Review Article

Return to work after myocardial infarction: A systematic review

Introduction

According to the World Health Organization (WHO), Cardiovascular Disease (CVD) is responsible for approximately 17.9 million deaths each year, positioning it as the foremost cause of mortality globally by 2030.¹ Among its various manifestations, Myocardial Infarction (MI) stands out as a significant contributor to both illness and death worldwide, including in Brazil.² From January 2012 to December 2021, Brazil recorded a staggering 1,103,858 hospital admissions attributed to Myocardial Infarction.³

In this scenario, the demand for both clinical and surgical interventions, along with the complications arising from Myocardial Infarction and necessary lifestyle adjustments for patients, substantially influences their physical health, psychological well-being, financial stability, and social interactions. ⁴ It is recognized that beyond conventional outcomes such as mortality rates and readmission statistics, a crucial determinant of functional recovery and health-related quality of life (HRQoL) is the capacity to return to work. ⁵ Consequently, it becomes imperative to identify the facilitators and/or obstacles that may influence this return-to-work process.

It is important to highlight that a majority of individuals who experience Myocardial Infarction are typically of working age, which can result in prolonged work disabilities.⁶ Although the 2023 guidelines from the European Society of Cardiology (ESC) emphasize that maintaining or regaining employment constitutes a vital aspect of recovery post-Myocardial Infarction, ⁷ medical professionals frequently prescribe sick leave as part of rehabilitation strategies for these patients. ⁸

Within this framework, those patients who do not resume work within six months following a Myocardial Infarction are statistically less likely to achieve reintegration into the workforce in subsequent years. ⁹ Therefore, collating information on the return-to-work experiences of Myocardial Infarction patients—alongside its correlation with disease severity, occupational roles, and duration of hospitalization—can aid in formulating tailored interventions for these individuals while simultaneously mitigating healthcare expenditures. This study aims to consolidate existing research regarding the return-to-work dynamics for individuals recovering from Myocardial Infarction and explore its association with disease severity, job engagement, and length of hospital stay.

Methods

This systematic review was carried out following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines established by Moher et al.¹⁰ The research utilized several databases, including MEDLINE (Medical Literature Analysis and Retrieval System Online), Lilacs (Latin American and Caribbean Health Sciences Literature), SciELO (Scientific Electronic Library Online), and Web of Science. Data collection occurred between November 2023 and June 2024.

The study was designed using the PICOS framework, which stands for Population (individuals who experienced Myocardial Infarction), Intervention or Exposure (hospitalization due to Myocardial Infarction), Comparison (severity, occupational activity, and duration of hospitalization), Outcomes (return to work), and Study design (cohort study). Keywords and their synonyms were selected based on the respective databases, referencing the Health Sciences Descriptors (DeCS), Medical Subject Headings (MeSH), and Embase Subject Headings (Emtree). Boolean operators “AND” and “OR” were utilized as detailed in Table 1. The search strategy focused on terms appearing in article titles, subject headings, and abstracts.

Cohort studies assessing the return to work for individuals who experienced a Myocardial Infarction were included in this review, without any restrictions based on language. Studies that also addressed other conditions within the same cohort, such as Heart Failure and Rheumatic Heart Disease, were excluded. Relevant articles identified through database searches underwent a systematic selection process consisting of three stages: initial title screening, followed by abstract evaluation, and finally a comprehensive reading of the full text.

Subsequently, an exploratory review of all selected materials was conducted, leading to a focused and analytical reading of the most pertinent sections. The identification of methodological features and data extraction from these articles was performed by two independent reviewers. In instances of disagreement, both reviewers revisited the entire article for reevaluation. If discrepancies remained unresolved, a third independent reviewer was brought in to provide further insight.

The quality assessment of the studies included in this review utilized the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies provided by the National Heart, Lung, and Blood Institute (NHLBI). Information from the articles was systematically organized into tables detailing key research attributes such as first author, publication year, study type, database utilized, classification of Myocardial Infarction, inclusion criteria, sample size, along with outcomes studied and their principal findings and conclusions.

The protocol outlining the various stages involved in constructing this systematic review has been submitted to the International Prospective Register of Systematic Reviews (PROSPERO), under registration number CRD42023464316.

Results

The search of the database yielded a total of 4,695 articles (MEDLINE: 8; PubMed: 4,686; Lilacs: 0; Scielo: 0; Web of Science: 1). After eliminating duplicates, 4,686 records remained. From these, 17 articles were chosen through title screening. Three articles were excluded due to their abstracts failing to satisfy the selection criteria, which left 14 articles for comprehensive review. Of those reviewed, 2 did not fulfill all inclusion requirements, leading to a final count of 12 articles, as illustrated in Figure 1.

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Figure 1.

Flow diagram of the study search and identification process, according to the PRISMA methodology

Figure 1.

Flow diagram of the study search and identification process, according to the PRISMA methodology

The twelve articles were meticulously reviewed and categorized, resulting in the creation of three tables that encapsulate pertinent research details. These tables include key attributes such as the first author’s name, publication year, study design, country of origin, classification of Myocardial Infarction, sample size, and criteria for inclusion (refer to Table 2). Table 3 summarizes the outcomes investigated, principal findings, and overall conclusions derived from the studies. Additionally, Table 4 provides information regarding disease characterization, duration of hospital stay, time required for return to work, and associated comorbidities. All studies included in this review were cohort studies, comprising nine prospective studies^11-19 and three retrospective ones.^20-22 The geographical origins of the research spanned Europe,^{12,14,16-18,20,21} Asia,^11,13,22 Oceania,¹⁹ and North America.¹⁵ The inclusion criteria prominently featured the diagnosis of Myocardial Infarction,^{11,12,14,15,18,20-22} age ( > 18 ^15,22, 18-63 ²⁰, ≥ 55 for women and ≥ 60 for men,¹³ < 60¹⁶ > 18-60,¹⁴ 18-64,¹⁷ 30-65,²¹ ≤ 75¹⁹), and employment status at the time of or prior to the event. Collectively, these studies involved a total of 83,702 participants, with sample sizes ranging from as few as 102¹² to as many as 22,394 ²¹ volunteers. A predominance of male participants was noted, with average ages at both minimum (48.65 years)²² and maximum (64.35 years)¹¹ extremes.

Regarding educational level, most participants had an education level below high school, with mentions of vocational education, basic education,^14,21 and secondary education,²² high school,¹⁷ and low to medium high school levels.¹⁸ Only five cohort studies provided insights into participants’ job classifications; predominant occupations included office/coordination roles and manual laborers, ¹² agricultural workers,¹³ private sector employees across specialized categories and business professionals,²² as well as government agency staff.¹⁶ de Jonge et al also noted that most participants who returned to work had sedentary jobs, classified as light work.¹⁸

As for being active in the labor market at the time of the MI, among groups of people working or on leave, no more than three articles reported that 41.2%,¹¹ 51%,¹⁵ and 56.9%²¹ of the participants were employed. The prevalence of return to work (RTW) after the acute event varied during the follow-up period. After one month, the return rate was 21.5%,¹² 37%,¹⁷ and 41.7%²¹; after two months, it was 59.2%¹²; after three months, it was 46.2%,¹⁸ 86.4%,²¹ and 87.5%¹¹; after four months, 91.1%¹⁹; after six months, 83.6%¹⁴; within one year, 55.9%¹³; one year: 76.9%,¹⁸ 79.9%,¹⁹ 80%,¹⁴ 91.1%,²¹ 92.7%¹² and MI without SC 83% and with SC 52%²⁰; after two years, 91.6%.¹⁴ Only one study presented the return rate without a time limit, with a general rate of 66.1%.²²

Among those who returned to work, researchers from Malaysia (2017) identified that 93.2% returned to the same job, while 6.8% switched to a less demanding job.²² Osler et al noted that 17.9% of patients reported a significant salary reduction compared to the period before the coronary event.¹⁷ Another point concerns job termination within one or two years, particularly among those who had received medical leave.^14,17,21 The average time of work leave was 44 days,¹² 125.83 ± 125.04 days,¹⁶ and 8.62 weeks.¹⁹ The main circumstances leading to not returning to work were the inability to work and/or choosing not to work due to the MI,^13,17 early retirement/disability retirement,^13,14 regular retirement,^15,17,19 unemployment,^13,15,17,19 dismissal,^15,17 paid medical leave,^14,17 disability pension, death, emigration,¹⁴ and unspecified reasons.¹³

Another factor that interfered with RTW was the presence of depression^12,15,18,21 and anxiety,^12,18 as noted in four articles. Regarding comorbidities, Table 3 presents results on this variable from all articles. The most prevalent comorbidities were systemic arterial hypertension (SAH),^{11,12,14-16,18,20,22} diabetes mellitus (DM),^{11,12,14-16,18-22} dyslipidemia,^13,16,18,22 and depression.^12,21 Regarding the severity of the disease, seven articles provided data on the Left Ventricular Ejection Fraction (LVEF), with reduced EF (< 40),^13,18 borderline EF (41-49), ^11,19 and preserved EF ( ≥ 50). ^12,15 Three articles used the Killip Classification: Killip 3-4,¹⁶ ≥ 2, ¹⁸ and 2-3. ¹⁹ Regarding the length of hospital stay, six articles provided data, in days, ranging from 2.9,¹⁵ 4, ^12,20 5.05-9.92, ¹⁹ to 11.^13,16 The time to return to work was assessed at five weeks, ¹⁴ one month, ^12,13,17,21 two months,^12,16 three months, ^11,18,21 six months, ¹³ one year, ^{12,14,15,17-21} two years, and five years ¹⁷ after hospital discharge or after MI.

Regarding the assessment of the methodological quality of the articles, all the cohort studies were classified as good quality, with Stendardo et al, ¹² Warraich et al, ¹⁵ and Worcester et al ¹⁹ not clearly describing the study population. Additionally, none of the included articles justified the sample size (Table 5).

Discussion

The findings from this systematic review indicate that the rates of return-to-work (RTW) for individuals following a myocardial infarction (AMI) fluctuate based on the duration of follow-up, showing an upward trend over time. After one year post-event, the RTW rate is notably high, ranging from approximately 76.9% to 92.7%. ^{12,14,18,19,21} It is crucial to highlight that several factors influence the likelihood of an earlier return to work, including age, educational attainment, income level, type of employment—particularly those involving sedentary tasks or roles focused on office coordination—and self-employment status. ^12,14,18,21 Consequently, the intricate relationship between myocardial infarction and return-to-work encompasses various physiological, socioeconomic, and sociopsychological dimensions that shape individuals’ perceptions and experiences regarding their capacity to resume regular activities.

Severity of the disease

Regarding the disease’s severity, most participants demonstrated either preserved or borderline left ventricular ejection fraction (LVEF). A lower incidence of LVEF values below 40%, along with a higher Killip class and myocardial infarction (MI) history, correlated with returning to work (RTW) compared to those who did not. ¹⁸ Mohd Mustafah et al indicated that individuals with single-vessel and two-vessel disease were 8.9 times and 3.8 times more likely, respectively, to return to work than their counterparts with three-vessel disease. ²² In contrast, researchers from Croatia found no significant association between traditional risk factors for arterial disease—such as affected myocardial wall segments and culprit coronary arteries—and permanent work cessation or the duration until returning to work. ¹⁶ Consequently, utilizing clinical factors as variables for assessing RTW following MI remains a contentious issue due to its connection to various influencing elements.

Length of hospital stay

Regarding the duration of hospitalization, one study indicated that there were no notable differences in return-to-work (RTW) rates between patients who resumed employment and those who did not. ¹³ Conversely, another investigation found that hospital stays exceeding 30 days and instances of anoxic brain injury during admission were linked to a diminished probability of returning to work, ²⁰ alongside an increase in the number of hospitalization days. ¹⁹ These results are corroborated by Jiang et al, which emphasizes that complications occurring during a myocardial infarction can prolong the RTW process. ¹³ Consequently, the length of hospitalization reported in this study may be considered brief, likely reflecting improvements in treatment modalities and care protocols for the participants involved.

Comorbidity

All studies incorporated in this review examined various forms of comorbidity. The findings clearly indicated that individuals with a greater number of comorbid conditions had reduced chances of re-entering the workforce. ^14,15,20,21 Among the most commonly observed comorbidities were diabetes mellitus (DM), systemic arterial hypertension (SAH), and acute myocardial infarction (AMI). Specifically, research conducted in Malaysia revealed that participants without DM were 3.7 times more likely to resume work compared to those diagnosed with the condition. ²² The advancements in myocardial infarction treatment, along with the rising number of survivors post-event, underscore the necessity for effective management of disease burden, as inadequate management may result in additional negative consequences.

Anxiety and depression

A significant theme that emerged from the reviewed studies was the connection between the inability to return to work or a diminished likelihood of doing so among individuals exhibiting symptoms of anxiety and depression. de Jonge et al found that the presence of any anxiety disorders within the first three months following a myocardial infarction (MI) correlated with a heightened risk of not resuming work. ¹⁸ This observation is supported by Warraich et al, who noted that over the course of a year, patients experiencing negative changes in employment were more likely to have a Patient Health Questionnaire-2 (PHQ-2) score exceeding 3, indicating potential depression, as well as reduced EQ-5D VAS scores, reflecting lower quality of life. ¹⁵ These results underscore a diminished self-assessment of health status when individuals do not return to work, highlighting the role of positive mood as a predictive factor for successful reintegration into the workforce. ¹²

Time away from work

In a prospective cohort study conducted in Italy, the average duration of time off work was found to be 44 days. ¹² Similarly, another investigation revealed that the typical span from 30 days post-diagnosis to either retirement, death, or cessation of work was approximately 4.1 years. ¹⁷ Among employees who were unable to return following an acute myocardial infarction (AMI), the reasons for not resuming work varied significantly; these included inability to perform job duties, early retirement, receiving a disability pension, termination of employment, or death. ¹³ Researchers have indicated that the probability of experiencing disability or opting for voluntary early retirement was notably higher among specific groups—namely women, individuals aged over 50 years, those with limited educational backgrounds, people in low-skill occupations, those living with a partner, and individuals who were on sick leave or unemployed 30 days after their hospital admission. Additionally, factors such as having undergone myocardial revascularization and the presence of comorbidities also contributed to this increased likelihood.¹⁷

This review underscores critical factors associated with the return to work following a myocardial infarction (MI) and identifies elements that contribute to prolonged absence from employment. The findings presented offer insights that can inform intervention strategies and guide future research aimed at minimizing the duration of time away from work, thereby alleviating costs for both individuals and society at large.

While a majority of the studies reviewed exhibit strong methodological rigor and provide data on temporal trends, certain limitations are evident concerning the included research: notably, the small sample sizes and specific characteristics of the countries where these outcomes were assessed. Of the twelve studies analyzed, four were conducted in Denmark, with no representation from Latin America or Africa, potentially affecting the observed return-to-work rates. Furthermore, a significant limitation lies in the considerable variability in how results were reported across studies, which precluded the possibility of conducting a meta-analysis.

Conclusion

The rate of individuals returning to work following a Myocardial Infarction is notably high within the first year. This phenomenon is influenced by various physical, psychological, and social factors, alongside the identification of mechanisms that facilitate an expedited return to employment. Nevertheless, further research is essential, particularly studies conducted across diverse populations and separating professional categories, to gather more thorough insights.

Competing Interests

No conflicts of interest.

Ethical Approval

Not applicable.

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