Skip to main content
Log in

Cardiopulmonary exercise testing is predictive of return to work in cardiac patients after multicomponent rehabilitation

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript



Return to work (RTW) is a pivotal goal of cardiac rehabilitation (CR) in patients after acute cardiac event. We aimed to evaluate cardiopulmonary exercise testing (CPX) parameters as predictors for RTW at discharge after CR.


We analyzed data from a registry of 489 working-age patients (51.5 ± 6.9 years, 87.9 % men) who had undergone inpatient CR predominantly after percutaneous coronary intervention (PCI 62.6 %), coronary artery bypass graft (CABG 17.2 %), or heart valve replacement (9.0 %). Sociodemographic and clinical parameters, noninvasive cardiac diagnostic (2D echo, exercise ECG, 6MWT) and psychodiagnostic screening data, as well as CPX findings, were merged with RTW data from the German statutory pension insurance program and analyzed for prognostic ability.


During a mean follow-up of 26.5 ± 11.9 months, 373 (76.3 %) patients returned to work, 116 (23.7 %) did not, and 60 (12.3 %) retired. After adjustment for covariates, elective CABG (HR 0.68, 95 % CI 0.47–0.98; p = 0.036) and work intensity (per level HR 0.83, 95 % CI 0.73-0.93; p = 0.002) were negatively associated with the probability of RTW. Exercise capacity in CPX (in Watts) and the VE/VCO2-slope had independent prognostic significance for RTW. A higher work load increased (HR 1.17, 95 % CI 1.02–1.35; p = 0.028) the probability of RTW, while a higher VE/VCO2 slope decreased (HR 0.85, 95 % CI 0.76–0.96; p = 0.009) it. CPX also had prognostic value for retirement: the likelihood of retirement decreased with increasing exercise capacity (HR 0.50, 95 % CI 0.30–0.82; p = 0.006).


CPX is a valid tool for assessing patients’ ability to return to work. Therefore, it may be an essential part of functional assessment during CR for predicting participation in employment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others


  1. Balady GJ, Ades PA, Bittner VA, Franklin BA, Gordon NF, Thomas RJ, Tomaselli GF, Yancy CW (2011) Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation 124:2951–2960

    Article  PubMed  Google Scholar 

  2. Piepoli MF, Corrà U, Adamopoulos S, Benzer W, Bjarnason-Wehrens B et al (2012) Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery: a policy statement from the cardiac rehabilitation section of the European Association for Cardiovascular Prevention and Rehabilitation. Endorsed by the Committee for Practice Guidelines of the European Society of Cardiology. Eur J Prev Cardiol 21:664–681

    Article  PubMed  Google Scholar 

  3. Vanhees L, Rauch B, Piepoli M, van Buuren F, Takken T, Borjesson M, Bjarnason-Wehrens B, Doherty P, Dugmore D, Halle M (2012) Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular disease (part III). Eur J Prev Cardiol 19:1333–1356

    Article  CAS  PubMed  Google Scholar 

  4. Söderman E, Lisspers J, Sundin O (2003) Depression as a predictor of return to work in patients with coronary artery disease. Soc Sci Med 56:193–202

    Article  PubMed  Google Scholar 

  5. Biering K, Nielsen TT, Rasmussen K, Niemann T, Hjollund NH (2012) Return to work after percutaneous coronary intervention: the predictive value of self-reported health compared to clinical measures. PLoS One 7:e49268

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  6. de Jonge P, Zuidersma M, Bültmann U (2014) The presence of a depressive episode predicts lower return to work rate after myocardial infarction. Gen Hosp Psychiatry 36:363–367

    Article  PubMed  Google Scholar 

  7. Bhattacharyya MR, Perkins-Porras L, Whitehead DL, Steptoe A (2007) Psychological and clinical predictors of return to work after acute coronary syndrome. Eur Heart J 28:160–165

    Article  PubMed  Google Scholar 

  8. Pinto N, Shah P, Haluska B, Griffin R, Holliday J, Mundy J (2012) Return to work after coronary artery bypass in patients aged under 50 years. Asian Cardiovasc Thorac Ann 20:387–391

    Article  PubMed  Google Scholar 

  9. Jin RL, Shah CP, Svoboda TJ (1995) The impact of unemployment on health: a review of the evidence. CMAJ 153:529–540

    PubMed Central  CAS  PubMed  Google Scholar 

  10. Pardaens K, Van Cleemput J, Vanhaecke J, Fagard RH (2000) Peak oxygen uptake better predicts outcome than submaximal respiratory data in heart transplant candidates. Circulation 101:1152–1157

    Article  CAS  PubMed  Google Scholar 

  11. Kleber FX, Vietzke G, Wernecke KD, Bauer U, Opitz C, Wensel R, Sperfeld A, Glaser S (2000) Impairment of ventilatory efficiency in heart failure: prognostic impact. Circulation 101:2803–2809

    Article  CAS  PubMed  Google Scholar 

  12. von Scheidt W, Zugck C, Pauschinger M, Hambrecht R, Bruder O, Hartmann A, Rauchhaus M, Zahn R, Brachmann J, Tebbe U, Neumann T, Strasser RH, Böhm M, Störk S, Hochadel M, Heidemann P, Senges J (2014) Characteristics, management modalities and outcome in chronic systolic heart failure patients treated in tertiary care centers: results from the EVIdence based TreAtment in Heart Failure (EVITA-HF) registry. Clin Res Cardiol 103:1006–1014

    Article  Google Scholar 

  13. Ohlmeier C, Mikolajczyk R, Frick J, Prütz F, Haverkamp W, Garbe E (2015) Incidence, prevalence and 1-year all-cause mortality of heart failure in Germany: a study based on electronic healthcare data of more than six million persons. Clin Res Cardiol (Epub ahead of print)

  14. Balady GJ, Arena R, Sietsema K, Myers J, Coke L, Fletcher GF et al (2010) Clinician’s Guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association. Circulation 122:191–225

    Article  PubMed  Google Scholar 

  15. Wasserman K, Hansen JE, Sue DY, Stringer W, Whipp BJ (2005) Normal values. In: Weinberg R (ed) Principles of exercise testing and interpretation, 4th edn. Lippincott Williams and Wilkins, Philadelphia, pp 160–182

    Google Scholar 

  16. Boudrez H, De Backer G (2000) Recent findings on return to work after an acute myocardial infarction or coronary artery bypass grafting. Acta Cardiol 55:341–349

    Article  CAS  PubMed  Google Scholar 

  17. Worcester MU, Elliott PC, Turner A, Pereira JJ, Murphy BM, Le Grande MR, Middleton KL, Navaratnam HS, Nguyen JK, Newman RW, Tatoulis J (2014) Resumption of work after acute coronary syndrome or coronary artery bypass graft surgery. Heart Lung Circ 23:444–453

    Article  PubMed  Google Scholar 

  18. Isaaz K, Coudrot M, Sabry MH, Cerisier A, Lamaud M, Robin C, Richard L, Da Costa A, Khamis H, Abd-Alaziz A, Gerenton C (2010) Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention. Arch Cardiovasc Dis 103:310–316

    Article  PubMed  Google Scholar 

  19. Lunel C, Laurent M, Corbineau H, Boulmier D, Chaperon J, Guillo P, Dewitte JD, Leguerrier A (2003) Return to work after cardiac valvular surgery. Retrospective study of a series of 105 patients. Arch Mal Coeur Vaiss 96:15–22

    CAS  PubMed  Google Scholar 

  20. Mirmohammadi SJ, Sadr-Bafghi SM, Mehrparvar AH, Gharavi M, Davari MH, Bahaloo M, Mostaghaci M, Sadr-Bafghi SA, Shokouh P (2014) Evaluation of the return to work and its duration after myocardial infarction. ARYA Atheroscler 10:137–140

    PubMed Central  PubMed  Google Scholar 

  21. Budde HG, Keck M (2001) Predictors of return to work after inpatient cardiac rehabilitation under workers’ compensation plan. Rehabilitation 40:208–216 (German)

  22. Mittag O, Kolenda KD, Nordman KJ, Bernien J, Maurischat C (2001) Return to work after myocardial infarction/coronary artery bypass grafting: patients’ and physicians’ initial viewpoints and outcome 12 months later. Soc Sci Med 52:1441–1450

    Article  CAS  PubMed  Google Scholar 

  23. Petrie KJ, Weinman J, Sharpe N, Buckley J (1996) Role of patients’ view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study. BMJ 312:1191–1194

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  24. Samkange-Zeeb F, Altenhöner T, Berg G, Schott T (2006) Predicting non-return to work in patients attending c ardiac rehabilitation. Int J Rehabil Res 29:43–49

    Article  PubMed  Google Scholar 

  25. Corra U, Piepoli MF, Carre F, Heuschmann P, Hoffmann U, Verschuren M, Halcox J, Giannuzzi P, Saner H, Wood D, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, McGee H, Mendes M, Niebauer J, Zwisler AD, Schmid JP (2010) Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the cardiac rehabilitation section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 31:1967–1974

    Article  PubMed  Google Scholar 

  26. Guazzi M, Adams V, Conraads V, Halle M, Mezzani A, Vanhees L, Arena R, Fletcher GF, Forman DE, Kitzman DW, Lavie CJ, Myers J (2012) EACPR/AHA Joint Scientific Statement. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Eur Heart J 33:2917–2927

    Article  PubMed  Google Scholar 

  27. Mezzani A, Agostoni P, Cohen-Solal A, Corrà U, Jegier A, Kouidi E, Mazic S, Meurin P, Piepoli M, Simon A, Laethem CV, Vanhees L (2009) Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: a report from the exercise physiology section of the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 16:249–267

    Article  PubMed  Google Scholar 

  28. Arena R, Myers J, Aslam SS et al (2004) Peak VO2 and VE/VCO2 slope in patients with heart failure: a prognostic comparison. Am Heart J 147:354–360

    Article  PubMed  Google Scholar 

  29. Arena R, Myers J, Guazzi M (2008) The clinical and research applications of aerobic capacity and ventilatory efficiency in heart failure: an evidence-based review. Heart Fail Rev 13:245–269

    Article  PubMed  Google Scholar 

  30. Cahalin LP, Chase P, Arena R, Myers J, Bensimhon D, Peberdy MA, Ashley E, West E, Forman DE, Pinkstaff S, Lavie CJ, Guazzi M (2013) A meta-analysis of the prognostic significance of cardiopulmonary exercise testing in patients with heart failure. Heart Fail Rev 18:79–94

    Article  PubMed  Google Scholar 

  31. Guazzi M, Myers J, Abella J et al (2008) The added prognostic value of ventilatory efficiency to the Weber classification system in patients with heart failure. Int J Cardiol 129:86–92

    Article  PubMed  Google Scholar 

  32. Guazzi M, Myers J, Arena R (2005) Cardiopulmonary exercise testing in the clinical and prognostic assessment of diastolic heart failure. J Am Coll Cardiol 46:1883–1890

    Article  PubMed  Google Scholar 

  33. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE (2002) Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 346:793–801

    Article  PubMed  Google Scholar 

  34. Ades PA, Savage PD, Brawner CA, Lyon CE, Ehrman JK, Bunn JY, Keteyian SJ (2006) Aerobic capacity in patients entering cardiac rehabilitation. Circulation 113:2706–2712

    Article  PubMed  Google Scholar 

  35. Poggio R, Arazi HC, Giorgi M, Miriuka SG (2010) Prediction of severe cardiovascular events by VE/VCO2 slope versus peak VO2 in systolic heart failure: a meta-analysis of the published literature. Am Heart J 160:1004–1014

    Article  PubMed  Google Scholar 

  36. Chua TP, Ponikowski P, Harrington D, Anker SD, Webb-Peploe K, Clark AL, Poole-Wilson PA, Coats AJ (1997) Clinical correlates and prognostic significance of the ventilatory response to exercise in CHF. J Am Coll Cardiol 29:1585–1590

    Article  CAS  PubMed  Google Scholar 

  37. Müller-Nordhorn J, Gehring J, Kulig M, Binting S, Klein G, Gohlke H, Völler H, Bestehorn K, Krobot KJ, Willich SN (2003) Return to work after cardiologic rehabilitation. Soz Praventivmed 48:370–378

    Article  PubMed  Google Scholar 

  38. Fioretti P, Baardman T, Deckers J, Salm E, Zwiers G, Kazemier M, Roelandt J (1988) Social fate and long-term survival of patients with a recent myocardial infarction, after cardiac rehabilitation. Eur Heart J 9:89–94

    Article  PubMed  Google Scholar 

  39. Sellier P, Varaillac P, Chatellier G, D’Agrosa-Boiteux MC, Douard H, Dubois C, Goepfert PC, Monpère C, Pierre AS, Investigators of the PERISCOP Study (2003) Factors influencing return to work at one year after coronary bypass graft surgery: results of the PERISCOP study. Eur J Cardiovasc Prev Rehabil 10:469–475

    Article  PubMed  Google Scholar 

  40. Nielsen FE, Nielsen SL, Knudsen F, Sørensen HT, Holberg F (1992) The value of exercise tests after acute myocardial infarction. Scand J Prim Health Care 10:47–52

    Article  CAS  PubMed  Google Scholar 

  41. Waszkowska M, Szymczak W (2009) Return to work after myocardial infarction: a retrospective study. Int J Occup Med Environ Health 22:373–381

    Article  PubMed  Google Scholar 

  42. Turkulin K, Cerovec D, Baborski F (1988) Predictive markers of occupational activity in 415 post myocardial infarction patients after one-year follow-up. Eur Heart J 9(Suppl L):103–108

  43. Rønnevik PK (1988) Predicting return to work after acute myocardial infarction. Significance of clinical data, exercise test variables and beta-blocker therapy. Cardiology 75:230–236

    Article  PubMed  Google Scholar 

Download references


This study was funded by a grant from the German statutory pension insurance program, Berlin-Brandenburg.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Heinz Völler.

Ethics declarations

Conflict of interest

No competing financial interests exist for any authors.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Salzwedel, A., Reibis, R., Wegscheider, K. et al. Cardiopulmonary exercise testing is predictive of return to work in cardiac patients after multicomponent rehabilitation. Clin Res Cardiol 105, 257–267 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: