Return to work: the challenge of cardiac rehabilitation in the modern era

This editorial refers to ‘Diagnostic group differences in return to work and subsequent detachment from employment following cardiovascular disease: a nationwide cohort study’, by S.M.B. Jørgensen et al., https://doi.org/10.1093/eurjpc/zwac249. It is now well recognized that cardiovascular disorders, from those considered more benign to those with a more severe impact on health status, can dramatically influence everyday life. On the one hand, it is the deterioration of functional capacity that many cardiovascular disorders, more commonly those affecting left ventricular systolic function, may induce, and on the other hand, there are the psychological effects, in the absence of substantial or relevant clinical findings. In fact, it has been shown that even patients with atrial fibrillation, a situation that rarely leads to impairment of functional status, are more likely to seek for mental health support and psychiatric services.1 Either way, the quality of life is significantly affected to the worse. In this context, cardiac rehabilitation programs are designed to provide supervised exercise training in patients with a recent acute cardiovascular event along with interventions for secondary prevention, aiming to accelerate recovery and get the patient to the previous quality-of-life state. For many employed individuals, recovering from an acute cardiovascular event is synonym to being able to return back to work. It is also a fact that the prevalence of cardiovascular disorders among younger individuals is on the rise. Beyond its financial aspects, preserving employment is of great importance for self-esteem and quality of life for patients with a chronic illness.2 Thus, employed individuals returning to work stands in the core of cardiac rehabilitation programs. Nevertheless, it remains an open question to identify those patients who are more likely to benefit from rehabilitation interventions. Although in previous years cardiac rehabilitation mainly focused on patients after an acute myocardial infarction or coronary bypass surgery, contemporary cardiac rehabilitation services are more widely offered to patients with arrhythmias, heart failure, and to those undergoing scheduled coronary and valvular interventions or interventions for arrhythmia management. In addition to reducing morbidity and mortality after a cardiac event and improving quality of life, the cost-effectiveness of cardiac rehabilitation programs is now highly recognized, mainly derived by their efficacy in reducing subsequent events and rehospitalizations and in shortening the periods of absence from work.3 Another major concern remains the disappointingly low participation and referral rates of eligible patients in many countries, with important disparities driven by socio-economic status, race, ethnicity, age, and sex.4 In addition to this, while a Class IIa recommendation for supervised, exercise-based, cardiac rehabilitation is made in the 2021 European Society of Cardiology Guidelines for Heart Failure, particularly for patients with more severe disease, frailty, or with comorbidities, concerns regarding occupational issues are not raised.5 An attempt to highlight these aspects of cardiac rehabilitation is made in the analysis of a Danish nationwide cohort by Jørgensen et al. presented in the current issue of the European Journal of Preventive Cardiology.6 In particular, the article examines potential differences regarding vocational reintegration among individuals of working age who were employed by the time of incident cardiovascular disease diagnosis in 2018. The main finding of the study is that patients with heart failure exhibit a lower probability of returning to work within 1 year after disease diagnosis and, when they do, they have higher chances of abandoning employment compared with patients diagnosed with other types of cardiovascular disease, including atrial fibrillation and ischaemic heart disease, with the authors underlining the particular need for targeted vocational rehabilitation in this population. The findings of this study emphatically confirm that heart failure significantly deteriorates the patients’ well-being and functional capacity. Functional limitations of the disease and comorbidities or even psychological effects of a heart failure diagnosis may explain this finding. However, the lowest age- and sex-adjusted probability of detachment was recorded among individuals diagnosed with atrial fibrillation. In fact, the majority of the individuals being employed at the time of cardiovascular disease diagnosis, approximately 90%, returned to work within 1 year after an acute event. During the next 6 months after their return, though, almost one out of four had already experienced detachment from employment. Younger age, higher educational level, higher income, and the absence of significant comorbidities were recognized as factors associated with higher probability of return to work, while lower income, lower educational attainment, and the presence of comorbidities favoured subsequent work detachment. Unfortunately, the impact of participation in rehabilitation programs on the aforementioned observations cannot be assessed, since relevant data were not evaluated in this study. It has been previously shown, however, that less deprived and less comorbid patients are more likely to receive cardiac rehabilitation, hence increasing their probability to return to work.7 In the same way, it is reasonable to assume that patients with heart failure represent the group with the highest probability of gaining benefit from vocational rehabilitation, but this remains only a hypothesis, since it is not known how many of these patients were finally offered participation in rehabilitation programs. Work barriers and factors related to the type of work may also influence return to work and job maintenance, which is also a logical assumption made by the authors. The exemplary organized Danish nationwide patient registries represent valuable tools that offer the ability to bring up matters and provide vital information related to the management of patients with cardiovascular disease that can be used to facilitate improvements in clinical practice. However, given that the Danish welfare system is characterized by a high level of social security, including sick leave benefits and financial coverage of cardiac rehabilitation programs, the outcomes of such analyses should be interpreted with caution, considering the socio-economic disparities among different countries. Less generous welfare systems and the lack of well-structured rehabilitation services in countries with considerably lower social expenditure are expected to lead to worse outcomes regarding return to work and maintenance of employment. In conclusion, the increasing prevalence of cardiovascular disease among professionally active individuals along with the high rates of individuals with a previous cardiovascular event leaving employment, as depicted by the current study, underlines the need for the development of vocational rehabilitation strategies targeting on both socio-occupational reintegration and employment maintenance. Return to work is a realistic target after hospitalization for a cardiovascular event and could be considered a measure of effective management of many cardiovascular disorders. To that end, investment in cardiac rehabilitation infrastructure and systems and referral of all qualifying patients to cardiac rehabilitation services appear to be of major importance to retain cardiovascular patients in the labour market, improve their well-being, and reduce the social costs in the long term.