Well-being among survivors of out-of-hospital cardiac arrest: a cross-sectional retrospective study in Sweden

The quality of care and long-term mortality of out of hospital cardiac arrest survivors after acute myocardial infarction: a nationwide cohort study

AIMS

The long-term outcomes of out of hospital cardiac arrest (OHCA) survivors are not well known.

METHODS AND RESULTS

Using the Myocardial Ischaemia National Audit Project (MINAP) registry, linked to Office for National Statistics mortality data, we analysed 661 326 England, Wales, and Northern Ireland acute myocardial infarction (AMI) patients; 14 127 (2%) suffered OHCA and survived beyond 30 days of hospitalization. Patients dying within 30 days of admission were excluded. Mean follow-up for the patients included was 1500 days. Cox regression models were fitted, adjusting for demographics and management strategy. OHCA survivors were younger (in years) {64 [interquartile range (IQR) 54-72] vs. 70 (IQR 59-80), P < 0.001}, more often underwent invasive coronary angiography (88% vs. 71%, P < 0.001) and percutaneous coronary intervention (72% vs. 45%, P < 0.001). Overall, the risk of mortality for OHCA patients that survived past 30 days was lower than patients that did not suffer cardiac arrest [adjusted hazard ratio (HR) 0.91; 95% CI; 0.87-0.95, P < 0.001]. 'Excellent care' according to the mean opportunity-based quality indicator (OBQI) score compared to 'Poor care', predicted a reduced risk of long-term mortality post-OHCA for all patients (HR: 0.77, CI; 0.76-0.78, P < 0.001), more for STEMI patients (HR: 0.73, CI; 0.71-0.75, P < 0.001), but less significantly in NSTEMI patients (HR: 0.79, CI; 0.78-0.81, P < 0.001).

CONCLUSION

OHCA patients remain at significant risk of mortality in-hospital. However, if surviving over 30 days post-arrest, OHCA survivors have good longer-term survival up to 10 years compared to the general AMI population. Higher-quality inpatient care appears to improve long-term survival in all OHCA patients, more so in STEMI.

Relatives' experiences of unsuccessful out-of-hospital cardiopulmonary resuscitation attempts: a qualitative analysis

AIM

Relatives of patients who have experienced an out of hospital cardiac arrest (OHCA) experience confusion and distress during resuscitation. Clear information from ambulance clinicians and the opportunity to witness the resuscitation helps them navigate the chaotic scene. However, UK-based evidence concerning relatives' experiences of unsuccessful resuscitation attempts and interactions with ambulance clinicians is lacking. This qualitative study explores those experiences to inform ambulance clinician practice.

METHODS

Two ambulance services in the UK identified OHCA events attended by their clinicians within the previous two weeks. After a minimum of three months relatives of non-survivors of these events were invited to participate in either a remote or face-to-face interview. Interviews focussed on their experiences of the resuscitation attempt and interactions with ambulance clinicians, their feelings at the time, and their reflections on the event afterwards. Data were analysed using reflexive thematic analysis.

RESULTS

Semi-structured interviews were conducted with 14 relatives of OHCA non-survivors. Thematic analysis identified four themes. Cardiac arrest is a traumatic event for relatives, with chaotic noisy scenes increasing their distress. Many described feelings symptomatic of Post-Traumatic Stress Disorder since the event. During resuscitation, participants needed information from clinicians about what was happening, and provided information about their relatives' wishes. Participants needed reassurance from clinicians that everything possible was done to save their relative and were reassured when they could witness some of the resuscitation. Participants were surprised how long resuscitation seemed to last; some were distressed that it lasted so long.

CONCLUSION

Relatives' experiences highlight two key challenges for ambulance clinicians: (1) being aware of the tension relatives feel between needing reassurance that the crew is doing everything to save the patient and wanting to avoid prolonged and ultimately futile resuscitation attempts; and (2) having ongoing conversations with those present to inform clinical decision-making whilst managing the resuscitation attempt.

Sex-specific health-related quality of life in survivors of cardiac arrest

Survival after out-of-hospital cardiac arrest (OHCA) remains low, although the number of survivors is increasing, and survivors are living longer. With increasing long-term survival, there is a need to understand health-related quality of life (HRQoL) measures. Although there are current recommendations for measuring HRQoL in OHCA survivors, there is significant heterogeneity in assessment timing and the measurement tools used to quantify HRQoL outcomes, making the interpretation and comparison of HRQoL difficult. Identifying groups of survivors of OHCA with poor HRQoL measures could be used for targeted intervention studies. Sex differences in OHCA resuscitation characteristics, post-cardiac arrest treatment, and short-term survival outcomes are well-documented, although variability in study methods and statistical adjustments appear to affect study results and conclusions. It is unclear whether sex differences exist in HRQoL among OHCA survivors and if study methods and statistical adjustment for patient characteristics or arrest circumstances impact the results. In this narrative review article, we provide an overview of the assessment of HRQoL and the main domains of HRQoL. We summarize the literature regarding sex differences in HRQoL in OHCA survivors. Few multivariable-adjusted studies reported HRQoL sex differences and there was significant heterogeneity in study size, timing of assessment, and domains measured and reported. What is reported suggests females have worse HRQoL than males, especially in the domains of physical function and mental health, but results should be interpreted with caution. Lastly, we discuss the challenges of a non-uniform approach to measurement and future directions for assessing and improving HRQoL in OHCA survivors.

How do survivors after out-of-hospital cardiac arrest perceive their health compared to the norm population? A nationwide registry study from Norway

Introduction

Self-perceived health status data is usually collected using patient-reported outcome measures. Information from the patients' perspective is one of the important components in planning person-centred care. The study aimed to compare EQ-5D-5L in survivors after out-of-hospital cardiac arrest (OHCA) with data for Norwegian population controls. Secondary aim included comparing characteristics of respondents and non-respondents from the OHCA population.

Methods

In this cross-sectional survey, 714 OHCA survivors received an electronic EQ-5D-5L questionnaire 3-6 months following OHCA. EQ-5D-5L assesses for five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with five-point descriptive scales and overall health on a visual analogue scale from 0 (worst) to 100 (best) (EQ VAS). Results are used to calculate the EQ index ranging from -0.59 (worst) to 1 (best). Patient responses were matched for age and sex with existing data from controls, collected through a postal survey (response rate 26%), and compared with Chi-square tests or t-tests as appropriate.

Results

Of 784 OHCA survivors, 714 received the EQ-5D-5L, and 445 (62%) responded. Respondents had higher rates of shockable first rhythm and better cerebral performance category scores than the non-respondents. OHCA survivors reported poorer health compared to controls as assessed by EQ-5D-5L dimensions, the EQ index (0.76 ± 0.24 vs 0.82 ± 0.18), and EQ VAS (69 ± 21 vs 79 ± 17), except for the pain/discomfort dimension.

Conclusions

Norwegian OHCA survivors reported poorer health than the general population as assessed by the EQ-5D-5L. PROMs use in this population can be used to inform follow-up and health care delivery.

Post-traumatic stress disorder among heart disease patients: a clinical follow-up of individuals with myocardial infarction in the Tromsø Study

BACKGROUND

Myocardial infarction is likely to be experienced as a life-threatening and potentially traumatic event. Approximately one-third of patients with myocardial infarction experience clinically significant symptoms of anxiety/depression. However, it is unclear how many of these patients experience these symptoms because of post-traumatic stress disorder (PTSD). We conducted a clinical screening of individuals with a confirmed myocardial infarction diagnosis. Our goal was to examine the prevalence of PTSD in myocardial infarction patients and study how PTSD symptoms were associated with exposure to potentially traumatic events.

METHOD

This is epidemiological research with a cross-sectional design following up participants from the Tromsø Study with a confirmed diagnosis of myocardial infarction. We sent invitations to participants in the Tromsø Study with clinically significant self-reported anxiety or depression symptoms following myocardial infarction. A cross-sectional sample of N = 79 participants (61 men and 18 women) was collected. During an interview, participants completed the Stressful Life Events Screening Questionnaire and the PTSD checklist PCL-5.

RESULTS

We found nine participants (11.6%) with probable PTSD. This was significantly higher than the postulated population prevalence in Norway (p < 0.015). We found no direct association between myocardial infarction as illness trauma and symptom levels (p = 0.123). However, we found a significant linear trend (p = 0.002), indicating that symptom severity increased proportionately as the number of post-traumatic events increased.

CONCLUSION

PTSD prevalence in myocardial infarction patients was related to lifetime exposure to traumatic events, not the myocardial infarction event alone. More research is required to examine the interaction between myocardial infarction and PTSD. Clinicians should be aware that anxiety or depression symptoms after MI could be secondary symptoms of PTSD.

Health-related quality of life in young Norwegian survivors of out-of-hospital cardiac arrest related to pre-arrest exercise habits

Aim

To compare health-related quality of life (HRQoL) in young survivors of out-of-hospital cardiac arrest (OHCA) in Norway with an age and sex-matched reference population and to assess the associations between exercise volume prior to OHCA and HRQoL after.

Methods

We present data from survivors aged 18-50 years registered with OHCA in the Norwegian Cardiac Arrest Registry between January 1st 2015 and December 31st 2017. Survivors were invited to answer two questionnaires; (1) the Short Form 36 (SF-36) Health Survey Version 1, and (2) about exercise habits prior to OHCA. Respondents were randomly matched 1:1 for age and sex with a reference population (data were available from the Norwegian Centre for Research Data).

Results

Of the 175 survivors invited, 95 (54%) responded, median age was 44 (range 35-48) years, 26 (27%) females. Valid results for SF-36 were available for 91 survivors, of whom 87 reported pre-OHCA exercise-volume. Prior to OHCA, 21 did no regular exercise, 44 exercised 1-4 hours/week and 22 exercised ≥5 hours/week. Compared to the reference population survivors had significantly (p < 0.01) poorer SF-36 scores for scales relating to physical- and mental health. SF-36 scale scores were similar in survivors who did and did not exercise regularly. Within the regular exercisers, survivors reporting ≥5 hours of exercise/week had better SF-36 scores than those exercising less.

Conclusion

Poorer HRQoL in survivors compared to the reference population should prompt us to explore how treatment and rehabilitation could be improved and adapted. More exercise before OHCA favoured better HRQoL after, which aligns well with the recognised positive association between HRQoL and physical activity in general.

Sex differences in symptoms of anxiety, depression, post-traumatic stress disorder, and cognitive function among survivors of out-of-hospital cardiac arrest

AIMS

Anxiety, depression, and post-traumatic stress disorder (PTSD) among out-of-hospital cardiac arrest (OHCA) survivors may impact long-term recovery. Coping and perception of symptoms may vary between sexes. The aim was to explore sex differences in psychological consequences following OHCA.

METHODS AND RESULTS

This was a prospective observational study of OHCA survivors who attended a structured 3-month follow-up. Symptoms of anxiety/depression were measured using the Hospital Anxiety and Depression Scale, range 0-21, with a cut-off score of ≥8 for significant symptoms; PTSD was measured with the PTSD Checklist for DSM-5 (PCL-5), range 0-80. A score of ≥33 indicated PTSD symptoms. Cognitive function was assessed by the Montreal Cognitive Assessment. From 2016 to 2021, 381 consecutive comatose OHCA survivors were invited. Of these, 288 patients (76%) participated in the follow-up visit [53 (18%) females out of 80 survivors and 235 (82%) males out of 300 alive at follow-up (78%)]. Significant symptoms of anxiety were present in 47 (20%) males and 19 (36%) females (P = 0.01). Significant symptoms of PTSD were present in 30% of males and 55% of females (P = 0.01). Adjusting for pre-specified covariates using multivariable logistic regression, female sex was significantly associated with anxiety [odds ratio (OR): 2.18, confidence interval (CI): 1.09-4.38, P = 0.03]. This difference was especially pronounced among young females (below median age, ORadjusted: 3.31, CI: 1.32-8.29, P = 0.01) compared with young males. No significant sex difference was observed for depression or cognitive function.

CONCLUSION

Symptoms of anxiety and PTSD are frequent in OHCA survivors, and female survivors report significantly more symptoms of anxiety and PTSD compared with males. In particular, young females were significantly more symptomatic than young males.

Sex Differences in Patient-Reported Outcomes in the Immediate Recovery Period After Resuscitation: Findings From the Cross-sectional DenHeart Survey

BACKGROUND

A paucity of resuscitation studies have examined sex differences in patient-reported outcomes upon hospital discharge. It remains unclear whether male and female patients differ in health outcomes in their immediate responses to trauma and treatment after resuscitation.

OBJECTIVES

The aim of this study was to examine sex differences in patient-reported outcomes in the immediate recovery period after resuscitation.

METHODS

In a national cross-sectional survey, patient-reported outcomes were measured by 5 instruments: symptoms of anxiety and depression (Hospital Anxiety and Depression Scale), illness perception (Brief Illness Perception Questionnaire [B-IPQ]), symptom burden (Edmonton Symptom Assessment Scale [ESAS]), quality of life (Heart Quality of Life Questionnaire), and perceived health status (12-Item Short Form Survey).

RESULTS

Of 491 eligible survivors of cardiac arrest, 176 (80% male) participated. Compared with male, resuscitated female reported worse symptoms of anxiety (Hospital Anxiety and Depression Scale-Anxiety score ≥8) (43% vs 23%; P = .04), emotional responses (B-IPQ) (mean [SD], 4.9 [3.12] vs 3.7 [2.99]; P = .05), identity (B-IPQ) (mean [SD], 4.3 [3.10] vs 4.0 [2.85]; P = .04), fatigue (ESAS) (mean [SD], 5.26 [2.48] vs 3.92 [2.93]; P = .01), and depressive symptoms (ESAS) (mean [SD], 2.60 [2.68] vs 1.67 [2.19]; P = .05).

CONCLUSIONS

Between sexes, female survivors of cardiac arrest reported worse psychological distress and illness perception and higher symptom burden in the immediate recovery period after resuscitation. Attention should focus on early symptom screening at hospital discharge to identify those in need of targeted psychological support and rehabilitation.

Determinants of health-related quality of life after out-of-hospital cardiac arrest (OHCA): A systematic review

OBJECTIVE

With a growing number of out-of-hospital cardiac arrest (OHCA) survivors globally, the focus of OHCA management has now broadened to survivorship. An outcome central to survivorship is health-related quality of life (HRQoL). This systematic review aimed to synthesise evidence related to the determinants of HRQoL of OHCA survivors.

METHODS

We systematically searched MEDLINE, Embase, and Scopus from inception to 15 August 2022 to identify studies investigating the association of at least one determinant and HRQoL in adult OHCA survivors. All articles were independently reviewed by two investigators. We abstracted data pertaining to determinants and classified them using a well-established HRQoL theoretical framework - the Wilson and Cleary (revised) model.

RESULTS

31 articles assessing a total of 35 determinants were included. Determinants were classified into the five domains in the HRQoL model. 26 studies assessed determinants related to individual characteristics (n=3), 12 studied biological function (n=7), nine studied symptoms (n=3), 16 studied functioning (n=5), and 35 studied characteristics of the environment (n=17). In studies that included multivariable analyses, most reported that individual characteristics (older age, female sex), symptoms (anxiety, depression), and functioning (impaired neurocognitive function) were significantly associated with poorer HRQoL.

CONCLUSIONS

Individual characteristics, symptoms, and functioning played significant roles in explaining the variability in HRQoL. Significant non-modifiable determinants such as age and sex could be used to identify populations at risk of poorer HRQoL, while significant modifiable determinants such as psychological health and neurocognitive functioning could serve as targets for post-discharge screening and rehabilitation plans. PROSPERO registration number: CRD42022359303.

The prevalence of anxiety and depression in cardiac arrest survivors: A systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to identify the prevalence of anxiety and depression in cardiac arrest (CA) survivors.

METHODS

A systematic review and network meta-analysis was performed on observational studies in adult cardiac arrest survivors with psychiatric disorders from PubMed, Embase, Cochrane Library and Web of Science. In the meta-analysis, we combined the prevalence quantitatively and analyzed the subgroup based on the classification indexes.

RESULTS

We identified 32 articles that met the inclusion criteria. Regarding anxiety,the pooled prevalence was 24% (95% CI, 17-31%) and 22% (95% CI, 13-26%) in short-term and long-term respectively. The subgroup analysis showed that the pooled incidence in in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrests (OHCA) survivors was 14.0% (95%CI, 9.0-20.0%) and 28.0% (95%CI, 20.0-36.0%) for short-term anxiety.The incidence of anxiety measured by, Hamilton Anxiety Rating Scale(HAM-A) and State-Trait Anxiety Inventory(STAI) was higher than other tools(P < 0.01). Regarding depression,the data analysis showed that the pooled incidence of short-term and long-term depression was 19% (95% CI, 13-26%) and 19% (95% CI, 16-25%), respectively. The subgroup analysis showed that the incidence of short-term and long-term depression was 8% (95% CI, 1-19%) and 30% (95% CI, 5-64%) for IHCA survivors, and was 18% (95% CI, 11-26%) and 17% (95% CI, 11-25%) for OHCA survivors. The incidence of depression measured by Hamilton Depression Rating Scale(HDRS) and Symptom check list-90(SCL-90) was higher than other assessment tools(P < 0.01).

CONCLUSIONS

The meta-analysis indicated a high prevalence of anxiety and depression in CA survivors, and those symptoms persisted 1 year or more after CA. Evaluation tool is an important factor affecting the measurement results.

Does time heal fatigue, psychological, cognitive and disability problems in people who experience an out-of-hospital cardiac arrest? Results from the DANCAS survey study

AIMS

Out-of-hospital cardiac arrest (OHCA) survivors may suffer short-term fatigue, psychological, cognitive and disability problems, but we lack information on the proportion of survivors with these problems in the long-term. Hence, we investigated these problems in survivors 1-5 years post-OHCA and whether the results are different at different time points post-OHCA.

METHODS

All adults who survived an OHCA in Denmark from 2016 to 2019 were identified using the Danish Cardiac Arrest Registry and invited to participate in a survey between October 2020 and March 2021. The survey included the Modified Fatigue Impact Scale, Hospital Anxiety and Depression Scale, "Two simple questions" (everyday activities and mental recovery), and the 12-item World Health Organisation Disability Assessment Schedule 2.0. To investigate results at different time points, survivors were divided into four time-groups (12-24, 25-36, 37-48 and 49-56 months post-OHCA). Differences between time-groups were determined using the Kruskall-Wallis test for the mean scores and Chi-square test for the proportion of survivors with symptoms.

RESULTS

Total eligible survey population was 2116, of which 1258 survivors (60 %) responded. Overall, 29 % of survivors reported fatigue, 20 % anxiety, 15 % depression, and 27 % disability. When survivors were sub-divided by time since OHCA, no significant difference was found on either means scores or proportion between time groups (p = 0.28 to 0.88).

CONCLUSION

Up to a third of survivors report fatigue, anxiety, depression, reduced mental function and disability 1-5 years after OHCA. This proportion is the same regardless of how much time has passed supporting early screening and tailored post-OHCA interventions to help survivors adapt to their new situation.

Cost-minimization analysis of a wearable cardioverter defibrillator in adult patients undergoing ICD explant procedures: Clinical and economic implications

Aims

Patients with permanently increased risk of sudden cardiac death (SCD) can be protected by implantable cardioverter defibrillators (ICD). If an ICD must be removed due to infection, for example, immediate reimplantation might not be possible or indicated. The wearable cardioverter defibrillator (WCD) is an established, safe and effective solution to protect patients from SCD during this high‐risk bridging period. Very few economic evaluations on WCD use are currently available.

Methods

We conducted a systematic review to evaluate the available evidence of WCD in patients undergoing ICD explant/lead extraction. Additionally, a decision model was developed to compare use and costs of the WCD with standard therapy (in‐hospital stay). For this purpose, a cost‐minimization analysis was conducted, and complemented by a one‐way sensitivity analysis.

Results

In the base case scenario, the WCD was less expensive compared to standard therapy. The cost‐minimization analysis showed a cost reduction of €1782 per patient using the WCD. If costs of standard care were changed, cost savings associated with the WCD varied from €3500 to €0, assuming costs for standard care of €6800 to €3600.

Conclusion

After ICD explantation, patients can be safely and effectively protected from SCD after hospital discharge through WCD utilization. Furthermore, the use of a WCD for this patient group is cost saving when compared to standard therapy.

Younger age is associated with higher levels of self-reported affective and cognitive sequelae six months post-cardiac arrest

BACKGROUND

Affective and cognitive sequelae are frequently reported in cardiac arrest survivors; however, little is known about the risk factors. We assessed the hypothesis that self-reported affective and cognitive sequelae six months after OHCA may be associated with demography, acute care and cerebral outcome.

METHODS

This is a sub-study of the multicentre "Target Temperature Management for 48 vs. 24 h and Neurologic Outcome after Out-of-Hospital Cardiac Arrest: A Randomised Clinical Trial" (the TTH48 trial) investigating the effect of prolonged TTM at 33 ± 1 °C. We invited patients with good outcome on the Cerebral Performances Categories (CPC score ≤ 2) to answer questionnaires on anxiety, depression, emotional distress, perceived stress and cognitive failures six months post OHCA.

RESULTS

In total 79 of 111 eligible patients were included in the analysis. There were no significant differences in baseline characteristics between the included group and the group lost to follow-up. Younger age was a negative predictor across all self-reported outcomes, even when controlling for gender, ROSC time, treatment allocation, cognitive impairment and global outcome (CPC 1 or 2). Female gender was a predictor of anxiety, though this should be interpreted cautiously as only eight women participated. A CPC score of 2 score was a negative predictor of self-reported affective outcomes, albeit not for self-reported cognitive failures.

CONCLUSION

Younger age was associated with higher levels of self-reported affective and cognitive sequelae six months post OHCA. Female gender may be associated with self-reported anxiety. A higher CPC score may be a proxy for self-reported affective sequelae.

Long-term physical and psychological outcomes after out-of-hospital cardiac arrest-protocol for a national cross-sectional survey of survivors and their relatives (the DANCAS survey)

INTRODUCTION

The number of out-of-hospital cardiac arrest (OHCA) survivors is increasing. However, there remains limited knowledge on the long-term physical and psychological problems suffered by survivors and their relatives. The aims of the DANCAS (DANish cardiac arrest survivorship) survey are to describe the prevalence of physical and psychological problems, identify predictors associated with suffering them and to determine unmet rehabilitation needs in order to make recommendations on the timing and content of future rehabilitation interventions.

METHODS AND ANALYSIS

The DANCAS survey has a cross-sectional design involving a survey of OHCA survivors and their relatives. OHCA survivors will be identified through the Danish Cardiac Arrest Registry as having suffered an OHCA between 1 January 2016 and 31 December 2019. Each survivor will be asked to identify their closest relative to complete the relatives' survey. Contents of survivor survey: EQ-5D-5Level, Hospital Anxiety and Depression Scale, Two Simple Questions, Modified Fatigue Impact Scale, 12-item WHO Disability Assessment Scale 2.0, plus questions on unmet rehabilitation and information needs. Contents of relatives' survey: World Health Organisation-Five Well-Being Index, Hospital Anxiety and Depression Scale, Informant Questionnaire on Cognitive Decline in the Elderly-Cardiac Arrest and the Modified Caregiver Strain Index. Self-report outcome data collected through the surveys will be enriched by data from Danish national registries including demographic characteristics, circumstances of cardiac arrest and comorbidities. The survey will be completed either electronically or by post December 2020-February 2021.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki. Surveys and registry-based research studies do not normally require ethical approval in Denmark. This has been confirmed for this study by the Region of Southern Denmark ethics committee (20192000-19). Results of the study will be disseminated via several peer-reviewed publications and will be presented at national and international conferences.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.

Opportunities and Risks of Resuscitation Attempts in Nursing Homes

BACKGROUND

Data supporting decision-making regarding cardiopulmonary resuscitation (CPR) in German nursing homes is insufficient.

METHODS

A retrospective evaluation of pre-hospital CPR was carried out with data from the German Resuscitation Registry (Deutsches Reanimationsregister) for the years 2011-2018. Patients under age 65 were excluded, as were patients from districts in which long-term data was available for less than 60% of patients. Subgroups were analyzed based on age and certain prehospital situations; patients treated outside nursing homes were used for comparison.

RESULTS

The study group consisted of 2900 patients, whose mean age was 83.7 years (standard deviation, 7.5 years). 1766 (60.9%) were women and 1134 (39.1%) were men. 118 patients (4.0%) were discharged alive, including 64 (2.2%) with a cerebral performance category (CPC) of 1 or 2, 30 (1.0%) with an unknown CPC, and 24 (0.8%) with a CPC of 3 or 4. 902 patients (31.1%) died in the hospital, including five (0.2%) who died more than 30 days after resuscitation, 279 (9.6%) between 24 hours and 30 days, and 618 (21.3%) within 24 hours. 1880 patients (64.8%) died at the site of attempted resuscitation. In 1056 cases (36.4%), CPR was initiated before the arrival of the emergency medical services. In the "initially shockable" subgroup, 13 of 208 patients (6.3%) were discharged alive with a CPC of 1 or 2.

CONCLUSION

CPR can lead to a good neurological outcome in rare cases even when carried out in a nursing home. The large percentage of CPR attempts that were initiated only after a delay indicates that nursing home staff may often be uncertain how to proceed. Uncertainty among caregivers points to a potential for advance care planning.

Are survivors of cardiac arrest provided with standard cardiac rehabilitation? - Results from a national survey of hospitals and municipalities in Denmark

AIM

To quantify the provision of standard cardiac rehabilitation to Danish survivors of cardiac arrest at a programme level, and to analyse whether organizational factors influenced the provision.

METHOD

We mapped the provision of cardiac rehabilitation core components to survivors of cardiac arrest and compared this with a reference group of patients after acute myocardial infarction using data from a cross-sectional programme-level survey among all hospitals (n = 34) and municipalities (n = 98) in Denmark. Organizational factors of potential importance to service provision were considered: health care region, size of catchment area/population, type of department/municipality and socioeconomic index.

RESULTS

Response rates for the provision of each core component of cardiac rehabilitation ranged from 64% to 98%. All hospitals and municipalities provided some aspect of cardiac rehabilitation to survivors of cardiac arrest. Across hospitals, provision of four core components of cardiac rehabilitation to survivors of cardiac arrest was lower compared with post acute myocardial infarction patients: patient education (relative risk (RR) = 0.45 (95% confidence interval (CI) 0.27 to 0.75)), exercise training (RR = 0.69 (95% CI 0.49 to 0.98)), screening for anxiety and depression (RR = 0.64 (95% CI 0.46 to 0.90) and nutritional counselling RR = 0.76 (95% CI 0.62 to 0.93)). No difference was found in the provision of core components across municipalities. Overall, the provision of cardiac rehabilitation to survivors of cardiac arrest was not affected by organizational factors.

CONCLUSION

This study indicates a need for future research to inform the development, adoption and implementation of equal access to all components of cardiac rehabilitation for survivors of cardiac arrest in Denmark.

Nation-Wide Observational Study of Cardiac Arrests Occurring in Nursing Homes and Nursing Facilities in Singapore

Introduction: Nursing home (NH) residents with out-of-hospital cardiac arrests (OHCA) have unique resuscitation priorities. This study aimed to describe OHCA characteristics in NH residents and identify independent predictors of survival. Materials and Methods: OHCA cases between 2010–16 in the Pan-Asian Resuscitation Outcomes Study were retrospectively analysed. Patients aged <18 years old and non-emergency cases were excluded. Primary outcome was survival at discharge or 30 days. Good neurological outcome was defined as a cerebral performance score between 1–2. Results: A total of 12,112 cases were included. Of these, 449 (3.7%) were NH residents who were older (median age 79 years, range 69–87 years) and more likely to have a history of stroke, heart and respiratory diseases. Fewer NH OHCA had presumed cardiac aetiology (62% vs 70%, P <0.01) and initial shockable rhythm (8.9% vs 18%, P <0.01), but had higher incidence of bystander cardiopulmonary resuscitation (74% vs 43%, P <0.01) and defibrillator use (8.5% vs 2.8%, P <0.01). Non-NH (2.8%) residents had better neurological outcomes than NH (0.9%) residents (P <0.05). Factors associated with survival for cardiac aetiology included age <65 years old, witnessed arrest, bystander defibrillator use and initial shockable rhythm; for non-cardiac aetiology, these included witnessed arrest (adjusted odds ratio [AOR] 3.8, P <0.001) and initial shockable rhythm (AOR 5.7, P <0.001). Conclusion: Neurological outcomes were poorer in NH survivors of OHCA. These findings should inform health policies on termination of resuscitation, advance care directives and do-not-resuscitate orders in this population. Ann Acad Med Singapore 2020;49:285–93 Key words: Advance care directives, Do-not-resuscitate orders, Geriatrics, Out-of- hospital, Palliative care

The association between heart diseases and suicide: a nationwide cohort study

OBJECTIVE

To assess the association between specific heart diseases and suicide.

DESIGN

Nationwide retrospective cohort study.

PARTICIPANTS

A total of 7 298 002 individuals (3 640 632 males and 3 657 370 females) aged ≥15 years and living in Denmark during 1980-2016.

MAIN OUTCOME MEASURES

Incidence rate ratios (IRR) with 95% confidence intervals. In multivariate analysis, we adjust for sex, period, age group, living status, income level, Charlson Comorbidity Index, psychiatric disorders prior to heart disease and self-harm prior to heart disease.

RESULTS

Excess suicide rate ratios were found for following disorders: heart failure (IRR: 1.48; 95% CI: 1.38-1.58); cardiomyopathy (IRR: 1.41; 95% CI: 1.16-1.70); acute myocardial infarction (IRR: 1.28; 95% CI: 1.21-1.36); cardiac arrest with successful resuscitation (IRR: 4.75; 95% CI: 3.57-6.33); atrial fibrillation and flutter (IRR: 1.42; 95% CI: 1.32-1.52); angina pectoris (IRR: 1.19; 95% CI: 1.12-1.26); and ventricular tachycardia (IRR: 1.53; 95% CI: 1.20-1.94). A higher rate of suicide was noted during the first 6 months after the diagnosis of heart failure (IRR: 2.38; 95% CI: 2.04-2.79); acute myocardial infarction (IRR: 2.24; 95% CI: 1.89-2.66); atrial fibrillation and flutter (IRR: 2.70; 95% CI: 2.30-3.18); and angina pectoris (IRR: 1.83; 95% CI: 1.53-2.19) when compared to later.

CONCLUSION

Several specific disorders were found to be associated with elevated rates of suicide. Additionally, we found temporal associations with higher suicide rates in the first time after diagnosis. Our results underscore the importance of being attentive towards psychological distress in individuals with heart disease.

One-year longitudinal study of psychological distress and self-assessed health in survivors of out-of-hospital cardiac arrest

OBJECTIVES

Few studies have investigated the psychological and health-related outcome after out-of-hospital cardiac arrest (OHCA) over time. This longitudinal study aims to evaluate psychological distress in terms of anxiety and depression, self-assessed health and predictors of these outcomes in survivors of OHCA, 3 and 12 months after resuscitation.

METHODS

Recruitment took place from 2008 to 2011 and survivors of OHCA were identified through the national Swedish Cardiopulmonary Resuscitation Registry. Inclusion criteria were age ≥18 years, survival ≥12 months and a Cerebral Performance Category score ≤2. Questionnaires containing the Hospital Anxiety and Depression Scale and European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L) were administered at 3 and 12 months after the OHCA. Participants were also asked to report treatment-requiring comorbidities.

RESULTS

Of 298 survivors, 85 (29%) were eligible for this study and 74 (25%) responded. Clinically relevant anxiety was reported by 22 survivors at 3 months and by 17 at 12 months, while clinical depression was reported by 10 at 3 months and 4 at 12 months. The mean EQ-5D-3L index value increased from 0.82 (±0.26) to 0.88 (±0.15) over time. There were significantly less symptoms of psychological distress (p=0.01) and better self-assessed health (p=0.003) at 12 months. Treatment-requiring comorbidity predicted anxiety (OR 4.07, p=0.04), while being female and young age predicted poor health (OR 6.33, p=0.04; OR 0.91, p=0.002) at 3 months. At 12 months, being female was linked to anxiety (OR 9.23, p=0.01) and depression (OR 14.78, p=0.002), while young age predicted poor health (OR 0.93, p=0.003).

CONCLUSION

The level of psychological distress and self-assessed health improves among survivors of OHCA between 3 and 12 months after resuscitation. Higher levels of psychological distress can be expected among female survivors and those with comorbidity, while survivors of young age and who are female are at greater risk of poor health.

Effect of interplay between age and low-flow duration on neurologic outcomes of extracorporeal cardiopulmonary resuscitation

Purpose

Caseloads of extracorporeal cardiopulmonary resuscitation (ECPR) have increased considerably, and hospital mortality rates remain high and unpredictable. The present study evaluated the effects of the interplay between age and prolonged low-flow duration (LFD) on hospital survival rates in elderly patients to identify subgroups that can benefit from ECPR.

Methods

Adult patients who received ECPR in our institution (2006–2016) were classified into groups 1, 2, and 3 (18–65, 65–75, and > 75 years, respectively). Data regarding ECPR and adverse events during hospitalization were collected prospectively. The primary end point was favorable neurologic outcome (cerebral performance category 1 or 2) at hospital discharge.

Results

In total, 482 patients were divided into groups 1, 2, and 3 (70.5%, 19.3%, and 10.2%, respectively). LFDs were comparable among the groups (40.3, 41.0, and 44.3 min in groups 1, 2, and 3, P = 0.781, 0.231, and 0.382, respectively). Favorable neurologic outcome rates were nonsignificantly lower in group 3 than in the other groups (27.6%, 24.7%, and 18.4% for group 1, 2, and 3, respectively). Subgroup analysis revealed that the favorable neurologic outcome rates in group 1 were 36.7%, 25.4%, and 13.0% for LFDs of < 30, 30–60, and > 60 min, respectively (P = 0.005); in group 2, they were 32.1%, 21.2%, and 23.1%, respectively (P = 0.548); in group 3 they were 25.0%, 20.8%, and 0.0%, respectively (P = 0.274).

Conclusion

On emergency consultation for ECPR, age and low-flow duration should be considered together to predict neurologic outcome.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5496-y) contains supplementary material, which is available to authorized users.