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RE-INITIATING PROFESSIONAL WORKING ACTIVITY AFTER MYOCARDIAL INFARCTION IN PRIMARY PERCUTANEOUS CORONARY INTERVENTION NETWORKS ERA.

INTRODUCTION

Up to 45% of patients with acute myocardial infarction (AMI) are younger than 65, which in most societies represents active population [1,2]. Primary percutaneous coronary intervention (PCI) networks organized in the developed countries ensure the best treatment results for patients with AMI, particularly those with STelevation myocardial infarction (STEMI) [1,2]. Croatian primary PCI network is recognized internationally as an example of good acute STEMI treatment at the national level with results comparable to randomised studies and registries of economically more developed countries [2,3].

Data from 1980's for the USA population showed that patients following uncomplicated AMI returned to work after 75 days, while in Europe the same occurred after 3 to 6 months. Modern guidelines proposed this period to be reduced to 1 to 3 months (50 days is the median (Me) in most countries) with variable protocols and policies in different European countries [4-6]. Kovoor et al. [7] consider return to full normal activities, including work, 2 weeks after AMI to be safe in patients stratified as low-risk. Perk [8] found that industrial and other jobs require significantly less effort than the average maximum work capacity of a healthy population (only 25% is generally demanded for modern workplace). Therefore, AMI patients without left ventricular dysfunction and exercise-induced myocardial ischemia are able to resume previous work as follows: light office work in 2 weeks, average manual work in 3 weeks, and strenuous physical work in 6 weeks. Rates of return to work found in Europe and USA are 60-95% (tendency of higher percentages in USA and Scandinavian countries). Predictors of return to work after AMI could be divided in 3 groups:

--medical and patient factors,

--psychosocial factors,

--economic and job related factors.

In 1st group (age, sex, education, previous AMI, severity of AMI, residual angina pectoris, poor left ventricular ejection fraction, low exercise capacity), age plays the most important role, while medical factors in general are less relevant. In dealing with psychosocial factors (anxiety, depression, stress at the workplace, motivation to resume work, patients' own perception of the severity of the disease) employer's role and sometimes psychiatrist's role is important. Finally, economic and job related factors (health insurance benefits and other financial incentives, employment rates, physical and mental workload demands) must be weighed against the possible risk for work-related recurrence of cardiac events. Cardiologist's role in this decision-making process for returning to work is evaluation of the sequelae and functional status after AMI, while occupational health doctor's role is to evaluate other aspects (day/night shift, location, position, environment, psychophysical stress, risks for a 3rd party). Responsibility for patients (return to work in the best condition) and society (expenses of sick leaves and retirements) is equally important for both specialties [9,10]. According to literature [10-12] quality of life decreases in 40-50% of patients after AMI. Predictors of quality of life after AMI are negative (diabetes, hypertension, hyperlipoproteinemia, history of myocardial infarction, myocardial infarction without ST-elevation in comparison with unstable angina pectoris) or positive (exercise of greater intensity, myocardial revascularization in the first 30 days after a coronary incident).

The main objective of the study has been to investigate different aspects of return to work, socio-economic and quality of life aspects in 145 employed patients under the age of 60 who suffered acute STEMI and were treated with primary PCI.

MATERIAL AND METHODS

Study design and population

The study was a prospective, single-centre, open trial involving the blinded evaluation of the end points. Patients admitted to the Coronary Care Unit (CCU) of the Department of Internal Medicine, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia for acute STEMI, as a part of Croatian Primary PCI Network were considered eligible for the study. Inclusion period was from February 10th 2008 to April 23rd 2011. The inclusion criteria were the age < 60 years and active employment. Non-inclusion criteria were: pre-existing coronary incident, presence of malignancy, renal failure and lack of informed consent. The follow-up period was set to 2 years. Exclusion criteria were death during follow-up and no contact after the follow-up. A total of 145 patients completed the study.

ST-elevation myocardial infarction was diagnosed in the quoted centre in Zagreb at the on-site PCI laboratory where primary PCI was performed (non-transferred patients) or in surrounding county hospitals (General Hospital Sisak, General Hospital Karlovac) without on-site catheterization laboratory. Later patients were urgently transferred to the PCI centre in Zagreb for primary PCI (transferred patients). The transfer was performed by an emergency ambulance on 24/7/365 basis.

ST-elevation myocardial infarction was diagnosed according to the criteria of the European Cardiac Society at the time of investigation [13] based on the presence of 2 out of 3 criteria:

--prolonged chest/retrosternal pain,

--ECG presence of ST-segment elevation > 1 mm in 2 consecutive leads at rest or de novo/transient left bundle branch block (LBBB),

--increased cardiac troponin T (cTnT), serum creatine kinase (CK) and iso-enzyme MB (CK-MB) levels.

Study protocol

Urgent coronarography was performed in all patients. Percutaneous coronary intervention of culprit lesion of acute STEMI was performed according to indication by means of the conventional technique and coronary stents used without restrictions. All diagnostic and therapeutic procedures were performed according to the clinical standard and in accordance with the recommendations relating to the current guidelines [13].

Investigated data (gender, age, dwelling, educational degree, employer, salary before STEMI, affected myocardial wall and coronary artery), presence of risk factors of CAD and comorbidities data (smoking status, hypertension, hyperlipoproteinemia, diabetes, family history) was collected once clinical symptoms diminished. Data about possible complications (cardiogenic shock, cardiopulmonary resuscitation) and duration of hospital stay was collected at the end of the hospitalization. Patients from Zagreb finished their hospitalization at the PCI centre, while those from surrounding counties were re-transferred to county hospitals on 2nd or 3rd day and finished their hospitalization there.

After the follow-up period, additional data was collected by telephone interview with patients or members of their family, or during regular outpatient visits. Data obtained was as follows: major adverse cardiovascular events (MACE) (re-infarction, restenosis, another coronary artery PCI, cardiac and non-cardiac re-hospitalisation, coronary artery by-pass graft (CABG), cerebrovascular insult (CVI) and angina pectoris (AP)) rate, rehabilitation (no/yes, in-hospital/out-hospital), sick leave (no/yes, number of days-cardiac/number of days non-cardiac), discharge from job (no/yes) and retirement (no/yes), salary before STEMI and at the time of questionnaire, major life events after STEMI (divorce, moving, death in family) and self-estimated quality of life in comparison with time before STEMI (same/worse/better).

Statistics

The data was processed by means of descriptive statistics. Smirnov-Kolmogorov test was used to assess data distribution regarding quantitative variables, and according to findings appropriate non parametric tests were used in the following analyses. Mann-Whitney U and Kruskal-Wallis tests were used to analyze differences in duration of return to work after STEMI (if there were [greater than or equal to]2 groups compared). Chi-square ([Chi.sup.2]) test was used to analyze frequency differences of categorical parameters (permanent working cessation, significant salary and quality of life lowering). The value of p < 0.05 was considered significant. The statistical analysis was carried out using Statistica 10.0 for Windows software (StatSoft Inc 2011, version 10).

Ethics

The investigation was performed in accordance with the ethical standards laid down in the Declaration of Helsinki and was approved by the appropriate institutional review committee.

RESULTS

Average age of 145 investigated patients was 53.17[+ or -]7.29 years. Study population characteristics are presented in Table 1. Average hospitalization duration was 11.84[+ or -]4.62 days. The follow-up duration was 836.12[+ or -]241.63 days with MACE evidenced in 29% of investigated patients (re-infarction: 2.1%, restenosis: 6.9%, re-PCI of another coronary artery: 6.9%, CABG: 1.4%, CVI: 0.0%, AP: 11.7%). Rehabilitation was carried out in 48.3% of patients (in-hospital in 26.2%, out-hospital in 22.1%).

Employment structure was as follows: 54.4% were employed in governmental firms, 16.6% --in private firms with less than 100 employees, 11.7% --in private firms with more than 100 employees, 14.5% --in their own business, and 2.1% --in a combination of the aforementioned. Average sick leave after STEMI was 125.83[+ or -]125.04 days. Additional sick leave during the follow-up was used by 35.2% of patients (cardiac cause: 17.1[+ or -]6.2 days, non-cardiac: 3.9[+ or -]2.5 days). After STEMI, 3.4% of patients were discharged from their jobs, while 31.7% retired. Out of total, 17.9% patients reported significant salary decrease in comparison to the time before a coronary incident. Major life event was reported in 9.7% of cases (divorce: 0.7%, moving: 1.4%, death in family: 7.6%). Finally, 29.7% of patients estimated quality of life to remain the same as before STEMI, 40.7% --as worse, and 29.7% --as better. Influences of different parameters on hospitalization duration after STEMI are shown in Table 2. Significantly longer hospitalization was observed in patients transferred from surrounding counties, those with inferior myocardial wall and right coronary artery affected. Salary before and after STEMI, and self-reported change in quality of life after STEMI was related to sick leave duration, as shown in Table 3. Table 4 shows influence of different parameters on permanent working cessation, decrease in quality of life, and time to return to work after STEMI. Age proved to be significantly related to permanent working cessation ([Chi.sup.2]). Significant salary decrease was observed in male patients (p = 0.043, [Chi.sup.2]).

None of the traditional coronary artery disease risk factors (smoking history, hypertension, hyperlipoproteinemia, diabetes and family history of coronary artery disease) as well as affected myocardial wall and culprit coronary artery proved to be significantly related to permanent working cessation, decrease in salary and quality of life, and time to return to work after STEMI, employer type related to sick leave duration. Impaired quality of life was observed in patients who underwent in-hospital rehabilitation and those from surrounding counties.

Longer sick leave was observed in patients with lower income before and after myocardial infarction. These patients reported lower quality of life after myocardial infarction. No investigated parameter had influence on major life events rate after STEMI. Multivariate regression analysis revealed that, beside age (p < 0.001, odds ratio (OR) = 1.5), hyperlipoproteinemia (p < 0.05, OR = 0.32) and lower education degree (p < 0.05, OR = 0.04) related to higher discharge and retirement rate after STEMI.

DISCUSSION

Descriptive data analysis obtained in this study could be expected and corresponds to such data in the literature [1,2]. High percentage of male gender, smokers, low rate of cardiogenic shock could be explained by inclusion and exclusion criteria: patients needed to be younger than 60 years old and alive 2 years after STEMI. Younger age may also explain high percentage of rehabilitated patients in comparison with data from the literature [14]. Comparing educational structure, there were more people with elementary school education in the general than in the study population [15].

Average hospitalization duration found in this study is longer than in other studies [16], particularly for transferred patients and those with inferior myocardial wall and right coronary artery affected. Longer hospital stay, designated as one of negative predictors of returning to work, is a consequence of traditional health care policy in Croatia, as well as longer waiting list for rehabilitation after STEMI [14]. For the same reasons average sick leave among investigated patients is relatively long as compared to other European countries (126 vs. 50 days) [4,5], although reports [17,18] with even longer average time to return to work after AMI exist.

Many studies [8,11,18-21], as this one, emphasize age as a prognostic factor for working ability and disablement after AMI. Several of psychosocial, economic and job related factors are confirmed as important for fast return to work and return to work at all after AMI: higher income [11], financial benefit that promts empoyees to retire [19], higher educational level, self-related health and quality of life [20], non-manual labor and lower physical job demands, married status [19,21]. The same was found in this study. Patients with lower education degree who most often perform jobs with higher physical demand, are more often perform or retire after STEMI, those with lower salary before and after STEMI are longer on sick leave and those with longer sick leave report lower quality of life after STEMI. Significantly shorter sick leave in smaller private firms and in own businesses as compared to governmental and larger private firms could be expected, bearing in mind possible financial consequences.

On the other hand, importance of medical factors on predicting return to work after AMI is controversial. There are studies that found them important [19], while others [8,18,21,22] found little or no relevance of medical variables for re-employment, including the type of AMI or revascularization strategy used and its success. Among investigated medical parameters, authors found myocardial wall, affected coronary artery and lipid status important for hospitalization and sick leave duration. No other clinical parameter proved to be important in predicting return to work in this study. Rate of return to work found in this study (64.9%) is near lower values found in other studies in Europe and USA (60-95%) [8,21,22]. Explanation could be current socio-economic situation in Croatia (low average income, high unemployment rate, health and pension insurance benefits).

Importance of income as a risk factor for AMI is well documented. According to investigators from Sweden [23], women experiencing financial strain have increased risk for recurrent acute coronary events. Several socio-economic factors including levels of education and income are closely associated with increase of AMI risk in China and the effect of education is stronger in women than men [24]. Even neighborhood income has influence on overall case fatality rates, being highest among AMI patients living in low neighborhood income areas in the USA [25].

Also, in a tax-financed healthcare system, patients with low socio-economic status treated with primary PCI could face a worse prognosis than those with high socioeconomic status [26]. Fortunately, using income level before acute STEMI, previous finding was not proved in this study. However, the fact that male gender in AMI patients is associated with an increased risk for experiencing a loss of annual income (data from the register-based study of Danish population [27]), was confirmed in this investigation. This income loss is most probably related to a job change to physically less demanding jobs but the authors cannot provide the proof to this statement.

Self-related quality of life is a positive predictor for early return to work after AMI [20]. Many parameters may lower (diabetes, hyperlipoproteinemia, multivessel disease, history of myocardial infarction) [10] or improve (exercise of greater intensity, myocardial revascularization in the first 30 days) [28] quality of life after AMI. Although some authors found no influence of cardiac rehabilitation after AMI on return to work [11,21], predominant opinion today is that cardiovascular rehabilitation encompasses the improvement of physical fitness and quality of life, reintegration into social life and employment, and decreases economic consequences of AIM [8,19]. One of important characteristics of modern cardiac rehabilitation, which assure all those positive effects, is its initiation as early as possible after AMI [19,29]. Absence of early admission to a rehabilitation centre, as was the case in investigated patients under this study [14], may even lead to lowering of quality of life after such rehabilitation.

CONCLUSIONS

Public and corporate policies without financial benefit, that prompts employees to be on prolonged sick leave or to retire should be promoted to help workers to return to their jobs [22]. Individualized cardiac rehabilitation should be considered and planned by designated team immediately after acute phase of AMI. Inadequate health policy and delayed cardiac rehabilitation after AMI may lead to prolonged hospitalization and sick leave, and quality of life lowering after AMI, regardless of optimal treatment in acute phase of disease.

http://dx.doi.org/ 10.13075/ijomeh.1896.00478

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[24.] Guo J, Li W, Wang Y, Chen T, Teo K, Liu LS, et al. Influence of socioeconomic status on acute myocardial infarction in the Chinese population: The INTERHEART China study. Chin Med J (Engl). 2012;125(23):4214-20.

[25.] Foraker RE, Patel MD, Whitsel EA, Suchindran CM, Heiss G, Rose KM, et al. Neighborhood socioeconomic disparities and 1-year case fatality after incident myocardial infarction: The Atherosclerosis Risk in Communities (ARIC) Community Surveillance (1992-2002). Am Heart J. 2013;165(1):102-7, http://dx.doi.org/10.1016/ j.ahj.2012.10.022.

[26.] Jakobsen L, Niemann T, Thorsgaard N, Thuesen L, Lassen JF, Jensen LO, et al. Dimensions of socioeconomic status and clinical outcome after primary percutaneous coronary intervention. Circ Cardiovasc Interv. 2012;5(5):641-8, http:// dx.doi.org/10.1161/CIRCINTERVENTI0NS.112.968271.

[27.] Rayce SL, Christensen U, Hougaard C0, Diderichsen F. Economic consequences of incident disease: The effect on loss of annual income. Scand J Public Health. 2008;36(3): 258-64, http://dx.doi.org/10.1177/1403494808086987.

[28.] Benetti M, Araujo CL, Santos RZ. Cardiorespiratory fitness and quality of life at different exercise intensities after myocardial infarction. Arq Bras Cardiol. 2010;95(3):399-404, http://dx.doi.org/10.1590/S0066-782X2010005000089.

[29.] Yonezawa R, Masuda T, Matsunaga A, Takahashi Y, Saitoh M, Ishii A, et al. Effects of phase II cardiac rehabilitation on job stress and health-related quality of life after return to work in middle-aged patients with acute myocardial infarction. Int Heart J. 2009;50(3):279-90, http://dx.doi. org/10.1536/ihj.50.279.

ZDRAVKO BABIC (1,2), MARIN PAVLOV (1), MIRJANA OSTRIC (3), MILAN MILOSEVIC (2), MARJETA MISIGOJ DURAKOVIC (4), and HRVOJE PINTARIC (5,6)

(1) Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia Cardiac Intensive Care Unit

(2) University of Zagreb, Zagreb, Croatia School of Medicine

(3) Zabok General Hospital, Zabok, Croatia Department of Internal Medicine

(4) University of Zagreb, Zagreb, Croatia Faculty of Kinesiology

(5) Sestre Milosrdnice University Hospital Centre, Zagreb, Croatia Department for Invasive Cardiac Care

(6) University of Zagreb, Zagreb, Croatia Faculty of Dental Medicine

Received: October 2, 2014. Accepted: February 6, 2015.

Corresponding author: M. Pavlov, Sestre Milosrdnice University Hospital Centre, Cardiac Intensive Care Unit, Vinogradska 29, 10000 Zagreb, Croatia (e-mail: marin.pavlov@gmail.com).
Table 1. Study group characteristics

                                              Respondents
Variable                                      (N = 145)

                                              n        %

Gender
  male                                       128      88.3
Admitted to PCI Centre directly              77       53.1
Smokers                                      104      71.7
History
  arterial hypertension                      82       56.6
  dyslipidaemia                              79       54.5
  diabetes                                   24       16.6
  CAD in family                              102      70.3
Educational degree
  elementary school                          16       11.0
  secondary school                           101      69.7
  high school                                 9       6.2
  university degree                          15       10.3
Myocardial wall infarction
  anterior                                   65       44.8
  inferior                                   70       48.3
  posterior                                  10       6.9
Culprit lesion of myocardial infarction
  LAD artery                                 64       44.2
  right coronary artery                      56       38.6
  circumflex artery                          25       17.2
Cardiogenic shock                             1       0.7
Cardiac arrest                                8       5.5

PCI--percutaneous coronary intervention; CAD--coronary artery
disease; LAD--left anterior descedent.

Table 2. Influence of different parameters on hospitalization
duration after ST-elevation myocardial infarction

Variable                    Respondents   Hospitalization duration
                            (N = 145)         [days]

                                [n]       min.         max
Age [years]
  < 40                           9         9           21
  40-50                         32         7           21
  51-60                         104        3           30
Gender
  male                          128        3           30
  female                        17         6           24
Smoking
  no                            41         3           30
  yes                           104        5           30
Hypertension
  no                            63         7           24
  yes                           82         3           30
Hyperlipoproteinemia
  no                            66         6           30
  yes                           79         3           29
Diabetes
  no                            121        3           30
  yes                           24         7           21
Positive family history
  no                            43         3           30
  yes                           102        5           30
County
  Zagreb                        77         3           30
  Karlovac                      27         7           18
  Sisak                         41         7           30
Educational degree
  elementary school             16         7           17
  secondary school              101        6           30
  high school                    9         7           25
  university degree             15         3           30
Myocardial wall affected
  anterior                      65         3           25
  inferior                      70         5           30
  posterior                     10         6           17
Coronary artery with
    culprit lesion of
    myocardial infarction
  LAD artery                    64         3           25
  right coronary artery         56         5           30
  circumflex artery             25         6           24
Major complication
  no                            136        3           30
  cardiogenic shock              1         12          12
  cardiac arrest                 8         7           21

Variable                      Hospitalization duration   p (a)
                                      [days]

                                  M [+ or -] SD
Age [years]
  < 40                         12.38 [+ or -] 3.89       0.722
  40-50                        11.06 [+ or -] 3.56
  51-60                        12.15 [+ or -] 5.49
Gender                                                   0.48
  male                         11.74 [+ or -] 4.61
  female                       12.59 [+ or -] 4.74
Smoking
  no                           12.03 [+ or -] 5.18       0.769
  yes                          11.77 [+ or -] 4.40
Hypertension
  no                           12.15 [+ or -] 4.23       0.498
  yes                          11.61 [+ or -] 4.91
Hyperlipoproteinemia
  no                           11.97 [+ or -] 4.58       0.768
  yes                          11.74 [+ or -] 4.68
Diabetes                                                 0.366
  no                           12.00 [+ or -] 4.84
  yes                          11.04 [+ or -] 3.21
Positive family history
  no                           11.64 [+ or -] 4.49       0.739
  yes                          11.93 [+ or -] 4.69
County                                                   < 0.001
  Zagreb                       10.49 [+ or -] 4.24
  Karlovac                     11.88 [+ or -] 3.12
  Sisak                        14.33 [+ or -] 5.13
Educational degree                                       0.642
  elementary school            11.94 [+ or -] 2.64
  secondary school             12.10 [+ or -] 4.57
  high school                  11.44 [+ or -] 5.48
  university degree            10.47 [+ or -] 6.16
Myocardial wall affected                                 0.012
  anterior                     10.86 [+ or -] 3.59
  inferior                     13.05 [+ or -] 5.36
  posterior                    10.20 [+ or -] 3.36
Coronary artery with                                     0.005
    culprit lesion of
    myocardial infarction
  LAD artery                   10.89 [+ or -] 3.61
  right coronary artery        12.98 [+ or -] 5.59
  circumflex artery            11.83 [+ or -] 4.19
Major complication                                       0.945
  no                           11.81 [+ or -] 4.67
  cardiogenic shock            12.00 [+ or -] 0.00
  cardiac arrest               12.38 [+ or -] 4.27

LAD--left anterior descedent; min.--minimum; max--maximum;
M--mean; SD--standard deviation.

(a) Independent t-test and one-way ANOVA.

Table 3. Interdependence of time to return to work after
ST-elevation myocardial infarction, quality of life and monthly
income

Variable                  Return to work after STEMI [days]

                            n     25th percentile
Quality of life
  same                     43          61.0
  worse                    60          61.0
  better                   42          29.0
Income
  before STEMI
    < 5 000 HRK            67          61.5
    5 000-10 000 HRK       57          61.0
    10 000-20 000 HRK      15          29.0
    > 20 000 HRK            6          14.0
  after STEMI
    < 5 000 HRK            87          61.0
    5 000-10 000 HRK       38          61.0
    10 000-20 000 HRK      13          28.0
    > 20 000 HRK            5          14.0

Variable                  Return to work after STEMI [days]  p (a)

                              Me         75th percentile
Quality of life                                              0.017
  same                        89               122
  worse                      123               244
  better                      61               121
Income
  before STEMI                                               0.007
    < 5 000 HRK              122               201
    5 000-10 000 HRK          89               154
    10 000-20 000 HRK         61              161.5
    > 20 000 HRK             23.5              28
  after STEMI                                                0.005
    < 5 000 HRK              122               212
    5 000-10 000 HRK          89               154
    10 000-20 000 HRK         49               92
    > 20 000 HRK              22               25

STEMI--ST-elevation myocardial infarction; HRK--Croatian kuna (1
HRK = 0.131 euros); Me--median.

(a) Pearson's [Chi.sup.2] test.

Table 4. Influence of different parameters on permanent working
cessation, quality of life lowering, and return to work after
ST-elevation myocardial infarction

Variable                   Permanent working cessation [n (%)]

                           no           discharged   retired     p (a)

Age [years]                                                      0.009
  < 40                      7 (7.4)      1 (20.0)     1 (2.2)
  40-50                    28 (29.8)     0 (0.0)      4 (8.7)
  > 50                     59 (62.7)     4 (80.0)    41 (89.1)
Gender                                                             1
  male                     85 (90.4)    5 (100.0)    38 (82.6)
  female                    9 (9.6)      0 (0.0)     8 (17.4)
County                                                           0.821
  Zagreb                   51 (54.3)     3 (60.0)    23 (50.0)
  Karlovac                 18 (19.1)     0 (0.0)     9 (19.6)
  Sisak                    25 (26.6)     2 (40.0)    14 (30.4)
Educational degree                                               0.108
  elementary school        10 (11.0)     0 (0.0)     6 (13.3)
  secondary school         59 (64.8)    5 (100.0)    37 (82.2)
  high school               8 (8.8)      0 (0.0)      1 (2.2)
  university degree        14 (15.4)     0 (0.0)      1 (2.2)
Major complication                                               0.447
  no                       90 (95.7)    5 (100.0)    41 (89.1)
  cardiogenic shock         0 (0.0)      0 (0.0)      1 (2.2)
  cardiac arrest            4 (4.3)      0 (0.0)      4 (8.7)
Hospitalization duration                                         0.174
  < 10 days                51 (56.0)     4 (80.0)    19 (43.2)
  [greater than or equal   40 (44.0)     1 (20.0)    25 (56.8)
    to] 10 days
Rehabilitation                                                   0.672
  no                       45 (47.9)     3 (60.0)    27 (58.7)
  out-hospital             24 (25.5)     1 (20.0)    7 (15.2)
  in-hospital              25 (26.6)     1 (20.0)    12 (26.1)
MACE                                                             0.517
  no                       71 (75.5)     2 (40.0)    30 (65.2)
  reinfarction              1 (1.1)      0 (0.0)      2 (4.3)
  restenosis                6 (6.4)      0 (0.0)      4 (8.7)
  re-PCI of another         5 (5.3)      1 (20.0)     4 (8.7)
  coronary artery
  CABG                      1 (1.1)      0 (0.0)      1 (2.2)
  stroke                    0 (0.0)      0 (0.0)      0 (0.0)
  angina pectoris          10 (10.6)     2 (40.0)    5 (10.9)
Employer                                                         0.177
  governmental firm        46 (48.9)     2 (40.0)    31 (68.9)
  private                  17 (18.1)     2 (40.0)    5 (11.1)
  firm [less than or
    equal to] 100
    employees
  private                  12 (12.8)     1 (20.0)     4 (8.9)
  firm > 100 employees
  own business             18 (19.1)     0 (0.0)      3 (6.0)
  combination               1 (1.1)      0 (0.0)      2 (4.4)

Variable                   Quality of life lowering [n (%)]

                           no            yes         p (a)

Age [years]                                          0.088
  < 40                       6 (7.1)      3 (5.0)
  40-50                     19 (22.4)    13 (21.7)
  > 50                      60 (70.6)    44 (73.4)
Gender                                               0.112
  male                      72 (84.7)    56 (93.3)
  female                    13 (15.3)     4 (6.7)
County                                               0.039
  Zagreb                    52 (61.2)    25 (41.7)
  Karlovac                  11 (12.9)    16 (26.7)
  Sisak                     22 (25.9)    19 (31.7)
Educational degree                                   0.080
  elementary school          6 (7.2)     10 (17.2)
  secondary school          59 (71.1)    42 (72.4)
  high school                8 (9.6)      1 (1.7)
  university degree         10 (12.0)     5 (8.6)
Major complication                                   0.621
  no                        80 (94.1)    56 (93.3)
  cardiogenic shock          1 (1.2)      0 (0.0)
  cardiac arrest             4 (4.7)      4 (6.7)
Hospitalization duration                             0.151
  < 10 days                 47 (58.0)    27 (45.8)
  [greater than or equal    34 (42.0)    32 (54.2)
    to] 10 days
Rehabilitation                                       0.029
  no                        51 (60.0)    24 (40.0)
  out-hospital              18 (21.2)    14 (23.3)
  in-hospital               16 (18.8)    22 (36.7)
MACE                                                 0.053
  no                        65 (76.5)    38 (63.3)
  reinfarction               2 (2.4)      1 (1.7)
  restenosis                 4 (4.7)     6 (10.0)
  re-PCI of another          8 (9.4)      2 (3.3)
  coronary artery
  CABG                       0 (0.0)      2 (3.3)
  stroke                     0 (0.0)      0 (0.0)
  angina pectoris            6 (7.1)     11 (18.3)
Employer                                             0.862
  governmental firm         47 (56.0)    32 (53.3)
  private                   15 (17.9)    9 (15.0)
  firm [less than or
    equal to] 100
    employees
  private                   10 (11.9)    7 (11.7)
  firm > 100 employees
  own business              10 (11.9)    11 (18.3)
  combination                2 (2.4)      1 (1.7)

Variable                      Return to work after
                                 STEMI [days]
                              n       Me     p (b)

Age [years]                                  0.618
  < 40                        9      83.0
  40-50                      32      106.0
  > 50                       104     82.0
Gender                                       0.820
  male                       128     92.0
  female                     17      90.0
County                                       0.245
  Zagreb                     77      89.0
  Karlovac                   27      107.0
  Sisak                      41      92.0
Educational degree                           0.092
  elementary school          16      107.5
  secondary school           101     91.0
  high school                 9      106.0
  university degree          15      49.0
Major complication                           0.144
  no                         136     91.0
  cardiogenic shock           1      n.a.
  cardiac arrest              8      184.0
Hospitalization duration
  < 10 days
  [greater than or equal
    to] 10 days
Rehabilitation                               0.350
  no                         75      90.0
  out-hospital               32      92.0
  in-hospital                38      106.0
MACE                                         0.066
  no                         103     89.0
  reinfarction                3      n.a.
  restenosis                 10      61.0
  re-PCI of another          10      184.0
  coronary artery
  CABG                        2      n.a.
  stroke                      0      n.a.
  angina pectoris            17      187.0
Employer                                     0.001
  governmental firm          79      92.0
  private                    24      81.5
  firm [less than or
    equal to] 100
    employees
  private                    17      152.0
  firm > 100 employees
  own business               21      31.0
  combination                 3      14.0

MACE--major adverse cardiovascular events; PCI--percutaneous
coronary intervention; CABG--coronary artery by-pass graft; STEMI
- ST-elevation myocardial infarction; n.a.--not available.

(a) [Chi.sup.2] test.

(b) Kruskal-Wallis test (differences between 3 or more groups) or
Mann-Whitney U test (differences between 2 groups).
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Title Annotation:ORIGINAL PAPER
Author:Babic, Zdravko; Pavlov, Marin; Ostric, Mirjana; Milosevic, Milan; Durakovic, Marjeta Misigoj; Pintar
Publication:International Journal of Occupational Medicine and Environmental Health
Geographic Code:4EXCR
Date:Nov 1, 2015
Words:5731
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