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Vocational reintegration in coronary heart disease patients – the holistic approach of the WHO biopsychosocial concept

Coronary heart disease (CHD) is the most common acquired cardiac disease and the leading cause of morbidity and mortality, contributing to over 8.75 million deaths in 2015 worldwide. After suffering an acute cardiac event, return to work (RTW), particularly in younger CHD patients, is a crucial step in the interdisciplinary disease management. The successful occupational reintegration is determined by medical parameters, including cardiopulmonary function (left ventricular function, residual ischaemia, heart rhythm stability, exercise capacity), as well as by the occupational requirement profile such as blue or white collar work, night shifts and the ability to commute. Psychosocial factors including anxiety and depression, self-perceived health situation, and pre-existing cognitive impairment determine the reintegration rate to a significant extent. While depression and a negative subjective occupational prognosis serve as important barriers of RTW, physical fitness acts as facilitator for reintegration. A comprehensive review including determinants of vocational reintegration has been recently published. Numerous determinants are interacting on diverse levels and must be considered multi-dimensionally. In this context, the biopsychosocial model of the International Classification of Functioning, Disability and Health by World Health Organization represents a suitable approach for integrating all factors in a parent model (Figure 1). The correct interlink of both environmental and personal, that is, individual, factors is essential for effective occupational reintegration. On this topic, the paper by van de Cauter and coworkers, published in this issue of the European Journal of Preventive Cardiology, investigated the relationship of RTW, psychosocial well-being and health-related quality of life in CHD patients. Based on data of the EUROASPIRE IV survey population the authors performed a secondary data analysis. EUROASPIRE is a large European cross-sectional study in coronary patients and individuals at high risk for developing CHD, starting in the mid-1990s. As part of the latest update, the European Society of Cardiology (ESC) published the EUROASPIRE V survey under the EURObservational Research Program in February 2019. The present study includes clinical, psychosocial and vocational parameters of 2661 CHD patients younger than 63 years across 24 countries (mean age 53.6 6.6 years, 85% male). Key objectives were the analysis of association between RTW and psychosocial well-being as well as health-related quality of life as outcome parameters. After a median time of 1.38 years after index event (range 0.96–2.01 years) the patients were interviewed. The interview contained the Hospital Anxiety and Depression Scale (HADS) and the health-related quality of life questionnaire for patients with ischaemic heart disease (HeartQoL) as well as self-reported status of RTW and attendance in cardiac rehabilitation. The total RTW rate was 76%. As the main result, a higher psychosocial distress (HADS 8) was negatively associated with occupational resumption (HADS-Depression: odds ratio (OR) 0.58, 95% confidence interval (CI) 0.46–0.74; anxiety: OR 0.54, 95% CI 0.44–0.67, respectively). The quality of life was higher in patients who returned to work (adjusted mean 2.20 vs. 1.95, p< 0.001). Particularly in younger, high-educated patients without a foregoing cardiovascular event the probability of RTW was more likely. Notably, no significant associations between RTW and cardiovascular risk factors, gender or participation in cardiac rehabilitation were found, although the underrepresentation of women should be considered. These findings of the EUROASPIRE IV survey once more emphasize the importance of vocational