How to cite this article: Huichan-Muñoz V, Justiniano-Cordero S, Solís-Hernández JL, Rodríguez-Abrego G, Millán-Hernández E, Rojano-Mejía D . [Return to work in patients with heart disease after cardiac rehabilitation]. Rev Med Inst Mex Seguro Soc. 2016;54(2):159-63.
Received: November 17th 2014
Accepted: April 7th 2015
Valeria Huichan-Muñoz,a Samuel Justiniano-Cordero,b José Luis Solís-Hernández,c Gabriela Rodríguez-Ábrego,d Edgar Millán-Hernández,e David Rojano-Mejíaf
aMedicina del trabajo, Hospital General de Zona 32 Villacoapa
bRehabilitación Cardiaca, Hospital de Cardiología, Centro Médico Nacional Siglo XXI
cUnidad de Medicina Familiar 2 Sor Juana Inés de la Cruz
dEpidemiología, Hospital General Regional 1 Carlos Mac Gregor Sánchez Navarro
eMedicina del Trabajo, Hospital General Regional 1 Carlos Mac Gregor Sánchez Navarro
fCoordinación Clínica de Educación e Investigación en Salud, Unidad de Medicina Física y Rehabilitación Centro, UMAE Hospital de Traumatología y Ortopedia “Lomas Verdes”
Instituto Mexicano del Seguro Social, Ciudad de México, México
Communication with: David Rojano-Mejía
Telephone: (55) 5629 0200, extensión 13846
Background: Cardiac rehabilitation is a secondary prevention strategy which it includes a set of activities that would assure cardiac patients a place as normal as it could be into the society, being also essential for going back to work, by improving their quality of life and reducing costs for institutions.
Methods: A non-randomized clinical study was conducted at the “Siglo XXI” Cardiology Hospital; We included patients with the diagnosis of ischemic heart disease and/or valve disease, the response variables were: percentage of patients going back to work and disability time upon return to duty. Cardiac rehabilitation program was applied for 1 month and followed up at 2 months and 1 year.
Results: Two groups were formed, the ones who received cardiac rehabilitation, N = 40 (experimental group) against a control group, N = 25. The percentage of patients going back to work with a cardiac rehabilitation was 75 % versus 60 % of the group did not receive cardiac rehabilitation, p = 0.2, with a mean of 68 days of disability in the experimental group against 128 in the control group, p = 0.001.
Conclusions: The experimental group showed a higher percentage of patients who returned to work, working time reentry (in days) was lower compared to the control group.Keywords: Heart diseases; Return to work; Quality of life
At present, cardiovascular diseases are one of the most important problems in public health, it is estimated that 30% of global mortality is secondary to this chronic disease;1-3 more than 80% of deaths secondary to this disease occur in low- to middle-income countries;4,5 and deaths from this cause are expected to increase 2 to 4 times more in developing countries by 2020.6
In Mexico, cardiovascular diseases have become a major public health problem, in 2005 the Secretaria de Salud reported 223,394 hospital discharges for cardiovascular disease and a total of 53,185 deaths from ischemic heart disease; major risk factors identified were: obesity (63%), diabetes mellitus 2 (7.5%), tobacco (6.4%), and depression (15%);7-9 the lack of physical activity proved to be a risk factor for cardiovascular disease progression. Cardiac rehabilitation (CR) is a strategy that aims to educate patients to do physical activity, and that gives advice on modifying risk factors for primary and secondary prevention of these diseases;10-13 therefore, this is an important tool to improve function, aerobic capacity, and quality of life.14
CR is defined by the World Health Organization as a set of activities needed to ensure cardiac patients optimal physical, mental, and social status that allows them to occupy, on their own, as normal as possible a place within the social framework.15 Within the social framework, one of the most valuable activities in the cardiac patient is returning to work;16 a systematic review prepared in 2011 highlighted that CR significantly reduces the risk of mortality and brings economic benefits by decreasing hospital readmissions.17 A decrease in mortality up to 25% has also been reported, compared to patients not admitted to these programs.18,19 In short, CR brings benefits in functional capacity, increased physical activity, decreased symptoms, increased return to work, reduced risk of recurrent heart attacks, and decreased mortality.20,21
Despite the benefits of CR, only in some European countries is CR fully accepted as part of the treatment of patients with cardiovascular disease;22 in the United States only 10 to 20% of patients go to a CR program,23-25 in Latin America the percentage is up to 30%.26 This can be explained by the lack of information from doctors about the therapeutic benefits and control of risk factors achieved by doing CR programs. With this small percentage of patients sent to CR programs, one must subtract those patients who leave the program due to lack of interest, leaving only 11% of people attending CR programs.26
In Mexico there are centers specialized in doing CR, but so far the effectiveness of these programs has not been reported in the percentage of patients who return to work, or the number of days of disability at the time of return to work.
The aim of this study is to determine the effectiveness of CR in the percentage of patients who return to work as well as the decrease in the number of days of disability.
A quasi-experimental study was conducted in the Servicio de Rehabilitación Cardiaca del Hospital de Cardiología del Centro Médico Nacional Siglo XXI in March 2009.
Inclusion criteria were: men and women with ischemic and / or valvular heart disease for the first time, who were workers with disabilities approved by the IMSS. It excluded workers who were already in CR inside or outside the institution, and patients who dropped out or did not complete their final assessments. 2 groups were formed: the experimental group received the CR program, and the control group was composed of patients who decided not to enter the CR program. The CR program lasted four weeks, consisting of 2 weeks of calisthenics and 2 weeks of ergonomics, daily sessions from Monday to Friday lasting approximately 1 hour and 30 minutes, with talks on secondary prevention, nutritional counseling, and psychological support. Both groups performed baseline and final measurements in order to see the difference in the variables studied. The following variables were identified: percentage of people who returned to work, and days of disability at the time of return to work. This information was obtained by contacting workers at 2 months and one year after the cardiac event.
Mean and standard deviation were used for quantitative variables; qualitative variables were summarized as absolute frequencies and relative frequencies. To determine the difference between quantitative variables, Student’s t-test was used for qualitative variables and Chi-squared was used, considering a p-value equal to or less than 0.05 as statistically significant.
65 workers with the diagnosis of ischemic and / or valvular heart disease were studied, with an average age of 53.18 years (SD 9.29), the predominant risk factors were smoking and hypertension, no significant difference was found between the risk factors of both groups (Table I).
|Table I Risk factors|
|Risk factors||n (%)|
|SAH = systemic arterial hypertension; DM2 = Diabetes mellitus 2|
Two groups were formed, those receiving CR (n = 40) compared with those (n = 25) who did not receive it; the percentage of patients in the CR program who returned to work was higher than the control group, without attaining statistical significance (Table II); the average time in days before return to work was lower in the experimental group compared to the control group, with a statistically significant difference (Table III). Work activity in patients who returned to work was similar in the two groups (Table IV).
|Table II Patients who returned to work by intervention group|
|Cardiac rehabilitation||Total||P -value|
|Return to work||Yes, n (%)||30 (75)||15 (60)||45 (70)||0.2|
|No, n (%)||10 (25)||10 (40)||20 (30)|
|Total, n (%)||40 (100)||25 (100)||65 (100)|
|Table III Days of disability by intervention group|
|Cardiac rehabilitation||P -value|
|Average days of disability, (SD)||68.09 (47.6).||128.25 (91.4).||0.001|
|Table IV Occupation by intervention group|
|Occupation||Return to work||Total||p|
|Office, n (%)||10 (22.2).||5 (25)||15 (23.1).||0.41|
|Not qualified, n (%)||7 (15.6).||4 (20)||11 (16.9).|
|Technician, n (%)||6 (13.3).||3 (15)||9 (13.8).|
|Sales, n (%)||5 (11.1).||4 (20)||9 (13.8).|
|Scientist, n (%)||8 (17.8).||-||8 (12.3).|
|Operator, n (%)||4 (8.9).||3 (15)||7 (10.8).|
|Director, n (%)||4 (8.9).||-||4 (6.2).|
|Machines, n (%)||1 (2.2)||1 (5)||2 (3.1).|
|Total, n (%)||45 (100.0).||20 (100)||65 (100.0).|
Our study found an average age of 53.18 years, the risk factors were presented equally in both groups, and return to work was higher in the group with CR (75%) than the control group (60%); although significant statistical difference was not found, the results are consistent with studies published by other researchers.
A study in Cuba found that patients who received a CR program returned to work in more than 26%, compared with the group that did not receive CR, with a statistical significance of 0.0001;27 a similar study in Spain found that on average, patients who received CR had a higher rate of return to work than those patients who did not receive CR, with a statistically significant difference.
In assessing the number of days after which patients returned to work in both groups, we found that the control group took on average 60 days, compared with the group receiving CR. Something similar was reported in Alvarez’s study, the author reported that the average labor reentry time in the group that received CR was 7.2 months compared to 11.9 months in the group that did not receive CR, with a p-value = 0.074; however, the sample size in this study was 12.16
CR is an intervention that favors labor reintegration and decreases the number of days of disability in patients who have suffered a cardiac event, however, so far it is not well accepted by doctors and patients, which means a small percentage of cardiac patients are sent to CR centers; therefore, it is important to publicize the benefits of this intervention, not only to medical personnel, but to the entire multidisciplinary team to achieve timely referral by second-level staff and timely treatment by staff trained in CR (such as cardiologists or rehabilitation doctors). With this we hope to increase the quality of life in these patients and reduce costs at the institutional level, since the percentage of patients returning to the labor market would increase and labor reentry time would decrease.
Patients who received CR were disabled for a shorter time and returned to work earlier than those who did not receive CR.
One of the main limitations of our study is the sample size, which did not allow us to find a statistically significant difference in the percentage difference of those who returned to work between the group receiving CR and the group that did not receive it, so in the future it is recommended to do further studies considering a larger sample size and a longer follow-up period.
To our knowledge, this is the first study in Mexico that assesses the effectiveness of cardiac rehabilitation in return to work, also it is a prospective study, with the certainty that the cause precedes the effect. There was no loss of participants to follow up and the two groups were homogeneous upon admission.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.