Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association

Physical, psychological, cognitive, social health outcomes, and health-related quality of life in out-of-hospital cardiac arrest survivors and their caregivers: Protocol of the quality cardiac arrest survivorship cohort study (QualiCAS)

Background

Out-of-hospital cardiac arrest (OHCA) is an emergency with historically low survival rates. Advances in resuscitation and post-resuscitation care have improved survival, precipitating greater scientific interest in OHCA patients' survivorship. However, there is insufficient high-quality population-based long-term survivorship data and limited research on the impact of OHCA sequelae on survivors' caregivers.

Objective

Our primary aim is to determine neurological function, physical, psychological, cognitive, social outcomes, and health-related quality of life (HRQoL) of OHCA survivors in Singapore. Secondary aims are to quantify caregivers' burden and its association with their HRQoL, and psychological well-being.

Methods

The Quality Cardiac Arrest Survivorship Cohort Study (QualiCAS) is a prospective population-based cohort study of OHCA survivors and their caregivers in Singapore. Participants aged ≥18 years and caregivers aged ≥21 years will be recruited from all public hospitals in Singapore. Health outcomes will be evaluated at 3, 6, and 12 months, and 3 and 5 years using the Hospital Anxiety and Depression Scale, PTSD Checklist for DSM-5, Fatigue Severity Scale, Montreal Cognitive Assessment Tool, EQ-5D-5L, Community Integration Questionnaire-Revised, Barthel Index, Lawton's Instrumental Activities of Daily Living, Timed Up and Go Test, Handgrip strength assessment, and Zarit Burden Interview.

Discussion

This study allows us to understand the natural history of OHCA survivorship and quantify the burdens on patients and their caregivers. Findings can guide clinical follow-up, identify high-risk patients, intervention targets, and inform rehabilitation strategies for OHCA sequelae.

Cardiac arrest survivors' self-reported cognitive function, and its association with self-reported health status, psychological distress, and life satisfaction-a Swedish nationwide registry study

AIM

Self-reported cognitive function has been described as an important complement to performance-based measurements but has seldom been investigated in cardiac arrest (CA) survivors. Therefore, the aim was to describe self-reported cognitive function and its association with health status, psychological distress, and life satisfaction.

METHODS

This study utilised data from the Swedish Register of Cardiopulmonary Resuscitation (2018-2021), registered 3-6 months post-CA. Cognitive function was assessed by a single question: "How do you experience your memory, concentration, and/or planning abilities today compared to before the cardiac arrest?". Health status was measured using the EQ VAS, psychological distress with the Hospital Anxiety and Depression Scale, and overall life satisfaction with the Life Satisfaction checklist. Data were analysed using binary logistic regression.

RESULTS

Among 4026 identified survivors, 1254 fulfilled the inclusion criteria. The mean age was 65.9 years (SD = 13.4) and 31.7% were female. Self-reported cognitive function among survivors was reported as: 'Much worse' by 3.1%, 'Worse' by 23.8%, 'Unchanged' by 68.3%, 'Better' by 3.3%, and 'Much better' by 1.5%. Declined cognitive function was associated with lower health status (OR = 2.76, 95% CI = 2.09-3.64), symptoms of anxiety (OR = 3.84, 95% CI = 2.80-5.24) and depression (OR = 4.52, 95% CI = 3.22-6.32), and being dissatisfied with overall life (OR = 2.74, 95% CI = 2.11-3.54). These associations remained significant after age, sex, place of CA, aetiology, initial rhythm, initial witnessed status, and cerebral performance were controlled.

CONCLUSIONS

Survivors experiencing declined cognitive function post-CA are at a higher risk of poorer health status, increased psychological distress, and reduced life satisfaction, and these risks should be acknowledged by healthcare professionals.

Lower Perceived Social Support During Hospitalization by Close Family Members may have Significant Associations with Psychological Distress 1 Month After Cardiac Arrest

BACKGROUND

The perception of having poor social support is associated with worse symptoms of psychological distress in close family members of critically ill patients, yet this has never been tested after cardiac arrest.

METHODS

Close family members of consecutive patients with cardiac arrest hospitalized at an academic tertiary care center participated in a prospective study. The validated Multidimensional Scale of Perceived Social Support (MSPSS) cued to index hospitalization was administered before discharge. Multivariate linear regressions estimated the associations between the total MSPSS score and total scores on the Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder 2-item (GAD-2), and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), assessed 1 month after cardiac arrest.

RESULTS

In 102 participants (mean age 52 ± 15 years, 70% female, 21% Black, 33% Hispanic) with complete data, the prevalence of depression, generalized anxiety, and probable posttraumatic stress disorder at a median duration of 28.5 days (interquartile range 10-63 days) from cardiac arrest was 61%, 34%, and 13%, respectively. A lower MSPSS score was significantly associated with higher PHQ-8 scores (β =  - 0.11 [95% confidence interval - 0.04 to - 0.18]; p < 0.01), even after adjusting for family members' age, sex, prior psychiatric condition, and witnessing of cardiopulmonary resuscitation and patient's discharge disposition (β =  - 0.11 [95% confidence interval - 0.02 to - 0.15]; p < 0.01). Similarly, significant inverse associations of total MSPSS scores were seen with 1-month GAD-2 and PCL-5 scores.

CONCLUSIONS

Poor social support during hospitalization, as perceived by close family members of cardiac arrest survivors, is associated with worse depressive symptoms at 1 month. Temporal changes in social networks and psychological distress warrant further investigation.

Multi-dimensional outcomes following extracorporeal cardiopulmonary resuscitation

Background

Recent trials suggested that extracorporeal cardio-pulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (VA-ECMO plus Impella®) may improve short-term survival and neurological outcomes in selected patients with refractory cardiac arrest. However, long-term effects on cardiac, cognitive, physical and psychological health need further study. A multidisciplinary post-ECPR outpatient care program was developed at two centers, involving cardiologists, neurologists, psychologists and medical sociologists to assess seven key health dimensions.

Methods

This bicentric, multidisciplinary study, conducted from May 2021 to April 2023, included adult ECPR survivors. Outcomes were assessed approximately 22 months post-cardiac arrest, focusing on cardiac, neurological, psychological and multi-organ functions, as well as social, professional and physical performance.

Results

This study included 33 ECPR survivors, who were predominantly male (70%) with a mean age of 55 years. Left-ventricular ejection fraction improved significantly, from 22% during ICU stay to 51% at follow-up in the ECMELLA group and from 31% to 51% in the VA-ECMO group (p = 0.006). Many patients reported dizziness or dyspnea (>52%) during daily activities, with a median New York Heart Association class of 2, EQ-5D-5L score of 53 and elevated NT-proBNP levels. Despite normal neurological scores, 46% had memory issues, 39% struggled with daily organization, 52% had depression and 12% had suicidal thoughts. Physical performance was reduced, with a mean distance of 394 meters in the 6-minute walk test and a 6-minute bicycle ergometry time.

Conclusion

ECPR patients showed significant improvement in left ventricular function over time but their neuropsychological and physical abilities remained compromised. Timely, multidisciplinary rehabilitation is required, starting in the intensive care unit and extending to include psychological support and community reintegration strategies after discharge.

Evaluation of interventions in prehospital and in-hospital settings and outcomes for out-of-hospital cardiac arrest patients meeting the termination of resuscitation rule in Japan: A nationwide database study (The JAAM-OHCA Registry)

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a global health burden with low survival rates. The termination of resuscitation (TOR) rule, widely adopted internationally, aims to preserve dignity, optimize resources, and protect healthcare providers. However, prehospital TOR is not implemented in Japan, presenting legal and practical challenges. This study analyzes temporal trends in prehospital and in-hospital interventions for OHCA patients with poor predicted outcomes.

METHODS

This retrospective study analyzed data from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) registry (June 2014-December 2021). Adult OHCA patients with medical causes were included if they fulfilled all the advanced life support (ALS) TOR rule criteria: unwitnessed arrest, no return of spontaneous circulation, no bystander-initiated cardiopulmonary resuscitation, and no automated external defibrillator use or defibrillation. Prehospital and in-hospital interventions were evaluated.

RESULTS

Among 11,334 patients meeting the inclusion criteria, 2,447 received all three ALS interventions (advanced airway management, intravenous access, and epinephrine administration). Over time, in-hospital interventions, including endotracheal intubation (56%) and epinephrine administration (82%), decreased, while advanced therapies, including coronary angiography, extracorporeal membrane oxygenation, and targeted temperature management, remained rare (<1%). The median time to TOR after hospital arrival shortened to 18 min. In contrast, prehospital epinephrine administration increased, while advanced airway management and intravenous access decreased.

CONCLUSIONS

OHCA patients who met TOR rule showed a decrease in in-hospital interventions. Further efforts are warranted to avoid futile medical treatments and promote patient-centered care.

A mind-body resilience intervention for emotional distress in cardiac arrest survivors and their informal caregivers - Recovering together after cardiac arrest: Protocol for an open pilot trial

Background

Chronic emotional distress among cardiac arrest (CA) survivors and their caregivers is prevalent and worsens quality of life and recovery. Interventions to prevent chronic distress post-CA are needed. We developed Recovering Together after Cardiac Arrest (RT-CA), an intervention to increase resiliency in CA survivor-caregiver dyads (pairs).

Method

We will conduct an open pilot clinical trial of RT-CA to examine preliminary feasibility and refine the intervention based on participant feedback. We will enroll at least 7 CA survivor-caregiver dyads during their hospitalization at a single academic medical center. We will identify eligible survivors by screening admission reports and through referrals from medical staff. Inclusion criteria: Survivors - sufficient cognitive status to meaningfully participate (Short Form of the Mini Mental State Exam ≥5). Dyads - English-speakers; one member must have clinically significant distress (≥8 on either Hospital Anxiety and Depression Scale subscale). Procedure: dyads will participate in 6, 30-45 min sessions with a study clinician. Sessions will include mind-body coping skills training and provision of anticipatory guidance and resources to navigate CA-survivorship. Dyads will complete pre- and post-test measures of emotional distress and treatment targets. We will calculate frequencies and proportions of our primary outcomes (feasibility - recruitment, assessments, adherence, therapist fidelity and acceptability/credibility). After completing post-test assessments, dyads will provide feedback via exit interviews. We will integrate qualitative and quantitative data using explanatory-sequential mixed-methods.

Discussion

We will use our findings to refine RT-CA content and study procedures. If successful, RT-CA has potential to significantly improve quality of survivorship for CA survivors and their caregivers.

Psychological and behavioral dimensions in cardiac arrest survivors and their families: A state-of-the-art review

This article aims to highlight high-quality observational and intervention studies focused on promoting psychological well-being among cardiac arrest (CA) survivors and their families. Following CA, many patients experience significant psychological distress, including depression, generalized anxiety, and post-traumatic stress. Recent studies indicate that this distress can narrow patients' focus, resulting in heightened awareness of cardiac signals-such as fluctuations in heart rate or blood pressure-that lead to constant monitoring and increased anxiety. This anxiety, compounded by behavioral avoidance toward cardioprotective behaviors and physiological hyperarousal, may elevate the risk of secondary cardiovascular diseases and adversely affect the quality of life. Current research is exploring behavioral interventions aimed at reducing this psychological distress, strategies to enhance coping mechanisms, and improving overall health in the survivor-family dyad. Unlike other cardiovascular conditions, no clinical practice guidelines exist for assessing or treating the psychological consequences of CA. Future research should prioritize identifying and treating modifiable psychological factors using targeted therapies and behavioral interventions.

Impact of a Quality Cardiopulmonary Resuscitation Coach on Pediatric Intensive Care Unit Resuscitation Teams

BACKGROUND

The quality cardiopulmonary resuscitation (CPR) coach role was developed for hospital-based resuscitation teams. This supplementary team member (CPR coach) provides real-time, verbal feedback on chest compression quality to compressors during a cardiac arrest.

OBJECTIVES

To evaluate the impact of a quality CPR coach training intervention on resuscitation teams, including presence of coaches on teams and physiologic metrics of quality CPR delivery in real compression events.

METHODS

The quality CPR coach curriculum and role implementation were designed and evaluated using a logic model framework. Medical records of patients who had in-unit cardiopulmonary arrests were reviewed retrospectively. Data included physiologic metrics of quality CPR delivery. Analysis included descriptive statistics and comparison of arrest data before and after the intervention.

RESULTS

A total of 79 cardiopulmonary arrests were analyzed: 40 before and 39 after the intervention. Presence of a quality CPR coach on resuscitation teams was more frequent after training, increasing from 35% before the intervention to 72% after (P = .002). No significant difference was found in the frequency of application of Zoll defibrillator pads. Metrics of quality CPR delivery and adherence with American Heart Association recommendations were either unchanged or improved after the intervention.

CONCLUSIONS

The quality CPR coach training intervention significantly increased coach presence on code teams, which was associated with clinically significant improvements in some metrics of quality CPR delivery in real cardiopulmonary arrests.

Dopamine receptor agonist pramipexole exerts neuroprotection on global cerebral ischemia/reperfusion injury by inhibiting ferroptosis

OBJECTIVE

To explore the mechanism of dopamine receptor agonist pramipexole in exerting neuroprotection on global cerebral ischemia/reperfusion injury (GCI/R).

MATERIAL AND METHOD

Male Sprague-Dawley rats were randomly divided into four groups (n = 36 in each group), and the Pulsinelli's four-vessel occlusion method was used to establish the rat model of GCI/R injury. Pramipexole administration group was intraperitoneally injected with pramipexole 0.5 mg kg-1 once a day for 14 days. Pramipexole combined with levodopa administration group was intraperitoneally injected with pramipexole 0.5 mg kg-1 and levodopa 50 mg kg-1 once a day for 14 days. The mNSS scores and Y maze test were used to evaluate neurological behaviors. Nissl staining and transmission electron microscopy were used to respectively observe hippocampal neurons and mitochondrial ultrastructure. Molecular biological tests including tissue iron concentration, GSH, MDA were used to detect the degree of ferroptosis. Western blotting was used to detect the expression levels of Nrf2, GPX4, X-CT and p53 proteins at 3 days, 7 days and 14 days after GCI/R injury.

RESULTS

Pramipexole alone or combined with levodopa for 14 days improved neurological behaviors, improved the morphology of neurons, increased the number of surviving neurons in the hippocampal CA1 region of GCI/R rats, which showed similar neuroprotective effects. Pramipexole alone or combined with levodopa for 14 days restored mitochondrial ultrastructure, decreased tissue iron concentration and MDA concentration, increased GSH concentration in the brain of GCI/R rats, which also induced the relative expressions of Nrf2, GPX4 and X-CT proteins and reduced p53 protein.

CONCLUSION

Pramipexole alone or combined with levodopa exert neuroprotection by inhibiting ferroptosis after GCI/R injury via Nrf2/GPX4/SLC7A11 pathway, and long-term intervention could be applied as an effective therapeutic strategy for neuroprotection against GCI/R injury.

Knowledge, attitude and practice towards postoperative management among patients with type A aortic dissection or their relatives: a cross-sectional study in China

OBJECTIVES

To assess the knowledge, attitude and practice (KAP) of patients with type A aortic dissection (AD) or their relatives regarding postoperative management.

DESIGN

Cross-sectional study.

SETTING

The participants were recruited from three hospitals between October 2022 and February 2023.

PARTICIPANTS

Patients diagnosed with type A AD or their relatives.

INTERVENTIONS

No interventions were administered. A structured questionnaire was used to gather the demographic and KAP data from the participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measures included the levels of KAP regarding postoperative management.

RESULTS

A total of 483 participants were included. They exhibited poor knowledge (15.52±7.67, possible score: 0-32), positive attitude (31.10±5.86, possible score: 9-45) and poor practice (21.96±4.83, possible score: 8-40) towards postoperative management. The multivariable logistic analysis showed that knowledge scores (OR=1.09, 95% CI 1.05 to 1.12, p<0.001), attitude scores (OR=1.22, 95% CI 1.16 to 1.29, p<0.001) and diagnosis for ≤5 years (OR=1.97, 95% CI 1.23 to 3.15, p=0.005) were independently associated with good practice. The structured equation modelling analysis showed that knowledge directly influenced attitudes (β=0.22, p<0.001) and practice (β=0.15, p<0.001), while attitude directly impacted practice (β=0.52, p<0.001) and mediated the relationship between knowledge and practice (β=0.11, p<0.001).

CONCLUSIONS

Patients with type A AD and their relatives have poor knowledge, positive attitudes and poor practice towards postoperative management. Knowledge might be the prerequisite for practice, and attitudes have a mediating effect.

Navigating cardiac arrest together: A survivor and family-led co-design study of family needs and care touchpoints

Introduction

This study aimed to i) identify the care needs of families experiencing cardiac arrest; and ii) co-identify strategies for meeting the identified care needs. Cardiac arrest survivors and family members (of survivors and non-survivors) were engaged as "experience experts," collaborators and co-researchers in this study.

Methods

A qualitative study using semi-structured interviews of cardiac arrest survivors and family members was conducted. Participants were recruited from the membership of the Family Centred Cardiac Arrest Care Project. Interviews were recorded, transcribed, and analysed using Framework analysis.

Results

Twenty-eight participants described 22 unique cardiac arrest events. We identified five primary care need themes: 1) "Help us help our loved one"; 2) "Work with us as a cohesive team"; 3) "See us: treat us with humanity and dignity"; 4) "Address our family's ongoing emergency"; and 5) "Help us to heal after the cardiac arrest" as well as 29 subordinate care need themes. We performed touchpoint mapping to identify key moments of interaction between patients and families, and the health system to highlight potential areas for improvement, as well as strategies for meeting family care needs.

Conclusion

Our participants identified varied family care needs during and long after cardiac arrest. Fortunately, many proposed strategies are inexpensive and have low barriers to adoption. However, some unmet care needs identified suggest larger systemic issues such as service gaps that leave families feeling abandoned and isolated. Overall, our findings suggest that care during and after cardiac arrest are critical components of a comprehensive cardiac arrest care system.

Low physical activity level in out-of-hospital cardiac arrest survivors with obesity, mobility problems and cognitive impairment: Results from the TTM2 trial

AIMS

To describe the level of physical activity 6 months after an out-of-hospital cardiac arrest (OHCA) and to explore potential risk factors of a low level of physical activity.

METHODS

Post-hoc analyses of the international multicentre Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac arrest (TTM2) trial. At 6 months, survivors at 61 sites in Europe, Australia and New Zeeland were invited to a follow-up. The participants answered two questions on self-reported physical activity. Answers were categorized as a low, moderate, or high level of physical activity and further dichotomized into a low versus moderate/high level of physical activity. Potential risk factors for a low level of physical activity were collected and investigated by univariable and multivariable logistic regression.

RESULTS

At 6 months, 807 of 939 (86%) OHCA survivors answered the two questions of physical activity; 34% reported a low, 44% moderate and 22% high level of physical activity. Obesity (OR = 1.75, 95% CI 1.10-2.77, p = 0.018), mobility problems by EuroQol 5 dimensions 5 levels (OR = 1.73, 95% CI 1.06-2.84, p = 0.029), and cognitive impairment by Symbol Digit Modalities Test (OR = 1.78, 95% CI 1.13-2.82, p = 0.013) were significantly associated with a low level of physical activity in the multivariable analysis.

CONCLUSION

One third of the OHCA survivors reported a low level of physical activity. Obesity, mobility problems, and cognitive impairment were associated with a low level of physical activity.

CLINICALTRIALS

GOV IDENTIFIER

NCT02908308.

Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease

Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.

Neuroprognostication, withdrawal of care and long-term outcomes after cardiopulmonary resuscitation

PURPOSE OF REVIEW

Survivors of cardiac arrest often have increased long-term risks of mortality and disability that are primarily associated with hypoxic-ischemic brain injury (HIBI). This review aims to examine health-related long-term outcomes after cardiac arrest.

RECENT FINDINGS

A notable portion of cardiac arrest survivors face a decline in their quality of life, encountering persistent physical, cognitive, and mental health challenges emerging years after the initial event. Within the first-year postarrest, survivors are at elevated risk for stroke, epilepsy, and psychiatric conditions, along with a heightened susceptibility to developing dementia. Addressing these challenges necessitates establishing comprehensive, multidisciplinary care systems tailored to the needs of these individuals.

SUMMARY

HIBI remains the leading cause of disability among cardiac arrest survivors. No single strategy is likely to improve long term outcomes after cardiac arrest. A multimodal neuroprognostication approach (clinical examination, imaging, neurophysiology, and biomarkers) is recommended by guidelines, but fails to predict long-term outcomes. Cardiac arrest survivors often experience long-term disabilities that negatively impact their quality of life. The likelihood of such outcomes implements a multidisciplinary care an integral part of long-term recovery.

Associations between Post-Intensive Care Syndrome Domains in Cardiac Arrest Survivors and Their Families One Month Post-Event

Background: Post-intensive care syndrome (PICS) affects many critical care survivors and family members. Nevertheless, the relationship between PICS-relevant domains in cardiac arrest (CA) survivors and psychological distress in their family members (henceforth, PICS-F) remains underexplored. Methods: We enrolled consecutive CA patients admitted between 16 August 2021 and 28 June 2023 to an academic medical center, along with their close family members, in prospective studies. Survivors' PICS domains were: physical dependence (Physical Self-Maintenance Scale, PSMS), cognitive impairments (Modified Telephone Interview for Cognitive Status, TICS-M), and post-traumatic stress disorder (PTSS) symptoms (PTSD Checklist-PCL 5), as well as PICS-F (PCL-5 Total Score). Hierarchical multivariate linear regressions examined associations between PICS-F and survivors' PICS domains. Results: Of 74 dyads (n = 148), survivors had a mean (SD) age of 56 ± 16 years, with 61% being male and with a median hospital stay of 28 days. Family members (43% spouses) were slightly younger (52 ± 14 years), predominantly female (72%), and of minority race/ethnicity (62%). A high prevalence of PICS assessed 28.5 days (interquartile range 10-63) post-CA was observed in survivors (78% physical dependence, 54% cognitive impairment, 30% PTSS) and in family members (30% PTSS). Survivor PTSS was significantly associated with family member distress (β = 0.3, p = 0.02), independent of physical dependence (β = 0.0, p = 0.9), cognitive impairment (β = -0.1, p = 0.5), family member characteristics, and duration of hospitalization. Conclusions: Both CA survivors and their family members showed substantial evidence of likely PICS. Survivor PTSS is notably associated with family member distress, highlighting the need for dyadic interventions to enhance psychosocial outcomes.

Cost-effectiveness analysis of a 'Termination of Resuscitation' protocol for the management of out-of-hospital cardiac arrest

BACKGROUND

Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management.

METHODS

Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated.

RESULTS

A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR.

CONCLUSION

The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.

Evaluating neurocognitive outcomes in out-of-hospital cardiac arrest survivors: A comparative study of performance-based and reported measures

AIMS

To (1) describe the prevalence of cognitive dysfunctions using performance-based and reported measures, and (2) explore the correlations between selected performance-based, patient-reported, and observer-reported neurocognitive outcome measures three months after hospital discharge in a population of out-of-hospital cardiac arrest (OHCA) survivors.

METHODS

Data from 193 OHCA survivors was derived from the Danish multicenter REVIVAL cohort study. At three months, four subtests of the performance-based Delis-Kaplan Executive Function System (D-KEFS) (Trail making, Color-word interference, Verbal fluency, and Figure design), the patient-reported Behavior Rating Inventory of Executive Function - Adult (BRIEF-A), and the observer-reported 16-item Short Form (SF) Informant Questionnaire on Cognitive Decline after Cardiac Arrest (SF-16 IQCODE-CA) were collected. Spearman's rank coefficient correlation analysis was performed to examine correlations between D-KEFS, BRIEF-A, and SF-16 IQCODE-CA.

RESULTS

Overall, 21% of survivors exhibited impairment in executive functioning using the D-KEFS subtest Color-word interference, while only 9% self-reported executive impairment (BRIEF-A) and 7% of relatives reported cognitive decline (SF-16 IQCODE-CA) in survivors at three months post-arrest. All correlations between D-KEFS, BRIEF-A and SF-16 IQCODE-CA were negligible to low.

CONCLUSION

The results of this REVIVAL substudy suggest that although the performance-based and reported measures did not correlate, dual neurocognitive screening tools containing both a self-reported and an informant-reported version may have the potential to detect executive discrepancies in the return to everyday life and guide targeted neurorehabilitation after OHCA.

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.

Long-Term Socioeconomic and Mental Health Changes After Out-of-Hospital Cardiac Arrest in Women and Men

BACKGROUND

Long-term effects of out-of-hospital cardiac arrest (OHCA) may affect the ability to work and mental health. Our aim was to analyze 5-year changes in socioeconomic and mental health outcomes after OHCA in women and men.

METHODS

We included 259 women and 996 men from North Holland, the Netherlands, who survived 30 days after OHCA occurred between 2009 and 2015. We assessed changes in employment, income, primary earner status, and anxiety/depression (using medication proxies) from the year before the OHCA to 5 years after with generalized linear mixed models, stratified by sex. We tested differences in changes by sex with interaction terms. Additionally, we explored yearly changes. The 5-year changes after OHCA were compared with changes in a sex- and age-matched sample of people without OHCA. Differences were tested using an interaction term of time and OHCA status.

RESULTS

In both women and men (median age [Q1, Q3]: 51 [45, 55] and 54 [48, 57] years, respectively), decreases from before OHCA to 5 years thereafter were observed in the proportion employed (from 72.8% to 53.4% [women] and 80.9% to 63.7% [men]) and the median income. No change in primary earner status was observed in either sex. Dispensing of anxiety/depression medication increased only in women, especially after 1 year (odds ratio, 5.68 [95% CI, 2.05-15.74]) and 5 years (odds ratio, 5.73 [95% CI, 1.88-17.53]). Notable differences between women and men were observed for changes in primary earner status and anxiety/depression medication (eg, at year 1, odds ratio for women, 6.71 [95% CI, 1.96-23.01]; and for men, 0.69 [95% CI, 0.33-1.45]). However, except for anxiety/depression medication in women, similar changes were also observed in the general population.

CONCLUSIONS

OHCA survivors experience changes in employment, income, and primary earner status similar to the general population. However, women who survived OHCA more often received anxiety/depression medication in the years following OHCA.

Social determinants and pre-arrest care patterns associated with cardiac arrest and mortality

BACKGROUND

Understanding the impact of social determinants of health (SDOH) on CA, including access to care pre-cardiac arrest (CA) can improve outcomes. Large databases, such as Epic Cosmos, can help identify trends in patient demographics and SDOH that identify gaps in care. The purpose of this study was to determine the incidence of CA and subsequent mortality in a large national database across patient demographics and social determinants and characterize pre-arrest care patterns.

METHODS

This was a retrospective cohort study using a large national deidentified electronic health database (Epic Cosmos) with 227 million patients. Inclusion criteria was ED encounter for CA (ICD-10-CM: I46). Patient demographics and social determinants included age, sex, race, ethnicity, social vulnerability index (SVI, a composite measure with greater SVI representing more vulnerability). The primary outcome was difference in CA incidence between groups, reported as odds ratios (ORs). The secondary outcomes were 1) incidence of pre-arrest care within 30 days and 2) post-arrest mortality at 7,30, and 180 days. Statistical analysis was performed using Chi-squared analysis (unadjusted OR) and aggregated logistic procedure (adjusted OR).

RESULTS

There were 201,846 ED visits for CA between April 20, 2020, and April 19, 2023 (0.11% incidence). For all ages, males had a higher incidence of CA (OR 1.76, p < 0.0001). Black, Native Hawaiian or Pacific Islander, and American Indian or Alaska Native had a higher OR of CA while Asian patients were less likely than White patients (adjusted OR 1.85, 1.44,1.51, and 0.81 respectively, all p < 0.0001). Hispanic/Latino patients had a lower OR of CA (adjusted OR 0.72, p < 0.0001). CA was more common in the highest SVI quartile compared to the lowest (adjusted OR 1.71, p < 0.0001). Significant heterogeneities were identified in pre-arrest care across patient demographics and social determinants, where ED visits were more common than office visits among male patients, patients in the highest SVI, Hispanic/Latino, and minority patients, except for Asian patients. Post-arrest mortality after 30 days was highest in females, Black patients, and patients in the highest SVI.

CONCLUSIONS

SDOH have a significant impact on the risk of CA, pre-arrest care patterns, and post-arrest mortality. Determining the impact that SDOH have on the CA care continuum provides can provide actionable targets to prevent CA and subsequent mortality.

Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation

This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.

Associations between initial heart rhythm and self-reported health among cardiac arrest survivors - A nationwide registry study

BACKGROUND

Non-shockable initial rhythm is a known risk factor for high mortality at cardiac arrest (CA). However, knowledge on its association with self-reported health in CA survivors is still incomplete.

AIM

To examine the associations between initial rhythm and self-reported health in CA survivors.

METHODS

This nationwide study used data from the Swedish Register for Cardiopulmonary Resuscitation 3-6 months post CA. Health status was measured using EQ-5D-5L and psychological distress by the Hospital Anxiety and Depression Scale (HADS). Kruskal-Wallis test was used to examine differences in self-reported health between groups of different initial rhythms. To control for potential confounders, age, sex, place of CA, aetiology, witnessed status, time to CPR, time to defibrillation, and neurological function were included as covariates in multiple regression analyses for continuous and categorical outcomes.

RESULTS

The study included 1783 adult CA survivors. Overall, the CA survivors reported good health status and symptoms of anxiety or depression were uncommon (13.7% and 13.9% respectively). Survivors with PEA and asystole reported significantly more problems in all dimensions of health status (p = 0.037 to p < 0.001), anxiety (p = 0.034), and depression (p = 0.017) compared to VT/VF. Overall, these differences did not remain in the adjusted regression analyses.

CONCLUSIONS

Initial rhythm is not associated with self-reported health when potential confounders are controlled. Initial rhythm seems to be an indicator of unfavourable factors causing the arrest, or factors related to characteristics and treatment. Therefore, initial rhythm may be used as a proxy for identifying patients at risk for poor outcomes such as worse health status and psychological distress.

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Impact of Preexisting Depression and Anxiety on Hospital Readmission and Long-Term Survival After Cardiac Arrest

BACKGROUND

While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival.

METHODS

We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission.

RESULTS

We included 684 subjects. Past depression or anxiety was noted in 24% (n = 162) and 19% (n = 129) of subjects. A minority of subjects (n = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival.

CONCLUSIONS

Depression is an independent risk factor for hospital readmission in CA survivors.

The experiences of cardiac arrest survivors and their key supporters following cardiac arrest: A systematic review and meta-ethnography

AIM

To review qualitative studies on the experience of sudden cardiac arrest survival from the perspective of both survivors and their key supporters, including family/close friends.

METHODS

A seven-step meta-ethnography and synthesis of qualitative evidence was undertaken, informed by the Meta-Ethnography Reporting Guidelines (eMERGe). Four major databases were searched (Medline, EMBASE, CINAHL, PsycINFO; January 1995-January 2022, updated July 2023) for qualitative studies exploring survivors' and/or key supporters' experiences of cardiac arrest survival. The Critical Appraisal Skills Programme checklist and Grading of Recommendations Assessment, Development and Evaluation - Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) were applied to evaluate the overall confidence in research findings. Constructs were identified from each paper, informing theme and sub-theme development.

RESULTS

From 15,917 unique titles/abstracts and 196 full-text articles, 32 met the inclusion criteria. Three themes captured the survivors' experiences: 1) Making sense of my cardiac arrest; 2) Learning to trust my body and mind; and 3) Re-evaluating my life. A further three themes reflected key supporters' experiences: 1) Emotional turmoil; 2) Becoming a carer: same person but different me; and 3) Engaging with a new and unknown world. However, limited data and some methodological weaknesses in included studies reduced confidence in several themes. The findings were conceived within the overarching concept of 'negotiating a new normal'.

CONCLUSIONS

The enduring psychosocial and physical sequelae of cardiac arrest survival substantially impacts the lives of survivors and their key supporters, requiring negotiation of their 'new normality'. The need for sense-making, physical and psychological recovery, and the new roles for key supporters should be strong considerations in the development of future interventions.

Emotional distress, social support, and functional dependence predict readiness for hospital discharge in a prospective sample of cognitively intact cardiac arrest survivors

AIM

To inform screening, referral and treatment initiatives, we tested the hypothesis that emotional distress, social support, functional dependence, and cognitive impairment within 72 hours prior to discharge predict readiness for discharge in awake and alert cardiac arrest (CA) survivors.

METHODS

This was a secondary analysis of a prospective single-center cohort of CA survivors enrolled between 4/2021 and 9/2022. We quantified emotional distress using the Posttraumatic Stress Disorder Checklist-5 and PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a; perceived social support using the ENRICHD Social Support Inventory; functional dependence using the modified Rankin Scale; and cognitive impairment using the Telephone Interview for Cognitive Status. Our primary outcome was readiness for discharge, measured using the Readiness for Hospital Discharge Scale. We used multivariable linear regression to test the independent association of each survivorship factor and readiness for discharge.

RESULTS

We included 110 patients (64% male, 88% white, mean age 59 [standard deviation ± 13.1 years]). Emotional distress, functional dependence, and social support were independently associated with readiness for discharge (adjusted β's [absolute value]: 0.25-0.30, all p < 0.05).

CONCLUSIONS

Hospital systems should consider implementing routine in-hospital screening for emotional distress, social support, and functional dependence for CA survivors who are awake, alert and approaching hospital discharge, and prioritize brief in hospital treatment or post-discharge referrals.

Management of diabetes mellitus patients with sickle cell anemia: Challenges and therapeutic approaches

The coexistence of diabetes mellitus (DM) and sickle cell anemia (SCA) poses significant challenges in clinical management due to the complex interactions and overlapping complications associated with both conditions. Managing diabetes in individuals with SCA requires a comprehensive approach that addresses the unique physiological and pathological aspects of both diseases. This paper reviews the challenges encountered in the management of DM in patients with SCA and explores therapeutic strategies and approaches to optimize patient care. Challenges in the management of DM in individuals with SCA stem from several factors, including the impact of hemoglobin variants on glycemic control assessment, increased susceptibility to infections, altered immune response, and complications associated with both diseases. Moreover, the coexistence of SCA and DM heightens the susceptibility to infections due to compromised immune function, emphasizing the need for vigilant preventive measures, including vaccinations and close monitoring for infectious complications. Close collaboration among healthcare providers specializing in diabetes, hematology, and other relevant fields is crucial for developing comprehensive care plans. Individualized treatment strategies that balance glycemic control, pain management, and preventive care are essential to mitigate complications and optimize the overall health outcomes of patients with both DM and SCA. In conclusion, managing diabetes in the context of SCA necessitates a nuanced and patient-centered approach. By addressing the challenges and employing tailored therapeutic strategies, healthcare providers can improve the quality of life and health outcomes for individuals affected by both conditions.

Qualitative research in cardiac arrest research: A narrative review

Qualitative research is defined as "the study of the nature of phenomena", including "their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived". It is a methodology which is becoming extremely valuable in resuscitation science, especially in terms of improving our understanding of the true impact of sudden cardiac arrest on survivors, family members, lay responders and health care providers. This narrative review provides a high-level overview of qualitative methods as well as the current state of the qualitative evidence and key knowledge gaps in resuscitation science. It finishes with discussion of the bright future of qualitative research in our field.

Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study

OBJECTIVE

To quantify time dependent probabilities of outcomes in patients after in-hospital cardiac arrest as a function of duration of cardiopulmonary resuscitation, defined as the interval between start of chest compression and the first return of spontaneous circulation or termination of resuscitation.

DESIGN

Retrospective cohort study.

SETTING

Multicenter prospective in-hospital cardiac arrest registry in the United States.

PARTICIPANTS

348 996 adult patients (≥18 years) with an index in-hospital cardiac arrest who received cardiopulmonary resuscitation from 2000 through 2021.

MAIN OUTCOME MEASURES

Survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a cerebral performance category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Time dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome if patients pending the first return of spontaneous circulation at each minute received further cardiopulmonary resuscitation beyond the time point were estimated, assuming that all decisions on termination of resuscitation were accurate (that is, all patients with termination of resuscitation would have invariably failed to survive if cardiopulmonary resuscitation had continued for a longer period of time).

RESULTS

Among 348 996 included patients, 233 551 (66.9%) achieved return of spontaneous circulation with a median interval of 7 (interquartile range 3-13) minutes between start of chest compressions and first return of spontaneous circulation, whereas 115 445 (33.1%) patients did not achieve return of spontaneous circulation with a median interval of 20 (14-30) minutes between start of chest compressions and termination of resuscitation. 78 799 (22.6%) patients survived to hospital discharge. The time dependent probabilities of survival and favorable functional outcome among patients pending return of spontaneous circulation at one minute's duration of cardiopulmonary resuscitation were 22.0% (75 645/343 866) and 15.1% (49 769/328 771), respectively. The probabilities decreased over time and were <1% for survival at 39 minutes and <1% for favorable functional outcome at 32 minutes' duration of cardiopulmonary resuscitation.

CONCLUSIONS

This analysis of a large multicenter registry of in-hospital cardiac arrest quantified the time dependent probabilities of patients' outcomes in each minute of duration of cardiopulmonary resuscitation. The findings provide resuscitation teams, patients, and their surrogates with insights into the likelihood of favorable outcomes if patients pending the first return of spontaneous circulation continue to receive further cardiopulmonary resuscitation.

The effect of standalone audio-visual feedback devices on the quality of chest compressions during laypersons' cardiopulmonary resuscitation training: a systematic review and meta-analysis

AIMS

Individual studies that investigated the effect of standalone audio-visual feedback (AVF) devices during laypersons' cardiopulmonary resuscitation (CPR) training have yielded conflicting results. This review aimed to evaluate the effect of standalone AVF devices on the quality of chest compressions during laypersons' CPR training.

METHOD AND RESULT

Randomized controlled trials of simulation studies recruiting participants without actual patient CPR experience were included. The intervention evaluated was the quality of chest compressions with standalone AVF devices vs. without AVF devices. Databases, such as PubMed, Cochrane Central, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science, and PsycINFO, were searched from January 2010 to January 2022. The risk of bias was assessed using the Cochrane risk of bias tool. A meta-analysis alongside a narrative synthesis was used for examining the effect of standalone AVF devices.Sixteen studies were selected for this systematic review. A meta-analysis revealed an increased compression depth of 2.22 mm [95% CI (Confidence Interval), 0.88-3.55, P = 0.001] when participants performed CPR using the feedback devices. Besides, AVF devices enabled laypersons to deliver compression rates closer to the recommended range of 100-120 per min. No improvement was noted in chest recoil and hand positioning when participants used standalone AVF devices.

CONCLUSION

The quality of the included studies was variable, and different standalone AVF devices were used. Standalone AVF devices were instrumental in guiding laypersons to deliver deeper compressions without compromising the quality of compression rates. However, the devices did not improve the quality of chest recoil and placement of the hands.

REGISTRATION

PROSPERO: CRD42020205754.

Prioritizing intervention preferences to potentially reduce caregiver burden in racially and ethnically diverse close family members of cardiac arrest survivors

AIM

Close family members of cardiac arrest patients who survive to hospital discharge have elevated levels of psychological distress and caregiver burden. We assessed their preferences toward needs during hospitalization and beyond to inform intervention development.

METHODS

Through an online survey developed by a multidisciplinary team of researchers, clinicians, cardiac arrest survivors, and families, adult close family members recruited through advocacy organizations ranked top choice among 8 unique interventions addressing either information-based needs (n = 4) or well-being needs (n = 4). Logistic Regression analysis was conducted to assess the associations of family members' attributes, caregiving characteristics, and survivors' hospitalization factors with two intervention groups.

RESULTS

Of 657 responses received, ranking data of 550 close family members (59% between 18-40 years of age, 65% female, 51% of minority race/ethnicity, 53% partners, provided a median of 8 hours of caregiving, for a median of 4.5 months) were analyzed. Information needs were the more commonly preferred intervention group (63%; n = 347), with education on the potential recovery of survivors ranking first (28%; n = 149). In a multivariate model, family members age >40 years, families witnessing the cardiac arrest, assuming the caregiver role either during hospitalization or within one month of hospital discharge, and discharging directly to home were significantly associated with prioritizing information needs over well-being needs, after adjusting for sex, race, intensity, and duration of caregiving.

CONCLUSIONS

Interventions focusing on information needs are among the top priorities for families of cardiac arrest survivors. Prospective studies testing these hypotheses-generating findings are needed to inform further intervention development.

Peri-operative cardiac arrest: management and outcomes of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest in the UK, a topic of importance to patients, anaesthetists and surgeons. We report the results of the 12-month registry phase, from 16 June 2021 to 15 June 2022, focusing on management and outcomes. Among 881 cases of peri-operative cardiac arrest, the initial rhythm was non-shockable in 723 (82%) cases, most commonly pulseless electrical activity. There were 665 (75%) patients who survived the initial event and 384 (52%) who survived to hospital discharge. A favourable functional outcome (based on modified Rankin Scale score) was reported for 249 (88%) survivors. Outcomes varied according to arrest rhythm. The highest rates of survival were seen for bradycardic cardiac arrests with 111 (86%) patients surviving the initial event and 77 (60%) patients surviving the hospital episode. The lowest survival rates were seen for patients with pulseless electrical activity, with 312 (68%) surviving the initial episode and 156 (34%) surviving to hospital discharge. Survival to hospital discharge was worse in patients at the extremes of age with 76 (40%) patients aged > 75 y and 9 (45%) neonates surviving. Hospital survival was also associated with surgical priority, with 175 (88%) elective patients and 176 (37%) non-elective patients surviving to discharge. Outcomes varied with the cause of cardiac arrest, with lower initial survival rates for pulmonary embolism (5, 31%) and bone cement implantation syndrome (9, 45%), and hospital survival of < 25% for pulmonary embolism (0), septic shock (13, 24%) and significant hyperkalaemia (1, 20%). Overall care was rated good in 464 (53%) cases, and 18 (2%) cases had overall care rated as poor. Poor care elements were present in a further 245 (28%) cases. Care before cardiac arrest was the phase most frequently rated as poor (92, 11%) with elements of poor care identified in another 186 (21%) cases. These results describe the management and outcomes of peri-operative cardiac arrest in UK practice for the first time.

Explaining the Unexplained: A Practical Approach to Investigating the Cardiac Arrest Survivor

Sudden cardiac arrest (SCA) is a common cause of death. The majority of SCA is caused by ventricular arrhythmia due to underlying CHD. Aborted SCA with no apparent diagnosis after initial assessment with ECG, echocardiography and coronary assessment is referred to as unexplained cardiac arrest (UCA). Systematic evaluation of such patients may reveal a specific diagnosis in up to half of patients before a diagnosis of idiopathic VF is assigned. Specific diagnoses include inherited cardiac conditions, such as latent cardiomyopathies or inherited primary electrical disease. Identifying the cause of UCA is therefore not only critical for appropriate management of the SCA survivors to prevent recurrence, but also for their family members who may be at risk of the same condition. This review provides a tiered, systematic approach for the investigation of UCA.

Long-Term Quality of Life After Out-of-Hospital Cardiac Arrest

Importance

Allocating resources to increase survival after cardiac arrest requires survivors to have a good quality of life, but long-term data are lacking.

Objective

To determine the quality of life of survivors of out-of-hospital cardiac arrest from 2001 to 2019.

Design, Setting, and Participants

This survey study used the EuroQol Health Questionnaire, 12-Item Short Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) to assess the health-related quality of life of all adult survivors of out-of-hospital cardiac arrest included in the Danish Cardiac Arrest Registry between June 1, 2001, and August 31, 2019, who were alive in October 2020 (follow-up periods, 0-1, >1-2, >2-4, >4-6, >6-8, >8-10, >10-15, and >15-20 years since arrest). The survey was conducted from October 1, 2020, through May 31, 2021.

Exposure

All patients who experienced an out-of-hospital cardiac arrest.

Main Outcome and Measures

Self-reported health was measured using the EuroQol Health Questionnaire index (EQ index) score and EQ visual analog scale. Physical and mental health were measured using the SF-12, and anxiety and depression were measured using the HADS. Descriptive statistics were used for the analysis.

Results

Of 4545 survivors, 2552 (56.1%) completed the survey, with a median follow-up since their event of 5.5 years (IQR, 2.9-8.9 years). Age was comparable between responders and nonresponders (median [IQR], 67 [58-74] years vs 68 [56-78] years), and 2075 responders (81.3%) were men and 477 (18.7%) women (vs 1473 male [73.9%] and 520 female [26.1%] nonresponders). For the shortest follow-up (0-1 year) and longest follow-up (>15-20 years) groups, the median EQ index score was 0.9 (IQR, 0.7-1.0) and 0.9 (0.8-1.0), respectively. For all responders, the mean (SD) SF-12 physical health score was 43.3 (12.3) and SF-12 mental health score, 52.9 (8.3). All 3 scores were comparable to a general Danish reference population. Based on HADS scores, a low risk for anxiety was reported by 73.0% (54 of 74) of 0- to 1-year survivors vs 89.3% (100 of 112) of greater than 15- to 20-year survivors; for symptoms of depression, these proportions were 79.7% (n = 59) and 87.5% (n = 98), respectively. Health-related quality of life was similar in survivor groups across all follow-up periods.

Conclusions and Relevance

Among this survey study's responders, who comprised more than 50% of survivors of out-of-hospital cardiac arrest in Denmark, long-term health-related quality of life up to 20 years after their event was consistently high and comparable to that of the general population. These findings support resource allocation and efforts targeted to increasing survival after out-of-hospital cardiac arrest.

Reduced mobility is associated with adverse outcomes after in-hospital cardiac arrest

OBJECTIVE

In-hospital cardiac arrest is a critical medical emergency. Knowledge of prognostic factors could assist in cardiopulmonary resuscitation decision-making. Frailty and functional status are emerging risk factors and may play a role in prognostication. The objective was to evaluate the association between reduced mobility and in-hospital cardiac arrest outcomes.

METHODS

This retrospective cohort study included patients over 18 years of age with in-hospital cardiac arrest in Botucatu, Brazil, from April 2018 to December 2021. Exclusion criteria were patients with a do-not-resuscitate order or patients with recurrent in-hospital cardiac arrest. Reduced mobility was defined as the need for a bed bath 48 h before in-hospital cardiac arrest. The outcomes of no return of spontaneous circulation and in-hospital mortality were evaluated.

RESULTS

A total of 387 patients were included in the analysis. The mean age was 65.4±14.8 years; 53.7% were males and 75.4% had reduced mobility. Among the evaluated outcomes, the no return of spontaneous circulation rate was 57.1%, and in-hospital mortality was 94.3%. In multivariate analysis, reduced mobility was associated with no return of spontaneous circulation when adjusted by age, gender, initial shockable rhythm, duration of cardiopulmonary resuscitation, and epinephrine administration. However, in multiple logistic regression, there was no association between reduced mobility and in-hospital mortality.

CONCLUSION

In patients with in-hospital cardiac arrest, reduced mobility is associated with no return of spontaneous circulation. However, there is no relation to in-hospital mortality.

Emergency Medicine Perspectives: The Importance of Bystanders and Their Impact on On-Site Resuscitation Measures and Immediate Outcomes of Out-of-Hospital Cardiac Arrest

INTRODUCTION

Out-of-hospital cardiac arrests (OHCAs) represent critical medical emergencies in which timely interventions can make a significant difference in patient outcomes. Despite their importance, the role of on-scene witnesses during such events remains relatively unexplored.

AIM OF THE STUDY

This research seeks to shed light on the influence of witnesses, especially family members, during OHCAs and the effect of their interventions, or the absence thereof, on outcomes. Drawing from existing literature, our working hypothesis suggests that the presence of a witness, particularly one who is knowledgeable about CPR, can increase the likelihood of obtaining the return of spontaneous circulation (ROSC), potentially enhancing overall survival rates.

METHODS

Using a retrospective analytical method, we thoroughly reviewed medical records from the Lublin Voivodeship between 2014-2017. Out of 5111 events identified using ICD-10 diagnosis codes and ICD-9 medical procedure codes, 4361 cases specifically related to sudden cardiac arrest were chosen. Concurrently, 750 events were excluded based on predefined criteria.

RESULTS

Both basic and advanced EMS teams showed higher rates of CPR initiation and an increased likelihood of obtaining ROSC. Notably, the presence of a trained EMS professional as a witness significantly increased the chances of CPR initiation. The presenting rhythms most often detected were ventricular tachycardia (VT) and ventricular fibrillation (VF). Different urgency codes were directly linked to varying ROSC outcomes. When witnesses, especially family members, began chest compressions, the use of amiodarone was notably higher. A significant finding was that 46.85% of OHCA patients died without witnesses, while family members were present in 23.87% of cases. Actions taken by witnesses, especially chest compressions, generally extended the overall duration of patient care.

CONCLUSION

The crucial influence of witnesses, particularly family members, on OHCA outcomes is evident. Therefore, it is essential to increase public awareness of CPR techniques and rapid intervention strategies to improve outcomes in emergency situations.

The relationship between mindfulness and enduring somatic threat severity in long-term cardiac arrest survivors

BACKGROUND

Cardiac arrest (CA) survivors experience continuous exposures to potential traumas though chronic cognitive, physical and emotional sequelae and enduring somatic threats (ESTs) (i.e., recurring somatic traumatic reminders of the event). Sources of ESTs can include the daily sensation of an implantable cardioverter defibrillator (ICD), ICD-delivered shocks, pain from rescue compressions, fatigue, weakness, and changes in physical function. Mindfulness, defined as non-judgmental present-moment awareness, is a teachable skill that might help CA survivors cope with ESTs. Here we describe the severity of ESTs in a sample of long-term CA survivors and explore the cross-sectional relationship between mindfulness and severity of ESTs.

METHODS

We analyzed survey data of long-term CA survivors who were members of the Sudden Cardiac Arrest Foundation (collected 10-11/2020). We assessed ESTs using 4 cardiac threat items from the Anxiety Sensitivity Index-revised (items range from 0 "very little" to 4 "very much") which we summed to create a score reflecting total EST burden (range 0-16). We assessed mindfulness using the Cognitive and Affective Mindfulness Scale-Revised. First, we summarized the distribution of EST scores. Second, we used linear regression to describe the relationship between mindfulness and EST severity adjusting for age, gender, time since arrest, COVID-19-related stress, and loss of income due to COVID.

RESULTS

We included 145 CA survivors (mean age: 51 years, 52% male, 93.8% white, mean time since arrest: 6 years, 24.1% scored in the upper quarter of EST severity). Greater mindfulness (β: -30, p = 0.002), older age (β: -0.30, p = 0.01) and longer time since CA (β: -0.23, p = 0.005) were associated with lower EST severity. Male sex was also associated with greater EST severity (β: 0.21, p = 0.009).

CONCLUSION

ESTs are common among CA survivors. Mindfulness may be a protective skill that CA survivors use to cope with ESTs. Future psychosocial interventions for the CA population should consider using mindfulness as a core skill to reduce ESTs.

Disrupted Lives: Caregivers' Experiences of In-Hospital Cardiac Arrest Survivors' Recovery 5 Years Later

Background Survivors of in-hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of "disruption" was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver-patient relationship, and (3) disruption in caregiver's well-being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress-relieving activities, most indicated additional help and resources were still needed.

A Primer on Pacemakers and Defibrillators for Nurses

Although the concepts of pacing have been around for more than half a century, technological advances in cardiac implantable electronic devices (CIEDs) have changed the landscape for patients in need of pacing support or sudden death prevention. Nurses encounter patients with CIEDs in all aspects of the health care setting. Because exciting CIED therapies are on the horizon, nurses must stay up-to-date to promote optimal outcomes for CIED patients. This essential guide provides nurses with a comprehensive overview of the principles of pacing and implantable cardioverter defibrillators (ICDs), as well as innovative technologies such as leadless cardiac pacemakers and subcutaneous ICDs.

Cerebral hemodynamics after cardiac arrest: implications for clinical management

Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.