More people than ever are able to resume working after a heart attack, but those working less or unable to work reported lower quality of life with increased depression and difficulty affording their medication, according to new research in Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal.

Advances in the prevention and treatment of heart attacks have led to better survival rates and overall patient health. But researchers wanted to assess whether these improved health outcomes translated into the real-world benefit of remaining employed.

“Social determinants of health are strongly linked to the risk of heart disease, with employment—or the lack of employment—being one of the most significant,” said study lead author Haider J. Warraich, MD, cardiologist at Duke University Medical Center and the Duke Clinical Research Institute in Durham, North Carolina. “Job loss significantly interacts with other psychosocial factors, such as depression and health status.”

Researchers examined data from 9,319 heart attack patients (average age 61, 27% female) enrolled in a longitudinal registry at 233 US hospitals between April 2010 and October 2012.

More than half the patients were employed at the time of their heart attack. A year later, 90% of them were back at work, 3% were working less than before their heart attack, and 7% were not working. This is the lowest level of job loss after heart attack reported to date, with levels as high as 51% in 1940, 37% in 2003, and 20% in 2007.

However, among the 10% of patients who experienced employment difficulties, more people reported lower quality of life, increased rates of depression, and financial difficulties, including trouble paying for medications. Specifically, 41% of patients working less or not at all reported moderate to extreme financial hardship. The best predictor of whether patients would have adverse change in employment was unplanned readmission to the hospital or post heart attack bleeding.

“These findings help us identify patients at high risk of not returning to work,” Warraich said. “This can help us focus our resources on, for example, patients readmitted after a heart attack, as a way of targeting those at most risk of not returning to work.”

An accompanying editorial by Rachel P. Dreyer, PhD and Victoria Vaughan Dickson, PhD, RN, noted that the findings lacked detailed information on work type; ie, professional, clerical, skilled and occupational characteristics like level of stress, social support, and job satisfaction.

“As the demographics of America’s workforce changes, the magnitude of heart attacks among working adults and the need for interventions that support successful return to work requires continued attention by researchers and clinicians,” they wrote.