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Cardiac risk of coronary patients after reintegration into occupations with heavy physical exertion

Kardiales Risiko von Koronarpatienten nach Reintegration in Berufe mit schwerer körperlicher Belastung

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Zusammenfassung

Die berufliche Wiedereingliederung von Patienten mit koronarer Herzkrankheit (KHK) stellt eine der zentralen Aufgaben der kardiologischen Rehabilitation dar. Besondere berufliche Anforderungen, wie z. B. die Ausübung schwerer körperlicher Arbeit (> 6 METs) könnten jedoch das kardiovaskuläre Risiko erhöhen, da plötzliche, anstrengende Belastungen das relative Risiko für akuten Myokardinfarkt (MI) und kardialen Tod in Abhängigkeit vom körperlichen Fitnessgrad temporär steigern („hazard period“).

Wir haben daher bei allen männlichen KHK-Patienten, die im Jahr 2001 bis zum Auftreten eines Indexereignisses (MI bzw. akutes Koronarsyndrom, jede interventionelle oder operative Revaskularisationsmaßnahme) einen Beruf mit schwerer körperlicher Arbeit (> 6 METs) ausgeübt haben und rehabilitiert wurden nach durchschnittlich 20 Monaten eine Nachbefragung durchgeführt. Bei 108 von 119 eingeschlossenen Patienten (90,8%) lagen komplette Daten vor. Das Alter betrug 51,8±7,8 Jahre, die Ejektionsfraktion (EF) zum Zeitpunkt des Indexereignisses 61,5±13,1% und die fahrradergometrische Leistung bei Klinikentlassung 130,1±31,2 Watt. 75% der Patienten hatten einen früheren MI, in 59,3% erfolgte eine ACB-Operation. Während der Nachbeobachtung wurde der frühere Beruf mit schwerer körperlicher Arbeit über einen kumulierten Zeitraum von 74 Jahren ausgeübt. Studienziel war der Vergleich zwischen beobachtetem und erwartetem Risiko für MI und kardialen Tod mit bzw. ohne Berufsausübung. Das erwartete („basale“) Risiko für MI und kardialen Tod ohne körperlich schwere Arbeit wurde aus gepoolten Studiendaten ermittelt und mit 5,2%/Jahr angenommen. Das prognostizierte, kombinierte Risiko bei Ausübung eines körperlich schweren Berufes lässt sich durch arithmetische Mittlung von Stundenanteilen mit und ohne Berufsausübung und unter Berücksichtigung der relativen Risikoerhöhung errechnen und beträgt 11,9%.

Für die Dauer der Berufstätigkeit mit schwerer körperlicher Arbeit waren 0,119 · 74=8,8 kardiale Ereignisse zu erwarten, 5 MI (4 NSTEMI, 1 STEMI) wurden beobachtet (6,8%). Das relative Risiko für das erwartete Auftreten eines kardialen Ereignisses gegenüber dem basalen Risiko ohne körperlich schwere Arbeit betrug 2,3 (95% CI: 0,7–7,4). Für das beobachtete Auftreten eines Ereignisses ergab sich ein relatives Risiko von 1,3 (95% CI: 0,4–4,8).

Das deutlich geringere beobachtete Risiko ist wahrscheinlich auf den hohen Fitnessgrad des Patientenkollektivs zurückzuführen.

Trotz mehrerer Limitationen und vereinfachender Annahmen konnte in unserer Untersuchung kein überzeugender Hinweis auf eine Erhöhung des kardialen Risikos bei KHK-Patienten durch Ausübung eines körperlich schweren Berufes erbracht werden. Wegen der hiervon abhängenden weitreichenden Folgen sollte dies jedoch durch eine repräsentative, prospektive Studie abgesichert werden.

Summary

The job related reintegration of patients with coronary artery disease (CAD) is a central part of cardiac rehabilitation. However, specific occupational demands like jobs with heavy physical exertion (> 6 METs) could increase the cardiovascular risk because the relative risk for acute myocardial infarction (MI) and cardiac death is temporarily elevated after vigorous exertion (“hazard period”). Thus, in 2001 any male patient with proven CAD who performed a job with heavy exertion until the occurrence of an index event (MI/ACS, any interventional or surgical revascularization measure) received a questionnaire after an average of 20 months. Complete data were available in 108 from 119 included patients (90.8%), aged 51.8±7.8 years. Ejection fraction was 61.5±13.1% and the functional capacity at the time of hospital discharge averaged 130.1±31.2 W. 75% of the patients had a previous MI and 59.3% underwent bypass surgery. During follow-up the previous job with heavy exertion was performed over a cumulated time of 74 years.

The aim of the study was to compare the observed and the expected incidence of MI and cardiac death with and without job performance. The expected (“basal”) risk for MI and cardiac death without heavy physical exertion was determined from pooled study results and assumed to be 5.2% per year. The combined risk due to performing an occupation with strenuous exertion can be calculated from time periods with and without working hours and amounts to 11.9%. There could be expected 0.119 · 74=8.8 cardiac events related to the job. In contrast, 5 MIs (4 NSTEMI, 1 STEMI) were observed (6.8%). The relative risk for an expected event compared to the basal risk without heavy exertion was 2.3 (95% CI: 0.7–7.4). The relative risk for the observed cardiac events amounts to 1.3 (95% CI: 0.4–4.8). The lower observed risk is probably due to the high grade of physical fitness in this patient group.

In spite of several limitations, our study showed no convincing evidence for increasing the cardiac risk of patients with CAD performing occupations with heavy physical exertion. Because of the importance of this prognostic finding, a representative and prospective study is strongly required.

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Wolf, R., Habel, F., Heiermann, M. et al. Cardiac risk of coronary patients after reintegration into occupations with heavy physical exertion. ZS Kardiologie 94, 265–273 (2005). https://doi.org/10.1007/s00392-005-0209-2

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