THE EUROPEAN SOCIETY OF MEDICINE

Medical Research Archives, Volume 12 Issue 12

RESEARCH ARTICLE
The Role of Cardiac Rehabilitation in Facilitating Return to Work After
Cardiovascular Events
Cholid Tri Tjahjono1, Maimun Zulhaidah Arthamin2

1 Division of Cardiac Prevention and ABSTRACT

Rehabilitation, Department of Cardiology Returning to work (RTW) after a cardiovascular event, such as acute
and Vascular Medicine, Faculty of Medicine,
Universitas Brawijaya – Saiful Anwar coronary syndrome (ACS) or coronary artery bypass grafting (CABG), is a
Teaching Hospital Malang 65111, Indonesia
2 Department of Clinical Pathology, Faculty of critical aspect of cardiac rehabilitation (CR). Effective CR not only enhances
Medicine, Universitas Brawijaya – Saiful
Anwar Teaching Hospital Malang 65111, a patient's quality of life but also ensures financial stability by reducing
Indonesia. occupational disability-related costs. Multiple factors involved to return to
work process, including physical health, psychological well-being, work-
OPEN ACCESS
related factors, and the severity of the cardiac event. This review explores
PUBLISHED
31 December 2024 the role of CR in facilitating RTW for post-ACS and post-CABG patients,
highlighting key considerations for a safe and successful transition to work
CITATION
Tjahjono, CT., and Arthamin, MZ., 2024. The and daily activities. Interdisciplinary approaches are crucial, as different
Role of Cardiac Rehabilitation in Facilitating
Return to Work After Cardiovascular Events. medical and rehabilitation professionals contribute to optimizing patient
Medical Research Archives, [online] 12(12).
https://doi.org/10.18103/mra.v12i12.6016 outcomes. Furthermore, the type of work and associated physical demands
must be carefully evaluated for each patient. Special attention is needed
COPYRIGHT
© 2024 European Society of Medicine. This is for developing countries, where cardiac rehabilitation programs are less
an open- access article distributed under the
terms of the Creative Commons Attribution established, to ensure these patients receive adequate support. The article
License, which permits unrestricted use,
distribution, and reproduction in any medium, concludes by discussing future strategies to improve return to work rates,
provided the original author and source are improving quality of life, and minimize the economic burden of
credited.
DOI cardiovascular diseases.
https://doi.org/10.18103/mra.v12i12.6016
Keywords: Return to work, Cardiovascular events, Cardiac rehabilitation,
ISSN
2375-1924
Acute coronary syndrome, Coronary artery bypass grafting

© 2024 European Society of Medicine 1

 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
Introduction Cardiovascular Events
Return to work (RTW) refers to a patient who, after being 1. Acute Coronary Syndrome
absent from work due to an illness or accident, comes Acute coronary syndrome (ACS) are critical medical
back to work and resumes their duties. Returning to work conditions that raise from a sudden reduction in blood
is crucial for raising a patient's sense of self-worth and flow to the heart. The ACS encompasses a spectrum of
quality of life 1. Cardiovascular events increase the risk conditions, including ST elevation myocardial infarction
of worsening job conditions, including reduced (STEMI), non-ST elevation myocardial infarction (NSTEMI),
responsibilities, part-time work, salary reduction, and and unstable angina 14. These are types of coronary
exclusion from work with an average loss of productivity heart disease (CHD), which are responsible for one-third
2. RTW in patients with ACS considers objective clinical
of total deaths in people over the age of 35. ACS is a
data (e.g., left ventricular ejection fraction (LVEF), form of CHD that is always symptomatic 14. The
exercise capacity, and comorbidities), work-related retrospective study showed that return to work is an issue
factors (e.g., job satisfaction and expectations about for ACS patients, both in the short and long term after
returning), psychological conditions (e.g., anxiety, hospital discharge. Moreover, in gaining a patient's
depression, fear of recurrence), and other general clinical perspective, there are various factors that can influence
conditions 2,3. In addition, cardiovascular events also have this process and its end result. These different factors fall
an impact on a patient's ability to return to daily activities within the realm of different specialists, such as
such as driving and sexual intercourse with a partner. cardiologists, general practitioners, occupational health
Therefore, restoring work ability and mobility is a key specialists, and insurance physicians, who may share
goal in cardiac rehabilitation (CR), enhancing both responsibility for the cardiac patient's return to work 15.
personal and financial stability while reducing the Unfortunately, such interdisciplinary teams are currently
healthcare costs associated with long-term disability 4,5. rare. To facilitate vocational reintegration in the
community, cardiac rehabilitation plays an important
Cardiac rehabilitation (CR) is a type of rehabilitation role, as it has been shown to increase the success of full-
program designed to improve the health and quality of time RTW. In addition, patients attending cardiac
life of patients after a cardiac event so that they can rehabilitation programs return to work earlier and tend
resume their regular activities 6. It was initially focused on to take easier or lighter jobs 6.
patients post-myocardial infarction or coronary artery
disease, post-arterial bypass surgery, but is now being 1.1 CARDIAC REHABILITATION AFTER ACS
opened up more widely to patients post-coronary Cardiac rehabilitation or CR is essential for patients post-
intervention and heart failure. The main goal of the ACS, improving their physical, mental, and social well-
program is to restore the individual's condition, including being. Comprehensive CR programs provide tailored
optimal physical, mental, medical, psychological, social, exercise regimens, psychological support, and guidance
emotional, sexual, vocational, and economic status 7,8. on lifestyle modifications to prevent recurrence 13.
Numerous studies suggest that cardiovascular events has Cardiopulmonary exercise testing (CPET) and patient’s
an impact on RTW levels and employability 9–11. The metabolic equivalents (METs) , which helps assess a
presence of comorbidities 6, low education and economic patient’s overall cardiopulmonary capacity and identify
status, female, elderly, psychological conditions 12, and any remaining cardiovascular limitations during exercise
disease severity are some of the risk variables related to 16. In some cases, CPET results can be correlated with the

failed RTW after cardiovascular events. type of work the patient performed before the event,
helping to ensure a safer return to their professional
Numerous studies further elucidate that a significant duties. Low-level exercise testing provides enough
number of cardiovascular events patients struggle to information to guide patients toward initial outpatient
maintain their jobs after RTW. CR is essential for exercise therapy and suggest safe activities. Patients who
managing cardiovascular events, improving patients' do not receive exercise testing and revascularization, the
quality of life, physical activity, and medical costs. Most occurrence of ST depression during low-intensity exercise,
patients can return to work after CR in the current era of METs less than 5, and hypotensive exercise response have
invasive and intensive treatment for arrhythmias, ACS, a worse prognosis. The treadmill test is recommended as
and other types of heart disease 13. So we explored the the exercise modality of choice to determine ischemic
role and impact of CR in improving quality of life, ability threshold and electrical flow instability. If the treadmill
to perform activities of daily living independently, ability test is not feasible, a 6-minute walk test may be a viable
to drive, to have safe sex, and return to work. alternative 2.

Table 1. Estimation of maximum cardiopulmonary and full-time work capacity based on peak VO2 achieved, German
recommendations 2
Maximum capacity on Maximum capacity in Endurance capacity Estimation energy
the ergometer relation to BW on the ergometer expendure (METs) Work intensity
<50 Watts Up to 1 Watt/kgBW Up to 50 Watts <3.1 Very light
>50-75 Watts >1-1.5 Watts/kgBW >50-75 Watts <4.3 Light
>75-125 Watts >1.5-2 Watts/kgBW <75-100 Watts <6.4 Moderate
125-150 Watts >2 Watts/kgBW >100 Watts <7.4 Heavy
kgBW: kilogram body weight

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 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
In Germany, patients' maximum bicycle exercise capacity correlation between oxygen uptake and energy
and endurance are interpreted as absolute values, which expenditure under specific work conditions is necessary
are also related to body weight, called the Ludwigshafen to determine a patient's ability to perform physical
model, as shown in Table 1. In addition, there is a activity 2. Maximum cardiopulmonary and full-time work
correlation between the energy requirement in METs capacity is one of the considerations that must be made
according to body weight and the load performed during before patients can return to work. However, other
cycle ergometry 2. This scheme can be used for all aspects also need to be considered to determine the
patients but has limitations, such as not taking into appropriate work that can be performed by patients
consideration age and sex. The combination of these after CR, including: age, gender, work-related factors,
schemes in CPET makes it a more effective and objective comorbidities (diabetes mellitus, hypertension,
method, although there is limited data for work intensity dyslipidemia, obesity, and chronic kidney disease),
grouping using peak oxygen consumption (VO2). Cycle cardiac rhythm stability, complaints of shortness of
ergometry is usually sufficient for low- or moderate- breath, history of cardiogenic shock, cardiac arrest
intensity activities but not for high-intensity activities. The survivor, psychosocial status, and CR compliance 17,18.

Figure 1. Return to work consideration algorithm after ACS event (adapted from Reibis et al.2019)2

1.2 FACTORS THAT INFLUENCE RETURN TO WORK successful return to the same level of work for ACS
Return to work considerations are based various factors, patients 15.
such as clinical, psychological, and work-related factors.
Understanding these factors is essential for developing Chronic stress in the workplace results from high demands
rehabilitation strategies that improve patient outcomes and low decision-making potential, or from a combination
and facilitate a smoother transition back to employment, of high expectations and low professional satisfaction.
as shown in Figure 1 2. Dyspnea, chest pain, and other Especially for patients with psychological vulnerabilities,
physical complaints may slightly hinder RTW 19. On the persistent shift work, night shift work, or overtime hours
other hand, higher exercise capacity, measured by can aggravate individuals 21. Objectively, job strain has
workload and VE/VCO2 slope, is independently an important impact on the risk of cardiovascular disease,
associated with a higher probability of RTW. for example, the incidence of atrial fibrillation. Women
Comorbidities including chronic obstructive pulmonary with a double burden of work and family also increase
disease, diabetes, and psychiatric illnesses (such as the risk of CAD. A prospective Dutch cohort study found
schizophrenia and depression) are associated with lower a significant correlation between the absence of RTW
rates of RTW 6. The importance of understanding the and depression (odds ratio (OR) 3.48, 95% CI 1.45-
factors that can facilitate the return to work process helps 8.37) and anxiety disorders (OR 2.90, 95% CI 1.00-
improve effective communication between doctors and 6.38) 22. Professional reintegration is often limited by
patients 6. Facilitating factors associated with return to fear of self-harm due to physical or emotional stress
work include no complaints of heart disease 6, advice caused by or resulting from work. Thus, the patient's self-
from a cardiologist 12, younger age, high education level, assessment of their ability to adequately perform
high income level 6,20, a good work environment, and previous activities has a high prognostic value for RTW
supportive colleagues 15. Employment conditions and 23,24.

social security are embedded in the social environment

and are outside the domain of cardiology. However, 1.3 THE ROLE OF THE DISCIPLINES IN PREPARING ACS
discussing returning to work early in the recovery process PATIENTS FOR A RETURN TO WORK
can motivate patients. A comprehensive assessment of Working prior to coronary intervention has a higher
these factors is needed to determine the likelihood of a predictive impact for RTW, but the characteristics of the
© 2024 European Society of Medicine 3
 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
tasks performed are important to evaluate to determine or low pressure in the atmosphere, high noise levels, fine
the probability of RTW 25. Patients with overt dust load, hot or cold temperatures, being in an electric
cardiovascular disease with clear pathophysiology need field, etc.), should also be considered. Furthermore,
to be measured and evaluated for consideration of being patients with manual and physically demanding jobs are
able to perform tasks at previous jobs. Cardiologists play at risk of poor work outcomes 27. Patients with driving
a central role in assessing a patient’s cardiovascular restrictions may be limited in their ability to travel (reach
health, determining physical readiness for work, and the workplace on foot, by using a vehicle, or by using
guiding the overall rehabilitation plan. They monitor key public transportation).
indicators such as left ventricular ejection fraction (LVEF),
exercise capacity, and heart rhythm stability to ensure Therefore, the remaining work capacity after ACS
that the patient can safely resume professional activities. (partial-total/temporary-permanent disability) depends
Cardiologists also determine whether additional on the measured parameters. The RTW and subsequent
treatments, like revascularization, are necessary and vocational reintegration may be significantly improved
assess the patient’s response to medication and physical with CR because of the time required for assessment and
exertion 26. Occupational physicians are responsible for consideration by the institutional team (cardiologist,
determining whether the patient can return to their occupational physician, psychologist, and workplace
previous position or if adjustments, such as reduced hours, owner) as shown in Figure 2. A recently published meta-
modified tasks, or gradual reintegration, are necessary. analysis of 18 studies focusing on RTW rates after
Psychological tasks, including shift and night work, individually delivered psychosocial and vocational
production line work, piece work, or work under time interventions showed better employment rates at 3
pressure, are important professional parameters in the months compared with usual care, but the effect is
assessment of reintegration ability. Workers in three neutralized after 6–12 months 28,29. Identification of
rotating shifts or permanent night shift schedules show patients at risk of poor work outcomes should occur early
modifications in their cardiac neurovegetative regulation in the reintegration period, ideally during post-acute CR.
due to increased sympathetic tone both at night and In general, career-related information is rarely taken into
during daytime sleep. Work-related factors affecting consideration during CR. A survey in France showed that
occupational reintegration, including the intensity of only 53% of ACS patients were advised to consider RTW.
physical effort to be performed (lifting, carrying, and Therefore, treatment of the underlying heart disease and
moving heavy objects) and workplace situations of a CR is given relatively high priority, while reintegration
physical and chemical nature (toxic fumes, high pressure strategies leave room for improvement 30.

Figure 2. Work capacity and return to work consideration in patients with Acute Coronary Syndrome (Adapted from
Reibis et al.2019)2
CBT: cognitive behavioral therapy;;CR: cardiac rehabilitation;GP: general practitioner;ICF: International Classification of
Functioning, Disability and Health; QOL: quality of life; RTW: return to work; SCD: sudden cardiac death; 6MWT: 6 minute
walking test; CABG: Coronary Artery Bypass Graft

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 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
The following is an algorithm for considering an individual but positive stress test results could not perform all types
return to work after an ACS event, as shown in Figure 3 of work. Similarly, patients who did not undergo complete
31. Patients with ACS who undergo complete revascularization with an ejection fraction < 0.5 and a
revascularization, either percutaneous or surgical, with an positive stress test could not perform all types of work.
ejection fraction >0.5 and a negative result on the stress Meanwhile, patients who have not undergone complete
test are able to perform all types of work. Patients revascularization with an ejection fraction >0.5 and a
undergoing complete revascularization with an ejection positive stress test result, or with an ejection fraction <0.5
fraction >0.5 but a positive stress test or an ejection and a negative stress test result, can perform tasks that
fraction <0.5 and a negative stress test may perform require <3 METs 2. The stress test performed was a
tasks requiring <5 METs. Similarly, patients who have not symptom-limited stress test, defined as negative if no
undergone complete revascularization with an ejection clinical or electrocardiographic abnormalities (ST
fraction >0.5 and a negative stress test result may depression >1 mm or ventricular arrhythmia) occurred at
perform tasks requiring <5 METs. Patients who underwent >7 METs.
complete revascularization with an ejection fraction <0.5

Figure 3. Return-to-work algorithm after ACS event 31

Table 2. Selection of occupational activities according to metabolic equivalence (METs) (adapted from Ainsworth et al,
1993) 32
METs Description of the Recommended Occupational Activities
1.8 Engineer (e.g. mechanical or electrical)
2.3 Custodial work, light effort (e.g. cleaning sink and toilet, dusting, vacuuming, light cleaning)
2.5 Tailoring, machine sewing
3.5 Walking on job, 3.0 mph, in office, moderate speed, not carrying anything
3.8 Custodial work, moderate effor (e.g. electric buffer, feathering arena floors, mopping,
taking out trash, vacuuming)
4.0 Chambermaid, hotel housekeeper, making bed, cleaning bathroom, pushing cart
4.3 Walking on job, 3.5 mph, in office, brisk speed, not carrying anything
6.0* Building road, driving heavy machinery
6.8 Fire fighter, rescue victim, automobile accident, using pike pole
7.8 Farming, vigorous effort (e.g. baling hay, cleaning barn)
8.0* Manually carrying heavy loads (e.g. bricks, tools)
8.5 Walking or walk downstairs or standing, carrying objects about 100 pounds or over
METs: metabolic equivalents.
*Estimated

1.4 AIR TRAVEL SAFETY AFTER ACS pressure from 150 mmHg to around 107 mmHg. In
For patients recovering from acute coronary syndrome healthy individuals, this decrease triggers compensatory
(ACS), air travel presents unique challenges due to mechanisms such as increased cardiac output to maintain
potential physiological and psychological stressors. The adequate oxygenation 33. However, for post-ACS
combination of high altitude, reduced cabin pressure, patients, especially those with reduced physiological
limited access to medical care, and travel-related anxiety reserve or impaired cardiac function, this compensation
can pose risks, particularly for individuals with impaired may be insufficient.
cardiovascular function. Commercial aircraft are
pressurized to simulate an altitude of approximately Anxiety is a common issue for ACS patients during air
8,000 feet, reducing atmospheric oxygen partial travel. Flight delays, increased airport security, pre-flight
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 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
activities that cause excessive fatigue, including carrying plan to travel by air. Air travel is recommended within 3
heavy luggage or walking long distances to the flight days to 2 weeks after unstable angina, or NSTEMI, and
gate, and the fear of being far from medical care can more than 2 weeks after STEMI. For complicated patients,
elevate anxiety levels, which may increase serum the recommended time range is 10 days to 6 weeks.
catecholamine levels, which can heighten cardiovascular Patients who have undergone PCI revascularization can
stress. Though no specific data exist on anxiety-related travel by air 3 days to 2 weeks after the procedure. The
effects in commercial flights with pressurized cabins, the apparent risk of complications in ACS patients who are
potential for anxiety to exacerbate cardiac symptoms traveling during early hospitalization is noteworthy,
should be considered when assessing a patient’s fitness to including the identification of at-risk patients for
fly 34,35. A review of 288 air travel events involving ACS commercial air travel 36.
patients found four in-flight adverse events, though none
were fatal 34. Complications such as chest pain or 1.5 FITNESS TO DRIVE AFTER ACS
arrhythmia can arise during the flight, and while flight After ST-segment elevation myocardial infarction (MI),
crews are trained in basic life support and some aircraft patients are at risk for sudden arrhythmic death within
are equipped with automated external defibrillators one to two years, especially if early thrombolysis or
(AEDs), medical intervention options remain limited until primary angioplasty were not performed. The risk of
the aircraft lands 34. sudden cardiac death or cardiac arrest in patients with a
recent MI is highest in the first 30 days after the MI 37,38.
Some guidelines provide instructions for ACS patients who

Table 3. Return to driving recommendations after ACS 37

Cardiac conditions Private driving Commercial driving
ACS: PCI performed
- STEMI, LVEF <40% may return to driving after 1 month may return to driving after 3 months
- STEMI, LVEF >40% may return to driving after 2 weeks may return to driving after 1 month
- NSTEMI, LVEF <40% may return to driving after 1 month may return to driving after 3 months
- NSTEMI, LVEF >40% may return to driving after 2 weeks may return to driving after 1 month
- Unstable angina may return to driving after 48 hours may return to driving after 7 days
ACS: PCI not performed
- STEMI may return to driving after 1 month may return to driving after 3 months
- NSTEMI may return to driving after 1 month may return to driving after 3 months
- Unstable angina may return to driving after 7 days may return to driving after 1 month
CABG revascularization may return to driving after 1 month may return to driving after 3 months
ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; STEMI, ST-segment elevated MI; NSTEMI, non ST-
segment elevated MI; LVEF, left ventricular ejection fraction; CABG, coronary artery bypass grafting

The risk of sudden cardiac death (SCD) after acute 1.6 SAFE SEXUAL ACTIVITY FOLLOWING ACS
coronary syndrome (ACS) is a significant concern. Studies In patients without or with mild angina pectoris (class I or
have shown that patients with reduced left ventricular II), sexual activity can be performed, while in other
ejection fraction (LVEF) are at higher risk of SCD after patients it should be postponed until their condition is
ACS, regardless of the type of ACS (ST-segment stabilized or optimally controlled 42. In patients with
elevation myocardial infarction [STEMI] or non-STEMI intermediate symptoms or whose risk is unknown, an
[NSTEMI]). The incidence of SCD among patients with an exercise stress test can provide additional information on
LVEF of 40% within 3 months after ACS was found to be exercise tolerance and estimate the severity of ischemia.
0.76%. Therefore, it is reasonable to continue restricting If the person can achieve energy consumption of ≥3-5
commercial driving for 3 months after myocardial METs, then the risk of ischemia during sexual activity is
infarction (MI) in patients with an LVEF of 40% or less 39. very low. After myocardial infarction, asymptomatic
However, in post-MI patients with normal EF and high patients, patients without signs of ischemia during
rates of revascularization, the risk of SCD ranges from exercise stress tests, and subjects who have undergone
0.5% to 0.6% at 1 year 40. In a contemporary registry complete coronary revascularization have a low
study, the SCD rate between 1 and 3 months was found cardiovascular risk during sexual activity 43. The
to be well below the acceptable threshold of 0.083% ACC/AHA guidelines for managing non-ST elevation MI
per month (1% per year). This suggests that driving suggest that patients can start walking immediately after
restrictions can be eased for post-MI patients with LVEF hospital discharge and cardiac rehabilitation, resuming
>40%. sexual activity as early as one week after myocardial
infarction 42.
The risk of SCD after hospitalization for unstable angina
is relatively low compared to STEMI or NSTEMI. Data 2. Post- Coronary Artery Bypass Grafting
from a study of patients with unstable angina showed (CABG) Procedure
that the incidence of cardiovascular death, including SCD, Coronary artery bypass grafting (CABG) is the primary
was 2.6% at 2-year follow-up compared to 5.2% for treatment for patients with coronary artery disease
NSTEMI and 3.7% for STEMI. Therefore, the consensus is (CAD) and most common treatment performed in 60% of
to prohibit driving for 48 hours after a recent ACS with cases of advanced heart disease 44. In Canada, 15,000
intervention and 7 days for ACS patients without patients undergo coronary artery bypass grafting
intervention 41.
© 2024 European Society of Medicine 6
 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
(CABG) surgery each year 45. However, after surgery, heart disease through the return-to-work process, based
patients face challenges in managing their symptoms, on international research, and recommend return-to-work
returning to a normal life, and fulfilling their plans. Heart during CR to overcome possible barriers of fear and
surgery significantly impacts the patient's career and anxiety. The guidelines suggest partial or full RTW within
professional life. Patients undergoing CABG typically approximately six weeks for patients after CABG, as
require a hospital stay of almost a week, and after long as postoperative biological recovery is good.
discharge from the hospital, they typically require a Younger age 5, good job satisfaction 11, high job
recovery period of 2 to 6 weeks to resume normal expectations 5, and absence of comorbidities 2 are
activities and return to work if possible. Most patients factors that facilitate faster RTW but cannot be
need to address residual issues such as heart failure, considered comprehensive as they are all individualized
anemia, atrial fibrillation, pulmonary abnormalities, and internal factors. In RTW models, such as the ecological
pain associated with thoracotomy and saphenectomy. model of case management, external factors, factors
Patients face the risk of recurrent angina or ACS later in outside the individual, i.e., work-related factors, and
the follow-up period due to the progression of coronary other factors influence the disability process 2. However,
artery disease in the native coronary circulation or this model has never been applied to post-CABG
bypass failure, particularly with vein grafts that are more patients. Advice from cardiologists and occupational
susceptible to stenosis after several years. In geriatric physicians plays a role in patients' consideration of RTW.
and debilitated patients, an increased length of hospital Work-related barriers such as work stressors (i.e.,
stay was associated with a fivefold increased risk of poor excessive workload, busy workplace, staff shortage) and
1-year functional survival 46. Patients after CABG are communication with supervisors (i.e., difficult relationships)
prescribed complex medications and encouraged to are the most important barriers in the RTW process 2,5.
adopt a healthy lifestyle, including smoking cessation,
diet, moderate exercise, and psychological stress control 2.2 CARDIAC REHABILITATION AFTER CABG
47,48. An important goal of CR is to optimize social participation
in various aspects of daily life, such as household, work,
2.1 RETURN TO WORK AFTER CABG and leisure activities 50. Although participants were
Surgery procedure is a dramatic event and most people positive about their CR program, they also mentioned
who have the ability and need to return to work fail to that the lack of follow-up after CR led to feelings of
do so. Furthermore, due to long waiting lists for uncertainty about their activities at home and in
angiography and bypass surgery, many patients lose continuing their work. This feeling of uncertainty was
their jobs and have no work to return to 49. One study exacerbated by the fact that participants were advised
found that patients who lost their jobs more than 6 months to begin the RTW process only after completing CR, which
before surgery had a lower return to work rate (35%) is contrary to guideline recommendations. Return to work
than patients who lost their jobs less than 6 months before during CR requires coordination between the
surgery. Occlusion of the graft causes angina recurrence occupational physician and the cardiac rehabilitation
at a lower rate than before (4% per year), but it still has team, which is in line with the suggestions for improvement
an impact on long-term employment plans. Although mentioned in the Dutch rehabilitation guidelines. A
return to work (RTW) is faster after angioplasty than specialist managing the case as the primary contact is not
after CABG, the long-term employment outlook is the sufficiently embedded in current practice, resulting in
same for both 45. treatment and RTW plans not being sufficiently aligned 2

The RTW is an important aspect of life for post-CABG The acute phase of CR is performed under supervision in
patients, leading to improved quality of life, financial the intensive care unit (ICU), cardiac care unit (CCU), or
security, and a sense of well-being. Although RTW has an hospital ward. Acute CR aims to restore the patient's
impact on improving people's health after surgery, ability to safely perform activities of daily living (ADLs),
research shows that factors such as the type of job, such as feeding, toileting, and bathing, and prepare for
workplace accommodations, flexibility, and support from secondary prevention. CR is also used to achieve
co-workers and employers affect patients' motivation to hemodynamic stability after hospitalization for AMI or
RTW 12. Another study in Poland showed that economic heart failure or after surgery. Prolonged bed rest can
needs, emotional factors, anxiety, and low self-esteem reduce exercise capacity and weakness. The CR program
were factors to consider when returning to work after begins with early mobilization from the bedside, in
CABG. Failure to return to work causes irreparable harm parallel with acute care, and ends with a 6-minute walk
to the individual, family, and society. Identifying test. If the patient can walk more than 300 m, the
facilitators and barriers to returning to work can help program moves from an ambulation program to an
plan effective interventions and improve patients' quality exercise training program. Patient and family education
of life after cardiac surgery. about disease progression is also important for
subsequent lifestyle interventions and coronary risk factor
Guidelines from the Dutch Society of Occupational management, as well as motivating the patient to
Physicians describe how to guide employees with ischemic continue with the CR program 51,52.

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 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events

Figure 3. Step by step of Cardiovascular Rehabilitation (CR) based on disease phase (Adaptation from Izawa et al.
2019 with modifications) 51

The CR takes place during the recovery phase, starting exacerbation of the disease, heart failure, or excessive
from the patient's discharge to outpatient care and exercise, the medication and CR prescription should be
continuing until their condition stabilizes upon their return reviewed to intensify treatment 51,52.
to the community. Early recovery CR begins under
supervision in the CR room during hospitalization and is Maintenance-phase CR is performed throughout life,
followed by supervised exercise training in the outpatient after returning to the community. Maintaining the exercise
CR unit after discharge. Late-recovery CR involves capacity, lifestyle modification, and coronary risk factor
exercise training in the outpatient CR unit and at home. In management gained during recovery CR are the
low-risk patients, unsupervised exercise training may be priorities. This CR program is individualized based on
performed at home with themselves. An exercise plan is age, occupation, and the level of physical activity
prescribed based on disease severity converted to risk performed. When referring to a local institution or clinic,
classification, then exercise capacity is determined by a medical information sheet such as a medical history,
cardiopulmonary exercise testing (CPET), and a treatment current cardiac function, prescription, and exercise
and CR plan are made. If CPET cannot be performed program should be provided; then, a system that allows
because of complications, low physical fitness, or low left periodic evaluation and review of the exercise program
ventricular function, exercise capacity should be is required 51,52.
confirmed by a 6-minute walk test 52. In addition,
counseling programs for lifestyle modification and 2.3 AIR TRAVEL SAFETY AFTER CABG
medication adherence, identification and management of After CABG, patients are able to perform daily activities
comorbidities, and psychological counseling should be according to their capabilities, taking into consideration
provided, especially for patients planning to undergo safety issues. Airline companies also set rules for pilots
RTW. Patients with heart disease are prone to depression and flight crews to avoid life-threatening symptoms and
after hospital discharge due to anxiety about their disruptions to flight activities. In addition, since 2004,
physical health, financial problems, and concerns about airlines, especially those with passenger-carrying aircraft
returning to work or sexual potential 53. with a maximum payload of >7500 pounds, are
required to have ≥1 flight crew member trained in basic
In the recovery phase of CR, it is crucial to implement a life support (CPR), carry ≥1 automated external
comprehensive disease management program that defibrillator, and have emergency medical equipment in
includes exercise training and counseling on physical accordance with Federal Aviation Administration (FAA)
activities, smoking cessation, dietary management, regulations. 54. According to epidemiology, more than
appropriate treatment of coronary risk factors, 2.75 billion passengers travel by air each year, many of
psychological evaluation and support, and counseling for whom are cardiac patients with implanted pacemakers
RTW. In addition, self-management to prevent recurrence or automatic defibrillators, recent revascularization, or
should be explained to patients and their families. surgery that may predispose them to deep vein
Information about treatment goals and the content of the thrombosis (DVT) 55. An observational study using data
recovery CR program also needs to be shared with the from 744 million airline passengers between 2008 and
multidisciplinary CR team and discussed at regular 2010 reported a medical event rate of 1.6 per 100,000
conferences. If there are signs or findings suggesting passengers, with 36 medical deaths 55. Cardiac arrest is
© 2024 European Society of Medicine 8
 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
the most common cause of medical death and flight ≥9 minutes, and show no evidence of ischemia. 54. It is
diversion, accounting for 8% of medical emergencies 55. well known and documented that CABG is better than PCI
for revascularization of left main, left anterior
Although there are no specific guidelines from the descending, and multivessel disease. 59. In addition, PCI is
American Heart Association or the American College of known to be less effective than surgery at achieving
Cardiology for air travel after CABG, patients should not complete revascularization in complex CAD, which is a
travel by air until 10 days after uncomplicated CABG revalidation criterion for flight crews. The SYNTAX trial's
due to the risk of trapped gas expansion. A post- many publications provide strong evidence for the best
operative clinical evaluation must be performed before surgical procedure 60,61.
travel to rule out congestive heart failure, serious
arrhythmias, or residual ischemia 54. Various factors can The European Aviation Safety Agency (EASA) in Europe
affect cardiovascular health during flight, including has published the medical requirements for flight crew
reduced atmospheric pressure, reduced humidity, gas licenses in a unique document known as Part-MED 62. Part-
expansion, prolonged immobility, and increased physical MED represents an additional set of legally binding
and emotional stress. Most commercial aircraft fly at regulations that surgeons should be aware of when
cruising altitudes between 22,000 and 44,000 feet, with operating on a professional flight crew. For pilots
a decrease in the partial pressure of inhaled oxygen of undergoing cardiac surgery, there are many limitations
approximately 4 mmHg per 1,000 feet altitude. At this to the surgical procedure and post-operative therapy
altitude, the atmospheric pressure decreases by about modalities. Anticoagulation remains a disqualifying
65–85%, and the partial pressure of inspired oxygen condition for most commercial pilots, and partial
decreases by about 60–90% from sea level. Most revascularization often results in a loss of license in many
aircraft compress and pipe atmospheric air into the cabin countries 58,62.
to pressurize it to atmospheric pressure, typically around
7500 feet (only 25% lower than sea level) but not 2.4 GETTING STARTED WITH SAFE DRIVING AFTER
exceeding 8000 feet (cabin altitude) 33. This represents CABG
only a 30% reduction in the partial pressure of inhaled The Synergy Between Percutaneous Coronary
oxygen, which, although close to the rapid decline of the Intervention With Taxus and Cardiac Surgery (SYNTAX)
oxyhemoglobin dissociation curve, should maintain trial, which compared causes of death after PCI versus
arterial blood oxygen saturation >90% in a healthy CABG in patients with complex CAD, showed that
individual. Healthy individuals typically compensate for patients who underwent CABG had a 0.9% risk of SCD
this condition by increasing their tidal volume and heart within 30 days, 1.5% risk of SCD within 1 year, and 1.9%
rate. However, during turbulence or in bad weather, risk of SCD within 5 years 63. Other studies have shown
higher cruising altitudes may be required, resulting in a lower rates of SCD after CABG surgery. The Coronary
further loss of cabin pressure. In these situations, cabin Revascularization Demonstrating Outcome Study in Kyoto
altitudes above 10,000 feet are practically prohibited, (CREDO-Kyoto) PCI/CABG registry study showed that
as all crew and passengers must use supplemental the SCD rate at 1 year after CABG for multivessel CAD
oxygen 56. Therefore, passengers with ischemic heart was only 0.3%. The Surgical Treatment for Ischemic Heart
disease and underlying heart failure (especially those Failure (STICH) trial showed that people with LVEF <35%
with pulmonary disease) may be more susceptible to were going to have CABG. It found that among 1,411
increased hypoxia because lower initial oxygen levels people who were going to have CABG, the risk of SCD
may lead to a further decrease in the steep portion of was 0.35 percent at 30 days, 1.25 percent at 3 months,
the oxyhemoglobin dissociation curve as atmospheric 2.0 percent at 6 months, and 2.8 percent at a year 64.
oxygen pressure decreases. It can also raise the blood According to the Canadian Cardiovascular Society's
pressure in the pulmonary arteries and the heart rate, 2023 Executive Summary on fitness to drive after cardiac
systemic blood pressure, myocardial contractility, and surgery, post-CABG patients can drive private
cardiac output 57. transportation 4 weeks after discharge and public
transportation 12 weeks after discharge 37.
Pilots and cardiac surgery patients require a long period
of intensive postoperative observation and evaluation, 2.5 SAFE SEXUAL ACTIVITY FOLLOWING CABG
and returning to flight earlier than six months Sexual activity is an important component of quality of
postoperatively is not considered. The stability of the life for patients and partners, particularly those with
sternum after median sternotomy is clinically assessed in CVD. cardiopulmonary bypass (CPB) for on-pump CABG
flight crews as well as in the general population 58. The can affect serum levels of androgenic hormones,
AMS may deem pilots who have undergone cardiac particularly testosterone, which maintain normal sexual
surgery and meet the regulatory requirements "fit to fly" activity. Male sexual dysfunction affects approximately
to prevent unnecessary license restrictions in the future 58. 10–25% of middle-aged men worldwide43,65. At least
Pilots who have undergone uncomplicated MI or PCI in a 75% of patients with heart disease experience one or
coronary artery other than the left main coronary artery more types of sexual dysfunction. A study by Faisal
may experience a shortened recovery period of Mourad et al. (2017) assessed sexual dysfunction using
approximately 3 months. Recommended tests include the Sexual Behavior Questionnaire (SBQ) in a study of all
angiography, electrocardiogram (ECG), and treadmill Arab male patients younger than 60 who were
stress tests no earlier than the recovery period. Imaging candidates for on-pump CABG at Ain Shams University
modalities such as stress echocardiography and nuclear Hospital. The study compared patients' sexual function
imaging are reserved for those with uninterpretable ECG before and after surgery. The data showed a significant
stress tests. A maximum ECG treadmill stress test should decrease in sexual function in patients who underwent
achieve 100% of the predicted maximal heart rate, last surgery compared to their preoperative status. The
© 2024 European Society of Medicine 9
 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
decline in sexual function was evident in the elements of programs, ongoing education, and workplace
ejaculation, erection, sexual arousal, masturbation, and adjustments is crucial to helping patients navigate the
spousal satisfaction 66. return-to-work process successfully. By providing a
supportive and accommodating environment, healthcare
During foreplay and sexual arousal, blood pressure and providers and employers can facilitate a smoother
heart rate increase and rise to a maximum during transition back to work for patients recovering from
orgasm. Thereafter, both quickly return to normal levels. cardiovascular events, ultimately improving their overall
Sexual activity is equivalent to a light or moderately short well-being and quality of life.
duration of physical activity (such as stairs or brisk
walking), which is equivalent to 3–4 METs. Heart rate and Author contributions
systolic blood pressure are usually less than 130 bpm and All authors collected the data for the article, contributed
170 mmHg, respectively. In medical and emotional substantially to the discussion of its content, wrote the
conditions, older age is a risk for difficulty in achieving article, and revised and/or edited the manuscript before
orgasm and imposes greater demands on the submission.
cardiovascular system 43. Exercise stress testing is
reasonable in patients with unknown cardiovascular risk
to assess exercise capacity and the development of
Conflict of interest
symptoms, ischemia, or arrhythmias. Thus, patients with The author declares no conflict of interest in the
≥3-5 METs without angina, exaggerated dyspnea, preparation of the article
ischemic ST-segment changes, cyanosis, hypotension, or
arrhythmias can be evaluated 42. CR and regular Acknowledgments
exercise in patients with CVD are useful in reducing the AUTHORS' CONTRIBUTIONS
risk of complications during sexual activity. This increases All authors collected the data for the article, contributed
maximum exercise capacity and leads to a decrease in substantially to the discussion of its content, wrote the
maximum blood pressure and pulse rate. Sexual activity article, and revised and/or edited the manuscript before
can be resumed a few days after percutaneous coronary submission
intervention or 6–8 weeks after coronary artery bypass
grafting or non-coronary open-heart surgery. If FUNDING
revascularization is incomplete, an exercise stress test This research received no external funding.
may provide information on residual ischemia 67.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
3. Conclusion Not applicable.
Returning to work after a cardiovascular event can cause
physical, emotional, and financial challenges. Physically, PATIENT CONSENT FOR PUBLICATION
patients may experience limited stamina, while Not applicable.
emotionally, anxiety and depression can undermine
motivation. Financial and social support are also COMPETING INTERESTS
important factors.Addressing these diverse challenges The authors declare that they have no competing
through comprehensive support, customized rehabilitation interests.

© 2024 European Society of Medicine 10

 The Role of Cardiac Rehabilitation in Facilitating Return to Work After Cardiovascular Events
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