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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