habiller
écrire
faire la vaisselle
50 watts
passer l'aspirateur ou balayer
lentement
conduite automobile
jardinage léger : taille des rosiers,
tonte de gazon sur tracteur,
semailles
petit bricolage (modélisme …)
loisirs : pêche, billard, croquet
LEGER
laver les vitres
(3 A 5 METS) cirer les parquets
faire les lits
porter des charges de 7 à 15 kgs
50 - 70 watts jardinage : usage tondeuse tractée
ratissage léger, binage
bricolage : peinture intérieure,
pose de papiers peints
loisirs : danse à rythme modéré
MODERE
porter des charges de 15 à 30 kgs
(5-7 METS)
laver une voiture
jardinage : bêchage en terre légère
70 - 100 watts usage d'une tondeuse manuelle à plat
fauchage lent, conduite petit
motoculteur
Activités
professionnelles
travail assis
travail de bureau
dactylographie
réparation électronique, mécanique de
précision
travail en position debout (vendeur, portier)
conduite de tracteur, camion
(en tenant compte de la législation)
travail à la chaîne, à cadence et charges
moyennes
travail de garage (réparation auto)
magasinage
construction d'un mur (mélange mécanique
du ciment, pose de pierres et de briques)
menuiserie légère
travaux du bâtiment, menuiserie lourde
(charpente, réfection extérieure)
travail de plâtrier
maniement du marteau pneumatique,
pelletage lent
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
EVALUATION OF METABOLIC AND CARDIOVASCULAR DEMANDS
(FROM HASKELL 1978 ; COMPENDIUM OF PHYSICAL ACTIVITIES AINSWORTH
B.E 2000)
LOURD
7-9 METS
porter des charges de 30 à 40 kgs
bricolage : scier du bois, pelletage lourd
jardinage : bêchage lourd
100 - 140 watts loisirs : danse à rythme rapide,
randonnées en montagne
TRES LOURD porter des charges de plus de 40 kgs
> 9 METS
montée rapide d'étages
jardinage : pelletage lourd, fauchage
> 140 watts rapide
entretien industriel lourd
maniement d'outils lourds (tronçonneuse,
outillage de terrassement …)
chargements de camions
bûcheronnage
travail lourd de manœuvre
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
WORK SIMULATION
Pulsemeter
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
 To allow good tolerance at
the work place, the peak
exercise work load should
be at least twice the average
physical requirement of
occupational tasks for a 6/8
hours work duration.
 Some cases need jobsimulation or on-site
evaluation to determine
cardiovascular responses to
specific work tasks.
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
WORK SIMULATION
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
PSYCHO-SOCIAL ASPECTS
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
PSYCHO SOCIAL JOB STRESS : A RISK FACTOR FOR CORONARY
DISEASE ?

.
Rosengren A. et al Lancet. 2004 Sep 11-17;364(9438):953-62 (INTERHEART
STUDY)
-Kornitzer, M et al.(2006) Eur J Cardiovasc Prev Rehabil 13(5). p.695-704
(JACE STUDY)
- Kivimäki M et al. Meta analysis (Lancet. 2012 27;380(9852):1491-7.
:The population attributable risk for job strain was 3·4%.
IMPORTANCE OF ASSESSMENT JOB STRESS ++
(ie KARASEK SCORE)
OTHER PSYCHOLOGIC PARAMETERS
- Depression syndrom, anxiety (HAD score)
- Spouse attitude : depression syndrom, maternal attitude
- Lack of social support ….
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Karasek classification :
DEMAND
JOB STRAIN
ACTIVE
PASSIVE
RELAXED
20
70
DECISION
LATITUDE
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
 Safety and legal considerations for some jobs where
sudden incapacity may compromise personal or public
safety
 In France :
 Police officers, fire fighters
 Commercial online pilots
 Air traffic controlers
 Professional drivers
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
FACTORS INFLUENCING RTW
CLINICAL AND FUNCTIONAL
PARAMETERS
ENERGY REQUIREMENT OF
THE JOB
LEGAL CONSIDERATIONS
PSYCHO-SOCIAL
ASPECTS
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Assessment of physical capacities of the patient
and physical demand of work-place
Contra- Indication (CI) of
RTW at previous job
No CI of RTW at previous job
(medical point of view ).
Temporary inadequation
between physical job
demand/physical capacities
Psychological barriers to
RTW:
Negative self-reported healthstatus
Psychosocial stress at work,
Focus on ExT. program
Work simulation if
possible
* Focus on psychological work
orientated support
Job reconversion
Help to sick-leave process
•
•
Or
Social Services
Vocational Medecine
RTW possible same
place
RTW possible with
modification workplace
Or
RTW possible at
the same place
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
RESULTS
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Study flowchart (personal study)
Patients admitted in cardiac rehabilitation center en 2009
n = 1715
< 65 years old
n = 1015
ACS
n = 307
Other diagnosis
n = 708
Included n = 252
Professional active at the time of the ACS
n = 143 (57 %)
RTW after 28 months
N = 111 (78 %)
Professional inactive at the time of the ACS
n = 109 (43 %)
Non RTW after 28 months
N = 32 (22 %)
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Multivariate analysis of the predicting factors of RTW
Factors
p
OR (CI 95 %)
Age
0,0005
0,87 (0,81-0,94)
Dyspnea
0,0004
0,12 (0,81-0,94)
Angina
0,003
0,04 (0,005-0,34)
« Relaxed » work-place
0,001
5,4 (1,9-15)
High social-professional status
0,03
9,5 (1,2-72)
0,006
0,22 (0,07-0,64)
Positive stress-test
p = probability
OR = odds ratio
CI = confidence interval
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
RTW RATES BEFORE DURING THE FOLLOW-UP PERIOD
ACCORDING TO THE MODE OF REVASCULARIZATION
MEAN TIME TO RTW : 4,1 Months
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
Predictors of RTW
Unique Predictors of 12month Return to WorkS
Doubt or unwilling of the patient :
1st cause of no RTW
Worcester M.U et al:
Heart Lung and
Circulation(2014)23:444-53
B
SE
p
OR
95 % CI
Uncertain or no intention of
resuming work
2.12
0.60
<.001
8.3
2.56-26.97
Comborbidity other than
diabetes
1.38
0.48
.005
3.96
1.53-10.25
Perceived financial stress
Negative perception of
health
0.96
0.46
.035
2.62
1.07-6.41
0.84
0.42
.045
2.32
1.02-5.29
Predictor
Note : In all cases degrees of freedom = 1, B, regression coefficient ; SE,
standard error ; OR, odds ratio ; CI, confidence interval.
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
AUTHOR / YEAR
NB PTS
%RTW
Time frame
(months)
F.UP
BHATTACHARYYA M.R (GB)
2007
126
80.2 %
(3,4)
1Y
ISAAZ K (F) 2010
200
76 %
(4,5)
? >M6
1589 (50%
at work)
86 %
1Y
SLEBUS FG (NL)
2012
84
88 %
2Y
No complaint
Feeling good
Physical incapacity
Comorbidity
MONPERE C (F)
2011
143
78 %
(4,1 months)
2Y
High socio prof
category
Relaxed work
Older age
Dyspnea
Positive stress test
WORCESTER M.A (AUS)
2015
401
79,9 %
(4 months)
1Y
SALZVEDEL A (D)
2015
489
76,3%
(2,6 months)
2Y
BIERING K (N) 2012
POSITIVE PREDICTIVE
FACTORS( +)
NEGATIVE PREDICTIVE FACTORS( -)
Arrhythmia
Recurrence
Depression
Older age
Manual work
Single
Poor SF12 score
LVEF < 35 %
No intention of RTW
Comorbidity other than T2DM
Perceived financial stress
Negative perception health
High Ex capacities
High VE/VCO2 slope
High physical demand workplace
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
In average
 After STEMI : 1 to 6 months
 After CABG : 2 to 4 months
 After planned PTCA without
MI : 1 week to 1 month
Any work stoppage > 6 months compromises a later resumption
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CARDIAC REHABILITATION
: a real opportunity to
optimize RTW ? YES!!....
-Lenght of stay of 3 to 4 weeks >
hospital stay
- Stabilisation of cardiac condition
and improvement of physical
capacities
- Psychological support : decrease of
fear of RTW
- Pluridisciplinary approach :
cardiologist, vocational physician,
dietetician,physiotherapist,
psychologist…
Return to work is possible in the
majority of the cases (80%) after
cardiac event

It must be optimised with a
specific consultation ++
and a consultation with
their vocational specialist

It requires the coordination
of the different practioners
RETURN TO WORK AFTER AN ACUTE CORONARY SYNDROM :
THE REHABILITATION CARDIOLOGIST’S POINT OF VIEW.
CARDIAC REHABILITATION : a real
opportunity to optimize RTW
YES!!.... BUT…
The social economic crisis , the
fear of loosing his jobs
are
becoming increasing barriers to
cardiac rehabilitation , and
therefore may compromise the
prognosis of cardiac patients.
Alternative and cost effective
models of CR must be discussed :
- « Tailored » planning of CR ?
- « Hybrid » CR : short
ambulatory phase followed by
Home-based rehabilitation
- Telemonitoring of CR …
- Cardiac rehabilitation Centers
should play a pivotal role in
implementation of new
models of CR.