In this issue of JCRP Jalowiec et al evaluated 237 adult heart transplant patients and assessed functional ability using the Sickness Impact Profile (which has been validated in other studies to reflect functional ability). They find that functional status improves significantly from pretransplantation to posttransplantation; however, there were many notable problem areas. Foremost among these included employment, eating, social interaction, recreation, home management, and ambulation. They conclude that many heart transplant recipients were still having functional problems and had not reached their full rehabilitation potential by the 1-year anniversary after transplantation.

Functional status includes many different areas but seems to center on physical capacity. If a patient does not feel well and does not have the physical ability to engage in strenuous activities, then overall functional status will likely decline. Certainly, this will impact other areas, such as ability to work, participation in social interactions, recreation, and ambulation.

Physical activity level or exercise capacity after heart transplantation is not normal. It remains markedly impaired when compared with healthy individuals and may not be much different from that of medically stabilized heart failure patients.1,2 This can lead to disappointing exercise performance and less optimal quality of life. Much of this impairment can be attributed to the physiology of the denervated donor heart, including chronotropic incompetence, increased resting heart rate, delayed normalization of heart rate after exercise, and diastolic dysfunction.1-3 An in-depth study of 95 heart transplant patients who underwent exercise testing 1 year after heart transplantation demonstrated a significant improvement in peak oxygen consumption (from 16.4 to 19.9 mL kg^-1 min^-1), exercise duration (from 5.5 to 7.6 minutes), and ventilatory response to exercise.4 Nonetheless, these values are quite impaired when compared with those of healthy control individuals matched for age and sex. In this study, transplant patients achieved only 54% of predicted peak oxygen consumption compared with healthy controls. The fact that heart transplant patients have reduced physical function 1 year after surgery is confirmed by the current article by Jalowiec et al. However, physical activity levels after heart transplantation may be improved by exercise training. A randomized trial of cardiac rehabilitation for 6 months in the first year after heart transplantation revealed that the exercise group had significantly greater increases in peak oxygen consumption and workload and a greater reduction in the ventilatory equivalent for carbon dioxide than the control group.5 However, even with these improvements in exercise parameters, these exercising heart transplant patients still had lower exercise capacity than did the normal controls. Therefore, exercise training may be one modifiable factor that could improve functional ability, but not to normal levels.

A majority of patients (90%) found work to be a significant problem area. Only 26% of the patients in this study returned to work within 1 year after heart transplantation. The heart transplant literature reports a return-to-work percentage between 22% and 86%.6 Although physical activity level no doubt limits return to work, as the authors of this current study suggest, other factors may be important. Reported factors at the time of transplantation that are associated with nonworking status after heart transplantation include age at time of transplantation, education, length of disability, type and status of health insurance, and the patients' perceived ability to work.7 Of particular importance (in the United States) is the fear of losing disability and medical health insurance by returning to the workforce. For example, if a patient returns to work and is deemed no longer disabled, then disability compensation (including health insurance) will cease. Moreover, a patient may not be able to determine in advance whether he or she will qualify for health insurance under the potential employer's medical insurance plan. In addition, if that same patient who returned to work becomes ill and cannot work, then that same patient will not have disability assistance, and a severe financial state may occur. It is understandable why such patients would be hesitant to reenter the workforce. Interestingly, a fear of losing adequate medical health insurance coverage seems to be less of an issue in those countries that provide national health coverage for their citizens. For example, the first-year return-to-work percentage reported by heart transplant programs from the United Kingdom is 69%8; European heart transplant patients, 56%9; and Australian heart transplant patients, 79%.10 These reported percentages are higher than those reported in the current study and in most studies from the United States.

Older age also seems to be an important factor in return to work. Many patients approaching retirement age may not consider it feasible to return to the workforce. It has been reported7 that patients who do not return to work tend to be older (older than 55 years). This is of great concern, as the average age of heart transplant patients according to the International Society of Heart and Lung Transplantation (ISHLT 2006 Registry) is 51 years.

There seem to be other factors that affect functional status and the ability to work. If patients do not feel well, there is no drive for them to return to their previous work or even seek new work opportunities. Medical complications affect how patients feel and, therefore, their functional status. From one study,6 at 1 year after heart transplant surgery, nonworking patients had more rejection episodes, infections, and total number of medical complications and rehospitalizations.

As mentioned, financial concerns are important factors that determine whether heart transplant patients will return to work. Maintaining medical health insurance is one of the most critical factors. Legislation (in the United States) that would guarantee health insurance for these patients would likely have a positive impact on the numbers of these patients who choose to return to work. The substantial cost of immunosuppression medications must also be addressed. Legislation has changed over the years to help patients overcome the financial burden associated with their medications. For example, in the United States, Medicare patients now have immunosuppression medications covered for their lifetime. Additional legislation is needed to assist patients who become ill after returning to work posttransplantation. A recently established program, "Ticket to Work," is a funded program that assists transplant patients with securing employment after surgery. Much more legislation to aid our patients is needed.

However, an excess emphasis on return to work may not be warranted. Heart transplant patients have received an extraordinary gift of a second chance at life. Still, this life-saving surgery is not without limits. For those patients surviving to 1 year, one half will not be alive after 12 years (ISHLT 2005 Registry). Significant medical complications also arise. Cardiac allograft vasculopathy (an accelerated form of atherosclerosis in the coronary arteries of the donor heart) can occur in up to 50% of all heart transplant recipients within 5 years after surgery. In addition, hypertension is seen in up to 77% and kidney dysfunction can be seen in up to 32% of heart transplant patients within 1 year after heart transplant surgery (ISHLT 2005 Registry). These medical problems can contribute to a reduced sense of well-being and a disincentive to work. In addition, because most of these patients are older than 50 years, many of these patients prefer the option of retirement, especially in the face of a shortened lifespan. It is also known that older patients (older than 56 years) are unlikely to secure new employment.7 Therefore, these patients may truly desire to "stop and smell the roses" in their final years.

Although functional status is not optimal at 1 year after heart transplantation, quality of life is still fulfilling and worthwhile. Heart transplant patients must be supported with legislation (in the United States) to help them maintain health insurance while they return to work or if they become ill after returning to work. Exercise rehabilitation should be emphasized because this will improve physical activity levels and promote improved functional capacity.

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