[Vocational integration of the worker suffering from ischemic heart disease: prognostic factors, occupational evaluation, and criteria for the assessment of their suitability for the specific task].

Ischemic heart disease, even if it has an incidence rate that increases with increasing age, can affect young people of working age. Remarkable progress in the treatment of acute coronary syndrome (ACS) and its complications, while it reduced the mortality due to myocardial infarction in both acute and later stages, on the other hand have contributed to increase prevalence, in people of working age, of ischemic heart disease and chronic conditions of post-ischemic left ventricular dysfunction in the outcomes of previous acute ischemic event. The first stage of the process of job placement is the study of worker health after acute coronary syndrome. After making all clinical and instrumental examinations, the first objective is risk stratification aimed to assess the prognosis of ischemic heart disease. The pathophysiological factors that allow risk stratification and thus constitute the determinants of prognosis after acute coronary event are: the presence of residual ischemia and inducibility of the same threshold; the left ventricular function; the presence of electrical instability and age. Only when the prognostic assessment has defined a low risk profile, an accurate study of work suitability, based both on hearth functional assessment and on work activity evaluation, becomes possible. Occupational assessment must consider, as a central factor (although not exclusive), measurement of energy expenditure required by work activity carried out through ergometric studies, but usually it occurs only in exceptional cases. However, although with some degree of approximation, energy expenditure of most occupational activities may be deducted from appropriate tables and should be regarded as a value "estimates". When the occupational physician has acquired, on the one hand all informations relating to the prognostic evaluation, risk stratification and clinical and instrumental analysis of residual work capacity, on the other hand all data pertaining to the evaluation (with models to "estimate") of energy expenditure of the specific task and data relating to occupational risk factors, he can compare the two groups of data. In the matching process, alongside the essential elements of judgment collected, criteria based on work physiology and on cardiac rehabilitation are necessary. It is assessed that a person is able to play for 6-8 hours continuous employment with consumption of oxygen equal to 35-40% (critical power - PCRIT) of maximum aerobic capacity (VO2 max) achieved in the ergospirometric test with peak values which must not exceed 2/3 of the maximal achieved. Return to work may be permitted and recommended if the patient's functional capacity is at least twice the energy demands of specific work activity.