Download RETURN TO WORK IN HEART FAILURE (HF) PATIENTS

JESFC - 2013
RETURN TO WORK (RTW) IN HEART FAILURE (HF)
PATIENTS
C. MONPERE
(TOURS - BOIS GIBERT)
Return to work (RTW) in heart
failure (HF) patients
 CONFLICT
OF INTEREST WITH THIS
PRESENTATION:
 NONE DECLARED
Return to work (RTW) in heart failure (HF) patients
 PAUCITY
OF DATA : WHY?
Return to work (RTW) in heart failure (HF) patients
 OLDER
AGE OF
THE HEART
FAILURE
POPULATION :
LESS CONCERNED
BY PROBLEM OF
RETURN TO WORK.
Return to work (RTW) in heart failure (HF) patients

PAUCITY OF DATA : WHY?

OLDER AGE OF THE POPULATION

HIGH-RISK PATIENTS AND FEAR OF WORSENING
HEART FAILURE BY THE PHYSICAL AND
PSYCHOLOGICAL DEMANDS OF THE JOB :
leading to restrictive medical advice
Return to work (RTW) in heart failure (HF) patients

PSYCHO SOCIAL JOB STRESS : A RISK FACTOR FOR
CORONARY DISEASE
- INTERHEART STUDY
-JACE STUDY (JOB STRESS,ABSENTEEISM AND
CORONARY HEART DISEASE EUROPE STUDY)
- META-ANALYSIS (LANCET 2012)
IS IT REASONABLE TO WORSEN PROGNOSIS IN ALREADY
HIGH–RISK PATIENTS ?
IMPORTANCE OF ASSESSMENT JOB STRESS ++
(ie KARASEK SCORE)
Return to work (RTW) in heart failure (HF) patients

PHYSICAL DEMAND AT THE WORK PLACE :
A RISK FACTOR ??
-LONG TERM MODERATE ENDURANCE TRAINING
IN CHF PATIENTS IMPROVES LONG-TERM VITAL PROGNOSIS
ANDQOL
(BELARDINELLI.R JACC 2012
EXTRA-MATCH STUDY BMJ 2004)
+
Return to work (RTW) in heart failure (HF) patients
Return to work (RTW) in heart failure (HF) patients
Changes in Peak Oxygen Uptake
Belardinelli R. et al. JAM Coll Cardiol 2012 ; 60 : 1521.
Return to work (RTW) in heart failure (HF) patients
Changes in Left Ventricular Ejection Fraction
Belardinelli R. et al. JAM Coll Cardiol 2012 ; 60 : 1521.
Return to work (RTW) in heart failure (HF) patients
Kaplan-Meier Survival Curves between Patients and Controls
Belardinelli R. et al. JAM Coll Cardiol 2012 ; 60 : 1521.
Return to work (RTW) in heart failure (HF) patients
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 (RTW) in heart failure (HF) patients

PAUCITY OF DATA : WHY?

OLDER AGE OF THE POPULATION

HIGH-RISK PATIENTS AND FEAR OF WORSENING
HEART FAILURE BY THE PHYSICAL AND
PSYCHOLOGICAL DEMANDS OF THE JOB :
leading to restrictive medical advice
NO APPROPRIATE GUIDELINES AVAILABLE
Return to work (RTW) in heart failure (HF) patients

HOWEVER :

- DESPITE LV DYSFUNCTION PHYSICAL PERFORMANCE
IS IN YOUNG PATIENTS MAY BE MODERATELY
DECREASED
- HIGHER % OF SEDENTARY JOBS.
- CRITICAL SOCIO ECONOMIC CONTEXT : WORK IS A
VITAL NECESSITY
- IMPROVEMENT IN SYMPTOMATOLOGY AND
PROGNOSIS IN HF PATIENTS.




NEED TO EVALUATE ADEQUATION BETWEEN JOB
DEMANDS AND MEDICAL AND FUNCTIONAL STATUS.
Return to work (RTW) in heart failure (HF) patients
FACTORS INFLUENCING RTW
CLINICAL AND
FUNCTIONAL
PARAMETERS
ENERGY REQUIREMENT OF
THE JOB
LEGAL CONSIDERATIONS
PSYCHO-SOCIAL
ASPECTS
Return to work (RTW) in heart failure (HF) patients
CARDIO-PULMONARY
EXERCISE- TEST :
Objective evaluation of
physical capacities
Reproducibility
Assessment aerobic
system , but different
from real work conditions
(static efforts)
+
Return to work (RTW) in heart failure (HF) patients
LAS … A.
LVEF 20 %
SLO … JF.
LVEF 20 %
+
Return to work (RTW) in heart failure (HF) patients
SLO… JF . 50 y
DCM
Stress test : 150 W 1 mn 76%PMHR
PIC VO2 18 ml mn kg-1 (78 % theor.)
SV1 : 90 w 13 ml mn kg
+
Return to work (RTW) in heart failure (HF) patients

Las … A . 55 ans .

Ischemic myocardiopathy

Stress test : 70 w 1mn 50% PMHR .

BP :100/80 à 115/75 mm Hg.

PIC VO2 11.9 ml mn kg-1 (47 % théorique)

SV1 : 50 W 9.9 ml mn kg
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
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
Caution : These values are determined from healthy patients.
Other parameters to consider :
- environmental conditions : hot and cold air temperatures, pollution
noise ...
-working and rest hours : deleterious effect of « 3x8h », transport …
-type of exercise encountered : dynamic, static,arm-shoulder exercises
Return to work (RTW) in heart failure (HF) patients

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 job-simulation
or on-site evaluation to determine
cardiovascular responses to
specific work tasks.
+
Return to work (RTW) in heart failure (HF) patients
: work simulation
+ Return to work (RTW) in heart failure (HF) patients
: work simulation
Return to work (RTW) in heart failure (HF) patients :
work simulation
Cardiofrequencemeter
Return to work (RTW) in heart failure (HF) patients
Return to work (RTW) in heart failure (HF) patients :
influence of LVEF
AUTHOR YEAR
NB PTS
%RTW
F.UP
BHATTACHARYY
A M.R (GB) 2007
126
80.2
ISAAZ K (F) 2010
200
BIERING K (N)
2012
PREDICTIVE
FACTORS +
PREDICTIVE
FACTORS -
COMMENTS
1Y
Arrhythmia
Recurrence
Depression
LVEF not
predictive
76
?
>M6
Older age
Manual work
Single
LVEF not
predictive
1589
(50%
WORK)
86
1Y
Poor SF12
score
LVEF < 35 %
Self rated
health < LVEF
SLEBUS FG (NL)
84
88
2Y
No complaint
Feeling good
Physical
incapacity
comorbidity
Pt’s
perspective
MONPERE C (F)
2012
143
78
2Y
High socio
prof category
Relaxed work
Older age
Dyspnea
Positive stress
test
LVEF not
predictive
Return to work (RTW) in heart failure (HF) patients

CARDIAC REHABILITATION : an opportunity to optimize RTW counselling.

- 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 :GP ,vocational physician,
cardiologist,physiotherapist , psychologist…







- better knowledge
-of the workplace
-psycho social job stress
- identification of barriers to RTW.
+ Return to work (RTW) in heart failure (HF) patients
Return to work (RTW) in heart failure (HF) patients


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 (RTW) in heart failure (HF) patients

Safety and legal considerati

Professional drivers
Arrêté du 31/08/2010
JO du 14/09/2010
« Affections which may expose any
professional driver with CV disease to a
sudden incapacity of cerebral function
represent a danger for the traffic safety »
Return to work (RTW) in heart failure (HF) patients
Arrêté du 31/08/2010
JO du 14/09/2010
« After an acute event, resuming professional
driving is conditioned by a medical advice and
determination of control periodicity »
Additional risks linked to heavy trucks driving …
should be considered with extrem caution.
These rules apply also to taxi-drivers, school-bus
drivers, public transports and driving teachers ».
Return to work (RTW) in heart failure (HF) patients
Safety and legal considerations
Arrêté du 31/08/2010
JO du 14/09/2010
1-5 Insuffisance cardiaque chronique
Incompatible si l’insuffisance cardiaque est au
stade 3 ou 4 permanent (classification New York
Heart Association : NYHA)
1-9 Cardiomyopathie hypertrophique
Incompatibilité
1-2-8 Défibrillateur automatique implantable en
prévention secondaire
Avis spécialisé obligatoire. Si confirmation de l’affection :
incompatibilité.
(en cas de refus d’implantation par le patient, se reporter
à l’affection justifiant l‘indication )
1-2-9 Défibrillateur automatique implantable en
prévention primaire
Avis spécialisé obligatoire. Si confirmation de l’affection :
incompatibilité.
(en cas de refus d’implantation par le patient, se reporter
à l’affection justifiant l‘indication )
Return to work (RTW) in heart failure (HF) patients
CONCLUSION

RTW in HF patients must be considered on an individual
basis, including :



Not only the CV condition, the physical capacities of the
patient, and the energy requirement of the job
But also the psychological job stress and the patient’s point of
view
Cardiac rehabilitation represents an opportunity to assess
and optimize patient’s RTW