Full research paper

European Journal of Preventive

Cardiology

Return to work and associations with 0(00) 1–10

! The European Society of
Cardiology 2019
psychosocial well-being and health-related Article reuse guidelines:
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quality of life in coronary heart disease DOI: 10.1177/2047487319843079
journals.sagepub.com/home/ejpc
patients: Results from EUROASPIRE IV

Joy Van de Cauter1, Dirk De Bacquer1, Els Clays1, Delphine

De Smedt1, Kornelia Kotseva2 and Lutgart Braeckman1

Abstract
Background: Coronary heart disease (CHD) can lead to loss of workability and early retirement. We aimed to
investigate return to work (RTW) and its relationship towards psychosocial well-being and health-related quality of
life (HRQoL).
Design: Secondary analyses were applied to cross-sectional data from the EUROASPIRE IV survey (European Action on
Secondary and Primary prevention through Intervention to Reduce Events).
Methods: Participants were examined and interviewed at 6–36 months following the recruiting event. Psychosocial well-
being and HRQoL were evaluated by completing the ‘Hospital Anxiety and Depression Scale’ and ‘HeartQoL’ question-
naire. Using generalised mixed models, we calculated the odds ratios for RTW. Depression, anxiety and adjusted means
of HeartQoL were estimated accounting for RTW.
Results: Out of 3291 employed patients, the majority (76.0%) returned to work, of which 85.6% were men, but there
was a general underrepresentation of women. Young (p < 0.001), high-educated (p < 0.001) patients without prior
cardiovascular events (p < 0.05) were better off regarding RTW. No significant associations with CHD risk factors
and cardiac rehabilitation were established. Those that rejoined the workforce were less susceptible to psychosocial
distress (anxiety/depression, p < 0.001) and experienced a better quality of life (p < 0.001).
Conclusion: These findings provide evidence that non-modifiable factors (sociodemographic factors, cardiovascular
history), more than classical risk factors, are associated with RTW, and that patients who resume work display better
psychosocial well-being and HRQoL. Our results illustrate a need for tailored cardiac rehabilitation with a focus on
work-related aspects, mental health and HRQoL indicators to reach sustainable RTW, especially in vulnerable groups like
less educated and elderly patients.

Keywords
Return to work, coronary heart disease, psychosocial well-being, anxiety, depression, health-related quality of life
Received 28 October 2018; accepted 19 March 2019

Studies have highlighted that severe CVD may result

Background
Cardiovascular diseases (CVDs) account for 45% of all
deaths across Europe, with coronary heart disease
(CHD) being the most prevalent cause (20%).1
Mortality rates have declined due to evolutions in diag-
nosis, treatment and risk factor control.1 However, the
disease burden remains high, with CHD patients having
substantial physical and mental problems2 and display-
ing impaired health-related quality of life (HRQoL)
scores.2,3
in loss of workability, thereby leading to disability,
early retirement and elevated risk of CVD mortality.4,5
1
Department of Public Health and Primary Care, Ghent University, Gent,
Belgium
2
Department of Cardiovascular Medicine, National Heart and Lung
Institute, Imperial College London, London, UK
Corresponding author:
Joy Van de Cauter, Corneel Heymanslaan 10, 4K3, 9000 Gent, Belgium.
Email: joy.vandecauter@ugent.be
2 European Journal of Preventive Cardiology 0(00)
Return to work (RTW) after CHD has been
linked to medical characteristics (e.g. low disease sever-
ity, no/few comorbidities, low-invasive intervention,
short hospital stay, cardiac rehabilitation (CR) partici-
pation and duration), demographic distributions (e.g.
young age, men, high education and socio-economic
status), mental well-being (no depression/anxiety), indi-
vidual characteristics (e.g. no type-A behaviour, no
type-D personality, positive illness beliefs, low work
stress, good work expectations, high job satisfaction),
occupational characteristics (e.g. balanced job
demands, autonomy, social support) and high
HRQol.6–15
Several studies7,11,15 discussed the importance of
RTW as an indicator of functional and mental rehabili-
tation after cardiac events. Patients that do return to
work display better HRQoL scores and less anxiety
and/or depression.11,16
The heterogeneity of the RTW literature makes
further exploration of this subject more than valid,
especially in a large study population and by using dis-
ease-specific questionnaires to assess psychosocial well-
being and HRQoL.
Based on the EUROASPIRE IV (European Action
on Secondary and Primary prevention through
Intervention to Reduce Events) survey in coronary
patients, we aimed to investigate RTW and several
characteristics at the time of the CHD event and, sec-
ondly, the relation of RTW to psychosocial well-being
and HRQoL.
Methods
Study population and data collection
EUROASPIRE IV was conducted in 78 centres across
24 European countries from 2012 to 2013. Male and
female patients were interviewed and examined 6–36
months after hospitalisation for a first or recurrent
CHD event. Detailed information about the study
design/methods can be found in the original publica-
tion.17 For the present study, only patients with a cor-
onary artery bypass graft (CABG), percutaneous
coronary intervention (PCI) or acute myocardial
infarction (AMI) as recruiting event and employed at
that time (full-time, part-time or self-employed) were
eligible. An age restriction of <63 years was applied
to include only patients with a fair chance at RTW
considering age and the time between the recruiting
event and the interview. Furthermore, when categoris-
ing our age variable, we took the possibility of an early
retirement age into account: < 50 years; 50–<58 years;
58– < 63years. Education was divided into three levels:
primary education was considered as primary school or
less; secondary education as secondary school or high
school completed; high education consisted of univer-
sity/college degree.
Data were retrieved from the interview unless indi-
cated otherwise, in accordance with the research
questions.
RTW
Employment status, 6–36 months later, was dichoto-
mised in RTW (full-time, part-time or self-employed)
or no RTW (retired, unemployed, home maker, stu-
dent). Self-employment was added as a dichotomous
independent variable.
From the hospital discharge letter, risk factor infor-
mation (yes/no) such as hypertension, dyslipidaemia,
abnormal glucose metabolism, smoking status and
obesity were retrospectively retrieved. Body mass
index (BMI) at hospitalisation was calculated and com-
bined with the discharge information to optimise our
obesity data into a dichotomous variable (‘overweight
or obese’). From self-reported medical history, we
determined prior CHD as a CHD event which occurred
before the recruiting event (including CABG, PCI,
AMI, acute myocardial (AM) ischaemia, angina) and
prior stroke/transient ischaemic attack (TIA) as an
event which occurred before the recruiting event. CR
was defined as attending 50% of the sessions.
Psychosocial well-being and HRQoL
Participants were asked to fill in the Hospital Anxiety
and Depression Scale (HADS) and HeartQoL ques-
tionnaires. HADS depicts symptoms of anxiety (sub-
scale HADS-A) and depression (subscale HADS-D)
by way of 14 questions with a response scale of 0–3.18
HADS scores  7 were considered as normal, 8–10 as
mild and 11 as moderate to severe symptoms.19 The
HeartQoL questionnaire is a disease-specific tool for
measuring HRQoL in CHD patients.20,21 It consists
of 14 items; 10 items focus on physical well-being and
four items on emotional well-being, together providing
a global (HeartQoLglobal), physical (HeartQoLphysical)
and emotional scale (HeartQoLemotional), each ranging
between 0 (worst) and 3 (best).
We retrieved medical history such as self-reported
hypertension (HT), diabetes, dyslipidaemia and the
occurrence of a new (since hospital discharge) CHD
(including CABG, PTCA, AMI, AM ischaemia) from
the interview after the recruiting event, which was defined
as ‘recurrent CHD’. Because of an insufficient number of
cases, other recurrent pathologies were not included.
Regarding disease management, only CR and the use of
antidepressants/anxiolytics were taken into account.
Physical activity (PA) outside of work was divided into
three categories: no PA, light PA (most weeks) and
Van de Cauter et al.
vigorous PA (1–3/week). Current smoking was defined
as self-reported smoking and/or a breath carbon monox-
ide exceeding 10 ppm. BMI was calculated and was cate-
gorised as normal (<25 kg/m2), overweight (25–30 kg/m2)
and obese (30 kg/m2). Patients were asked if and what
actions they undertook to stop smoking, change their
diet, lose weight and increase their PA. For each category
the total information was dichotomised.
Statistical analyses
Descriptive analyses of the baseline-, RTW- and
non-RTW groups were performed. This was
reported separately for HADS-D/A categories and as
HeartQoLglobal/physical/emotional scores (mean, standard
deviation) and lifestyle factors within the RTW and
non-RTW groups.
All association models were assessed by way of gen-
eralised mixed models accounting for country-related
clustering, and all baseline adjustments included age,
sex, education and recruiting event.
Odds ratios (ORs) and 95% confidence intervals
(CIs) by way of multilevel logistic regressions were cal-
culated for RTW, with additional adjustments includ-
ing clinical information at discharge, medical history,
CR and self-employment.
HADS was dichotomised as an outcome (nor-
mal: < 8; symptomatic  8) for each subscale and ORs
(95% CI) were calculated by logistic multilevel regres-
sions. For HRQoL, the adjusted means (standard error)
of HeartQoL scores were assessed by multilevel linear
regressions. All HADS and HeartQoL models were add-
itionally adjusted for RTW status, self-reported clinical
risk factors, recurrent CHD, CR and lifestyle.
After analysing possible interaction terms (between
age/sex and every independent variable, p < 0.01) only
an age-stratification (<50 years, 50–<58 years, 58–<63
years) was performed for RTW, HADS-A,
HeartQoLglobal and HeartQoLemotional. By including
age as a continuous variable, the effect of age was ana-
lysed in each determined age group. A sensitivity ana-
lysis (HADS-D/A  11) was also performed to test the
robustness of our results. All analyses were performed
with IBM Corp. Released 2017. IBM SPSS Statistics for
Windows, Version 25.0. Armonk, New York: IBM Corp
and overall significance was defined as p < 0.05.
Results
From a total of 7998 CHD patients, 3291 (41.2%) were
employed before the event, of which 2661 were
aged < 63 years. Of those eligible, the employment
status at the time of the interview was available for
2651 patients (99.6%). The median time (interquartile
range) between index event and interview was 1.38
3
years (0.96–2.01 years). The majority of participants
(n ¼ 2014; 76.0%) returned to work and the baseline
characteristics and results of the regression analysis
can be found in Table 1. RTW was more prevalent in
younger, high-educated patients without a foregoing
cardiovascular event. Risk factors, as identified at dis-
charge, and CR participation were not associated with
a higher RTW rate when adjusted for sociodemo-
graphic and clinical factors and self-employment.
Age stratification (Appendix 1) showed lower RTW
in hypertensive patients 58 years and younger patients
treated with CABG. Higher RTW odds were found in
young non-smokers.
As shown in Table 2, possible (HADS  8) or prob-
able (HADS  11) depression (26.5%) and anxiety
(35.5%) were more prevalent in the non-RTW group,
but the majority in both groups were untreated. The
non-RTW group was more obese and less physically
active, but included more smokers undertaking actions
to quit. HeartQoL scores were better, especially on the
physical level, in the RTW group.
Table 3 presents data on associations between
depression/anxiety/HeartQoL and RTW.
RTW was associated with less depression, even after
full adjustments. After age stratification, the odds for
anxiety became higher in the case of RTW with rising
age, and in the oldest group RTW appeared to be no
longer significant (p ¼ 0.08) for displaying symptoms of
anxiety (see Appendices 2 and 3).
The sensitivity analysis (full model) showed a similar
significant association between HADS-D  11 and
RTW (OR 0.63; 95% CI (0.44, 0.90); p < 0.05) and
between HADS-A  11 and RTW (OR 0.61; 95% CI
(0.46, 0.82); p < 0.01).
Adjusted means for HeartQoLglobal/physical/emotional
(Table 3; Appendix 4), when CHD patients RTW, are
higher than when they fail to RTW. After performing
an interaction analysis for age, sex and HeartQoL, only
age displayed a significant relationship for
HeartQoLglobal/emotional. After age stratification
(Appendix 5), RTW remained significantly (p < 0.001)
associated with HeartQoLglobal/emotional. The highest
HeartQoLglobal scores were found in the youngest age
group, whereas the highest HeartQoLemotional scores
were reported by the oldest age group. The difference
between RTW and non-RTW participants, however, is
the most prominent in the youngest age group for both
HeartQoL domains.
Discussion
From the EUROASPIRE IV database, a large inter-
national cross-sectional study, we examined the propor-
tion of CHD patients that RTW and the concomitant
clinical information at discharge.
 4

Table 1. Baseline characteristics at discharge in function of work status and associations between return to work (RTW) and sociodemographics, clinical and work factors.

Odds for RTW

Employed pre-event RTW Non-RTW
(N ¼ 2661) (n ¼ 2014) (n ¼ 637)
% (n) % (n) % (n) OR (95% CI)a pa OR (95% CI)b pb OR (95% CI)c pc

Age, y (SD) 53.6 (6.60) 53.0 (6.64) 55.4 (6.17)

Age*
<50 y 26.0 (693) 29.0 (585) 17.0 (108) 2.80 (1.90, 4.12) <0.001 2.92 (1.39, 5.81) <0.001 2.86 (1.89, 4.34) <0.001
50– < 58 y 43.8 (1165) 44.2 (891) 42.1 (268) 1.76 (1.44, 2.14) <0.001 1.88 (1.51, 2.35) <0.001 1.88 (1.50, 2.36) <0.001
 58– < 63 y 30.2 (803) 26.7 (538) 41.0 (261) – – – –
Sex*
Female 15.1 (401) 14.4 (291) 17.0 (108) 0.77 (0.59, 1.02) 0.65 0.89 (0.67, 1.17) 0.40 0.92 (0.68, 1.24) 0.57
Male 84.9 (2260) 85.6 (1723) 83.0 (529) – – – – – –
Education$
Low 10.2 (271) 8.7 (174) 14.4 (91) 0.34 (0.25, 0.47) <0.001 0.25 (0.17, 0.37) <0.001 0.25 (0.17, 0.36) <0.001
Medium 61.8 (1636) 59.9 (1200) 68.3 (433) 0.55 (0.44, 0.68) <0.001 0.17 (0.37, 0.60) <0.0001 0.47 (0.37, 0.59) <0.001
High 28.0 (741) 31.5 (631) 17.4 (110) – – – – –
MV (n) 13 9 3
Event*
CABG 10.5 (256) 9.3 (172) 14.1 (82) 0.63 (0.45, 0.88) <0.01 0.66 (0.42, 1.03) 0.07 0.73 (0.49, 1.09) 0.13
PCI 62.2 (1517) 63.1 (1166) 59.5 (345) 1.14 (0.88, 1.49) 0.32 1.12 (0.81, 1.55) 0.48 1.20 (0.88, 1.64) 0.25
Infarction 27.3 (665) 27.6 (511) 26.4 (153) – – – – – –
MV (n) 223 165 57
Hypertension*
No 35.8 (952) 37.1 (747) 31.9 (203) 1.21 (1.02, 1.43) <0.05 1.07 (0.88, 1.30) 0.49 1.06 (0.87, 1.29) 0.58
Yes 64.2 (1709) 62.9 (1267) 68.1 (434) – – – – – –
Dyslipidaemia*
No 36.7 (977) 37.3 (752) 34.9 (222) 0.99 (0.86, 1.15) 0.91 0.97 (0.79, 1.20) 0.79 0.95 (0.76, 1.19) 0.67
Yes 63.3 (1684) 62.7 (1262) 65.1 (415) – – – – – –
Smoking*
Non-smoker 45.5 (1212) 45.5 (916) 45.8 (292) 0.79 (0.68, 0.91) <0.01 1.01 (0.82, 1.25) 0.90 1.04 (0.83, 1.29) 0.75
Ex-smoker 23.4 (623) 23.6 (475) 22.8 (145) 0.87 (0.70, 1.09) 0.24 1.13 (0.88, 1.45) 0.34 1.16 (0.90, 1.50) 0.24
Smoker 31.0 (826) 30.9 (623) 31.4 (200) – – – – – –
(continued)
European Journal of Preventive Cardiology 0(00)
Table 1. Continued
Van de Cauter et al.

Odds for RTW

Employed pre-event RTW Non-RTW
(N ¼ 2661) (n ¼ 2014) (n ¼ 637)
% (n) % (n) % (n) OR (95% CI)a pa OR (95% CI)b pb OR (95% CI)c pc

Glucose disorder*
No 77.5 (2061) 78.1 (1572) 75.4 (480) 1.19 (0.92, 1.53) 0.19 1.09 (0.80, 1.48) 0.60 1.07 (0.79, 1.46) 0.66
Yes 22.5 (600) 21.9 (442) 24.6 (157) – – – – –
Overweight or obese*
No 31.0 (826) 31.6 (637) 29.2 (186) 1.07 (0.88, 1.30) 0.51 1.12 (0.87, 1.43) 0.39 1.11 (0.87, 1.41) 0.40
Yes 69.0 (1835) 68.4 (1377) 70.8 (451) – – – – – –
Prior CHD$
No 56.4 (1500) 58.3 (1174) 50.5 (322) 1.31 (1.11, 1.56) <0.01 1.21 (1.06, 1.38) <0.01 1.20 (1.04, 1.38) <0.05
Yes 43.6 (1161) 41.7 (840) 49.5 (315) – – – – – –
Prior Stroke/TIA$
No 97.0 (2580) 97.5 (1963) 95.4 (608) 2.02 (1.43, 2.85) <0.001 1.81 (1.13, 2.90) <0.05 1.74 (1.08, 2.81) <0.05
Yes 3.0 (81) 2.5 (51) 4.6 (29) – – – – – –
CR$
No 54.5 (1450) 55.2 (1111) 52.7 (336) 1.04 (0.88, 1.23) 0.65 1.03 (0.80, 1.32) 0.83 1.05 (0.82, 1.34) 0.71
Yes 45.5 (1211) 44.8 (903) 47.3 (301) – – – – – –
Self-employed$
No 91.0 (2422) 90.8 (1829) 91.7 (584) 0.74 (0.58, 0.93) <0.05 0.86 (0.64, 1.15) 0.31 0.87 (0.64, 1.16) 0.34
Yes 9.0 (239) 9.2 (185) 8.3 (53) – – – –
Descriptives and analyses based on multilevel logistic regression.
a
Crude values.
b
Values adjusted for age, sex, educational level, recruiting diagnosis.
c
Full-adjusted model.
*Information from medical files (risk factor information from discharge and medical history).
$
Information retrieved from the interview.
–: reference category; RTW: return-to-work; %: column percentages; OR: odds ratio; CI: confidence interval; SD: standard deviation; MV: missing values; overweight or obese: obesity in discharge letter or
body mass index 25 kg/m2; Prior CHD: CHD (coronary heart disease) event before the recruiting event; TIA: transient ischaemic attack; CR: cardiac rehabilitation.
5
6 European Journal of Preventive Cardiology 0(00)

Table 2. Characteristics at the time of the interview in function of employment status.

Employed RTW Non-RTW

pre-event (n ¼ 2014) (n ¼ 637)
(n ¼ 2661) % (n) % (n) % (n)

Recurrent CHD
No 85.1 (2265) 85.3 (1718) 84.5 (538)
Yes 14.9 (396) 14.7 (296) 15.5 (99)
Self-reported elevated blood pressure
No 32.5 (864) 34.2 (688) 27.3 (174)
Yes 67.5 (1797) 65.8 (1326) 72.7 (463)
Self-reported high cholesterol
No 27.8 (741) 28.2 (568) 26.7 (170)
Yes 72.2 (1920) 71.8 (1446) 73.3 (467)
Self-reported diabetes
No 75.1 (1987/2647) 75.6 (1513/2002) 73.7 (468/635)
Yes 24.9 (660/2647) 24.4 (489/2002) 26.3 (167/635)
HADS-D
Normal 81.1 (2050/2527) 83.7 (1594/1905) 73.5 (450/612)
Mild 12.9 (362/2527) 11.5 (220/1905) 17.0 (104/612)
Moderate to severe 6.0 (151/2527) 4.8 (91/1905) 9.5 (58/612)
HADS-A
Normal 74.0 (1870/2527) 77.2 (1470/1905) 64.5 (395/612)
Mild 14.9 (376/2527) 13.2 (252/1905) 19.8 (121/612)
Moderate to severe 11.1 (281/2527) 9.6 (183/1905) 15.7 (96/612)
Psychiatric medication
No 94.8 (2515/2654) 95.3 (1913) 93.2 (593/636)
Yes 5.2 (139/2654) 4.7 (95) 6.8 (43/636)
BMI
Normal 16.0 (424/2647) 16.4 (328/2003) 15.1 (96/634)
Overweight 45.2 (1197/2647) 46.3 (928/2003) 41.8 (265/634)
Obese 38.8 (1026/2647) 37.3 (747/2003) 43.1 (273/634)
Current smoker
No 78.0 (2076) 78.4 (1579) 76.5 (487)
Yes 22.0 (585) 21.6 (435) 23.5 (150)
Physical activity
Not weekly 7.0 (186) 7.1 (144) 6.1 (39)
Light in most weeks 42.2 (1123) 38.4 (773) 54.6 (348)
Vigorously 1–3/week 50.8 (1352) 54.5 (1097) 39.2 (250)
Action to stop smoking
Non-smoker 39.9 (806/2021) 40.0 (611/1529) 39.2 (190)
Smoker and action 49.7 (1005/2021) 48.6 (743/1529) 53.6 (260)
Smoker and no action 10.4 (210/2021) 11.4 (175/1529) 7.2 (35)
Action to change diet
No 8.8 (234) 9.3 (188) 7.2 (46)
Yes 91.2 (2427) 90.7 (1826) 92.8 (591)
Action to lose weight
No 32.4 (862) 31.9 (642) 34.2 (218)
Yes 67.6 (1799) 68.1 (1372) 65.8 (419)
(continued)
Van de Cauter et al. 7

Table 2. Continued

Employed RTW Non-RTW

pre-event (n ¼ 2014) (n ¼ 637)
(n ¼ 2661) % (n) % (n) % (n)

Action to increase physical activity

No 33.6 (893) 33.2 (668) 35.0 (223)
Yes 66.4 (1768) 66.8 (1346) 65.0 (414)
HeartQoLglobal (SD) 2.30 (0.61) 2.37 (0.56) 2.09 (0.68)
HeartQoLphysical (SD) 2.29 (0.65) 2.37 (0.61) 2.06 (0.72)
HeartQoLemo (SD) 2.33 (0.69) 2.39 (0.65) 2.14 (0.79)
RTW: return-to-work; %: column percentages; CHD: coronary heart disease; HADS-D: Hospital Anxiety and Depression Scale-subscale depression;
HADS-A: Hospital Anxiety and Depression Scale-subscale anxiety; classification of HADS scores <8 ¼ normal, 8–<11 ¼ mild,  11 ¼ moderate to
severe; recurrent CHD: coronary heart disease event between hospital discharge and interview; current smoker status: self-reported status at
interview combined with carbon monoxide levels; psychiatric medication: anxiolytics or antidepressants; BMI: body mass index; HeartQoL: tool for
health-related quality of life; SD: standard deviation.

We found that 76% of our included CHD patients
returned to work in the period of six months to three
years after discharge. Our RTW rate is in line with most
of the studies of the last 15 years displaying an average
score (70–80%). Some studies6,11,13–15,22,23 report a
higher RTW rate, but use a broader RTW definition
(‘return to the workforce’, also including unemployed
but workable participants) or are characterised by
smaller populations, single treatment selection, combin-
ation of recruiting diagnosis, national settings, shorter
follow-up period or alternative definitions of RTW out-
come. Furthermore, apart from prior CHD and CR
attendance, we focussed on the available clinical infor-
mation at the time of the recruiting event. However, the
design of our RTW model hinders accounting for clin-
ical events during follow-up that may influence work
resumption and social reintegration.
Although RTW is, in general, lower in
women9,10,12,23–25 and female patients were found to
display a worse CV risk factor profile in
EUROASPIRE IV,26 we could not find a significant
association between RTW and gender. This is in line
with the VIRGO study13 and the TRANSLATE-ACS
study11; however, the underrepresentation of women in
our study needs to be considered.
As with previous studies,10,12,15,23,24,27 CHD patients
who returned to work were younger and highly edu-
cated. Patients < 50 years were three times more likely
to RTW, while for patients of 50–58 years the odds were
about twice as high. With an increasing older working
population, it remains important to enhance a continued
participation of patients 58 years since they make up a
large proportion of the CHD spectrum.
Multiple studies10,13,15,27 have reported the beneficial
effect of education on RTW. High education is often
accompanied by better socio-economic status, more
physically favourable work conditions but often high
stress levels and sedentary conditions. Moreover,
within educational group levels there are also variations
of CVD prevalence between occupational sectors28 due
to distinctions in clinical health versus behavioural
health in each profession. These educational/occupa-
tional variations emphasise the importance of multidis-
ciplinary tailored reintegration beyond a focus on
classical cardiovascular risk factors (CV RFs).
Similar to the VIRGO study13 and the
TRANSLATE-ACS study,11 a foregoing CHD event
or TIA/stroke diminished the odds to RTW.
In contrast to previous studies,8,13 CR was not asso-
ciated with RTW, but the lack of detailed information
on the different regional CR programs and the low
attendance needs to be considered. Qualitative research
by O’Hagan et al.7 has mentioned that some patients
view CR as beneficial for lifestyle changes and building
up capacity, but it lacks the occupational focus and
barely contributes to RTW. This knowledge could
prove an opportunity for more dialogue with occupa-
tional physicians as at such time European guidelines
are being developed for CR involving work-related
aspects (personal communication).
Regarding CV RFs, we only found HT and smoking,
after age stratification, to be related to RTW, which is in
contrast to previous research.9,11,23 Lower RTW in
hypertensive older patients could be due to a more chal-
lenging disease management, which may influence its
compatibility with work demands. Younger patients dis-
played a negative influence of smoker status and CABG
on RTW. Treatment options need to be carefully con-
sidered here, because although they may be better can-
didates for surgery, it seems to negatively impact RTW.
Younger patients may have a worse CV profile or more
physical demanding jobs and a more stressful family life.
Although previous studies15,22 have shown conflict-
ing results regarding the association between self-
employment and RTW, we could not find a significant
association between RTW and self-employment after
8 European Journal of Preventive Cardiology 0(00)

Table 3. Association between return to work (RTW), mental health and health-related quality of life.

HADS-D  8 HADS-A  8 HeartQoLglobal HeartQoLphysical HeartQoLemotional

RTW OR (95% CI) OR (95% CI) adj. mean (SE) adj. mean (SE) adj. mean (SE)

Model 1
Yes 0.52 (0.40, 0.67) 0.54 (0.43, 0.68) 2.391 (0.038) 2.389 (0.043) 2.396 (0.038)
No* 2.092 (0.049) 2.069 (0.052) 2.148 (0.058)
p < 0.001 p < 0.001 p < 0.001 p < 0.001 p < 0.001
Model 2
Yes 0.56 (0.44, 0.72) 0.52 (0.42, 0.65) 2.337 (0.038) 2.330 (0.043) 2.353 (0.044)
No* 2.043 (0.052) 2.023 (0.057) 2.093 (0.061)
p < 0.001 p < 0.001 p < 0.001 p < 0.001 p < 0.001
Model 3
Yes 0.58 (0.46, 0.74) 0.54 (0.44, 0.67) 2.201 (0.052) 2.188 (0.057) 2.230 (0.054)
No* 1.948 (0.054) 1.927 (0.060) 1.997 (0.058)
p < 0.001 p < 0.001 p < 0.001 <0.001 p < 0.001
Multilevel logistic and linear regression analyses with RTW as an independent variable.
HADS-D: Hospital Anxiety and Depression Scale-subscale depression; HADS-A: Hospital Anxiety and Depression Scale-subscale anxiety; HeartQoL:
tool for health-related quality of life; OR: odds ratio; CI: confidence interval; adj. mean: adjusted means from regression analyses; SE: standard error.
*Reference category.
Model 1: crude values.
Model 2: values adjusted for age, sex, educational level, recruiting diagnosis.
Model 3: full-adjusted model (additional adjustments for recurrent coronary heart disease recurrent (between hospital discharge and interview)
coronary heart disease, self-reported blood pressure, self-reported high cholesterol, self-reported diabetes, cardiac rehabilitation, body mass index,
current smoking, physical activity).

adjustments. Of note, only a small percentage (9%,
n ¼ 239) of our population was self-employed.
In a large number of studies, depression10,13,24,27 and
other mental comorbidities6,10,24,29 have been suggested
as a barrier for RTW, but to our knowledge we are the
first to analyse depression/anxiety, using the HADS
scale, in relation to RTW as an independent variable
in a large CHD population.
In our employed group, about 16% (Table 2) were
working while having depressive symptoms, which is
similar to a study by Warraich et al.11. Twenty three
percent of our patients were able to work while experi-
encing anxiety. A possible deduction hereof could be
that the presence of depression has more consequences
regarding the ability to work than anxiety. The
unfavourable combination of depression and work
resumption was also emphasised by Smedegaard
et al.23 Our results from the regression analyses
(Table 3), could also suggest that the relationship
between RTW and depression/anxiety is unidirectional,
since RTW has a protective effect on depression and
anxiety. This is in line with the aforementioned stu-
dies,11,16,23 although, due to the heterogeneity of meas-
urements, comparisons should be carefully approached.
The sensitivity analysis also showed that RTW was
less prominent in patients displaying probable depres-
sive/anxiety symptoms. This emphasises the need for
careful follow-up of psychological comorbidities, as
shown in previous literature,6,24 the integration of psy-
chosocial guidance during rehabilitation and after-
wards and a step-by-step RTW approach.
Although work has, in general, been linked to qual-
ity of life,30 we could only retain two studies11, 16 where
RTW was also included in the regression analysis of a
HRQoL outcome in CHD patients. To the best of our
knowledge, our study is the first to analyse HRQoL
using the HeartQoL tool with RTW as a possible pre-
dictor, in employed CHD patients within a large multi-
national database.
RTW has been attributed as an important marker of
the degree of functional rehabilitation, the patient’s
return to ‘normality’, which is reflected in our results.
In all areas of HRQoL, RTW is associated with
higher mean HRQoL scores. When adjusting for socio-
demographic and clinical risk factors and lifestyle
behaviour, the difference between the mean scores
was the most prominent for HeartQoLemotional,
which suggests the importance of RTW for mental
well-being. After age stratification, RTW was also
more influential for HRQoL in patients <50 years. In
the young, who were more plagued by common mental
disorders and low HeartQoLemotional, RTW could be a
mediator.
While the cross-sectional design of EUROASPIRE
IV limits the interpretation of results, the study popu-
lation remains a major source of data.
Van de Cauter et al.
Like most studies, our selected patients were
employed before the CHD recruiting event, as this
status has been shown to influence later RTW.15
This does discard, however, patients that, although
unemployed, may have had the intention and motiv-
ation to regain employment after the event.
Unlike other studies, we applied a realistic age
restriction, with patients who have a chance at RTW,
since in this aging society a continued employment or
participation of the elderly workforce is encouraged.
Contrary to previous RTW studies, which focus on a
specific diagnostic event (CABG, PCI or AMI), we
applied a wider definition of index event (PCI,
CABG, AMI).
It is unclear whether patients who were still on sick
leave at the interview were labelled as retired. Due to
the single data collection in the interval time of 6–36
months, it is possible that some patients did RTW but
then retired or were again on sick leave. As such, we
have no information on the number of RTW attempts
(full/partial), time to RTW or work sustainability.
Information is also lacking about the patients’ occupa-
tion, their social support, their work environment and
their work (dis)ability. This hampers a thorough ana-
lysis of the RTW process in accordance with elabor-
ations of the biopsychosocial health paradigm.31
EUROASPIRE IV provides broad information
regarding psychosocial well-being (HADS,
HeartQoL), but these were only measured at the time
of the interview. As indicated in the study by Fiabane
et al.,6 it is relevant to measure and follow-up HRQoL,
depression/anxiety during the hospitalisation, during
CR and at later time points.
In summary, to our knowledge this is the first study
to investigate the relationship between HeartQoL and
RTW, and to use RTW for analysing HADS-A/D in
CHD patients.
CHD patients of EUROASPIRE IV returned to
work at a reasonable rate (76%) compared to other
studies. RTW is subject to non-modifiable factors like
age, education and prior CAD/TIA/stroke. Contrary to
our expectations, there was no significant typical
gender gap, and CR along with CV RFs were not asso-
ciated with RTW in this population.
Our results suggest that RTW is negatively associated
with psychosocial well-being (depression, anxiety) and
positively associated with HRQoL, whereby patients
whom resumed their work reported less symptoms of
anxiety/depression and better HeartQoL scores.
In consideration of a growing aging population
accompanied by a longer working age, we suggest
future research pay attention to a thorough follow-up
of mental health and HRQoL at different stages of
treatment and during RTW, and to CR programs
including relevant work characteristics.
9
Author contributions
DDB, DDS and KK contributed to data acquisition. JVdC,
DDB, DDS, EC and LB contributed to the design and con-
ception of the work, and interpretation of the data. JVdC
carried out the analyses and drafted the manuscript. JVdC,
LB, DDB, EC and DDS critically revised the manuscript. All
authors gave final approval and agree to be accountable for
all aspects of work ensuring integrity and accuracy.
Acknowledgements
The EUROASPIRE IV survey was carried out under the aus-
pices of the European Society of Cardiology,
EURObservational Research Programme. We thank the per-
sonnel of participating hospitals and all the patients who par-
took in the EUROASPIRE studies.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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