When to Resume Full Activities After an Acute Myocardial Infarction
Abstract & Commentary
By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman reports no financial relationship to this field of study.
This article originally appeared in the May 2006 issue of Internal Medicine Alert. It was reviewed by the physician editor, Stephen Brunton, MD, and peer reviewed by Gerald Roberts, MD. Dr. Brunton is Clinical Professor at the University of California, Irvine. He is a consultant for Sanofi-Aventis and Ortho-McNeil. Dr. Roberts is Clinical Professor of Medicine at Albert Einstein College of Medicine. He reports no financial relationship relevant to this field of study.
Synopsis: A return to full normal activities, including work at 2 weeks, after AMI appears to be safe in patients who are stratified to a low-risk group. This should have significant medical and socioeconomic implications.
Source: Kovoor P, et al. Return to Full Normal Activities Including Work at Two Weeks after Acute Myocardial Infarction. Am J Cardiol. 2006;97:952-958.
The modern era of cardiology is a constantly moving target. With respect to when patients who have suffered an acute myocardial infarction (AMI) should return to full activities and work, it is important to note the classic pathology study involving 72 patients published in 19391 by one of the giants of cardiology, Dr. Paul Dudley White. His detailed, critical, pathologic work revealed that small infarcts were almost completely healed after 5 weeks and larger infarcts were completely healed after 2 months. As a result of this study, the founders of modern cardiology, such as Dr. Samuel Levine and even Dr. White, would keep their patients in bed for as long as 3 to 4 weeks before mobilization and discharge from the hospital. Of course, in the era of reperfusion therapy, management of patients with an AMI has changed dramatically and patients are now frequently discharged from the hospital within 3 days and usually return to work well within 6 weeks after the acute cardiac injury.2-4
Kovoor and colleagues from the University of Sydney in Australia, randomized 72 patients to return to normal activities at 2 weeks after an AMI and 70 other patients, who were treated with standard cardiac rehabilitation, were returned to normal activities at 6 weeks after an AMI. There were no deaths or episodes of congestive heart failure in either group and, in addition, there were no significant differences in the incidence of reinfarction, revascularization, left ventricular function, lipid levels, body mass index, smoking, or the results of exercise testing at 6 months after the AMI. They concluded that a return to full normal activities including work at 2 weeks after an AMI appeared to be safe in patients who were stratified to a low-risk group.
Returning to work as soon as possible after an AMI is critically important to patients in any occupation but especially to patients who are self-employed. Multiple, previously published studies have assessed return-to-work time after an AMI. From 1982 through 1984, the median time of return to work was 51 days to 2.27 months after an uncomplicated AMI.3,5 In 1988, Topol and his group2 reported that 86% of the patients in his early discharge group returned to work in approximately 41 days, whereas the vast majority of the patients in the conventional discharge group returned to work in 57 days. The randomized, controlled trial by Kovoor et al demonstrated that patients who were determined to be at low risk for future cardiac events after an AMI could return safely to full normal activities in only 2 weeks after the acute event, and that the accelerated return to normal activities did not increase the reinfarction rate, the need for revascularization, and did not negatively affect left ventricular function. It also should be noted that the lack of formal cardiac rehabilitation in the accelerated return to normal activities group made no difference in risk factors or exercise test performance at 6 months compared with patients who underwent formal cardiac rehabilitation activities.
It is now quite clear that appropriate risk stratification after an AMI can identify patients who are at low risk for future cardiac events. Larger prospective clinical trials are certainly needed. However, it would appear that it is quite safe to consider returning low-risk post AMI patients to full normal activities including work as early as only two weeks after the acute myocardial injury.
1. Mallory G, et al. The Speed of Healing of Myocardial Infarction: A Study of the Pathologic Anatomy in 72 Cases. Am Heart J. 1939;18:647-671.
2. Topol EJ, et al. A Randomized Controlled Trial of Hospital Discharge Three Days after Myocardial Infarction in the Era of Reperfusion. N Engl J Med. 1988;318:1083-1088.
3. Picard MH, et al. Cost-Benefit Analysis of Early Return to Work after Uncomplicated Acute Myocardial Infarction. Am J Cardiol. 1989;63:1308-1314.
4. Dennis C, et al. Early Return to Work after Uncomplicated Myocardial Infarction. Results of a Randomized Trial. JAMA. 1988;260:214-220.
5. Mulcahy R, et al. The Long-Term Work Record of Postinfarction Patients Subjected to an Informal Rehabilitation and Secondary Prevention Programme. Eur Heart J. 1988;9:84-88.