Long-term survival and residual hazard after in-hospital cardiac arrest

One-Year Follow-Up of Patients Admitted for Emergency Coronary Angiography after Resuscitated Cardiac Arrest

(1) Background: Despite the improvement of the in-hospital survival rate after aborted sudden cardiac death (SCD), cerebral anoxia may have severe neurologic consequences and may impair long-term outcome and quality of life of surviving patients. The aim of this study was to assess neurological outcomes at one year after resuscitated cardiac arrest; (2) Methods: This prospective, observational, and multicentre study included patients >18 yo admitted in the catheterisation laboratory for coronary angiography after aborted SCD between 1 May 2018 and 31 May 2020. Only patients who were discharged alive from hospital were evaluated. The primary endpoint was survival without neurological sequelae at one-year follow-up defined by a cerebral performance category (CPC) of one or two. Secondary end points included all-cause mortality, New York Heart Association (NYHA) functional class, neurologic evaluation at discharge, three-month and one-year follow-up using the CPC scale, and quality of life at 1 year using the Quality of Life after Brain Injury (QOLIBRI) questionnaire; (3) Results: Among 143 patients admitted for SCD within the study period, 61 (42.7%) were discharged alive from hospital, among whom 55 (90.1%) completed the one-year follow-up. No flow and low flow times were 1.9 ± 2.4 min and 16.5 ± 10.4 min, respectively. For 93.4% of the surviving patients, an initial shockable rhythm (n = 57) was observed and acute coronary syndrome was diagnosed in 75.4% of them (n = 46). At 1 year, survival rate without neurologic sequelae was 87.2% (n = 48). Patients with poor outcome were older (69.3 vs. 57.4 yo; p = 0.04) and had lower body mass index (22.4 vs. 26.7; p = 0.013) and a lower initial Left Ventricle Ejection Fraction (LVEF) (32.1% vs. 40.3%; p = 0.046). During follow-up, neurological status improved in 36.8% of patients presenting sequelae at discharge, and overall quality of life was satisfying for 66.7% of patients according to the QOLIBRI questionnaire; (4) Conclusions: Among patients admitted to the catheterisation laboratory for aborted SCD, mainly related to Acute Coronary Syndrom (ACS), less than a half of them were alive at discharge. However, the one-year survival rate without neurological sequelae was high and overall quality of life was good.

Effect of Vasopressin and Methylprednisolone vs. Placebo on Long-Term Outcomes in Patients with In-Hospital Cardiac Arrest A Randomized Clinical Trial

OBJECTIVE

The primary results from the Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial have previously been reported. The objective of the current manuscript is to report long-term outcomes.

METHODS

The VAM-IHCA trial was a multicenter, randomized, double-blind, placebo-controlled trial conducted at ten hospitals in Denmark. Adult patients (age ≥ 18 years) were eligible for the trial if they had an in-hospital cardiac arrest and received at least one dose of epinephrine during resuscitation. The trial drugs consisted of 40 mg methylprednisolone (Solu-Medrol®, Pfizer) and 20 IU of vasopressin (Empressin®, Amomed Pharma GmbH) given as soon as possible after the first dose of epinephrine. This manuscript report outcomes at 6 months and 1 year including survival, survival with favorable neurological outcome, and health-related quality of life.

RESULTS

501 patients were included in the analysis. At 1 year, 15 patients (6.3%) in the intervention group and 22 patients (8.3%) in the placebo group were alive corresponding to a risk ratio of 0.76 (95% CI, 0.41-1.41). A favorable neurologic outcome at 1 year, based on the Cerebral Performance Category score, was observed in 14 patients (5.9%) in the intervention group and 20 patients (7.6%) in the placebo group (risk ratio, 0.78 [95% CI, 0.41-1.49]. No differences existed between groups for favorable neurological outcome and health-related quality of life at either 6 months or 1 year.

CONCLUSIONS

Administration of vasopressin and methylprednisolone, compared with placebo, in patients with in-hospital cardiac arrest did not improve long-term outcomes in this trial.

Long-term survival following in-hospital cardiac arrest: A matched cohort study

BACKGROUND

Each year, 200,000 patients undergo an in-hospital cardiac arrest (IHCA), with approximately 15-20% surviving to discharge. Little is known, however, about the long-term prognosis of these patients after discharge. Previous efforts to describe out-of-hospital survival of IHCA patients have been limited by small sample sizes and narrow patient populations

METHODS

A single institution matched cohort study was undertaken to describe mortality following IHCA. Patients surviving to discharge following an IHCA between 2008 and 2010 were matched on age, sex, race and hospital admission criteria with non-IHCA hospital controls and follow-up between 9 and 45 months. Kaplan-Meier curves and Cox PH models assessed differences in survival.

RESULTS

Of the 1262 IHCAs, 20% survived to hospital discharge. Of those discharged, survival at 1 year post-discharge was 59% for IHCA patients and 82% for controls (p<0.0001). Hazard ratios (IHCA vs. controls) for mortality were greatest within the 90 days following discharge (HR=2.90, p<0.0001) and decreased linearly thereafter, with those surviving to one year post-discharge having an HR for mortality below 1.0. Survival after discharge varied amongst IHCA survivors. When grouped by discharge destination, out of hospital survival varied; in fact, IHCA patients discharged home without services demonstrated no survival difference compared to their non-IHCA controls (HR 1.10, p=0.72). IHCA patients discharged to long-term hospital care or hospice, however, had a significantly higher mortality compared to matched controls (HR 3.91 and 20.3, respectively; p<0.0001).

CONCLUSION

Among IHCA patients who survive to hospital discharge, the highest risk of death is within the first 90 days after discharge. Additionally, IHCA survivors overall have increased long-term mortality vs.

CONTROLS

Survival rates were varied widely with different discharge destinations, and those discharged to home, skilled nursing facilities or to rehabilitation services had survival rates no different than controls. Thus, increased mortality was primarily driven by patients discharged to long-term care or hospice.

Hospital costs of out-of-hospital cardiac arrest patients treated in intensive care; a single centre evaluation using the national tariff-based system

OBJECTIVES

There is a scarcity of literature reporting hospital costs for treating out of hospital cardiac arrest (OOHCA) survivors, especially within the UK. This is essential for assessment of cost-effectiveness of interventions necessary to allow just allocation of resources within the National Health Service. We set out primarily to calculate costs stratified against hospital survival and neurological outcomes. Secondarily, we estimated cost effectiveness based on estimates of survival and utility from previous studies to calculate costs per quality adjusted life year (QALY).

SETTING

We performed a single centre (London) retrospective review of in-hospital costs of patients admitted to the intensive care unit (ICU) following return of spontaneous circulation (ROSC) after OOHCA over 18 months from January 2011 (following widespread introduction of targeted temperature management and primary percutaneous intervention).

PARTICIPANTS

Of 69 successive patients admitted over an 18-month period, survival and cerebral performance category (CPC) outcomes were obtained from review of databases and clinical notes. The Trust finance department supplied ICU and hospital costs using the Payment by Results UK system.

RESULTS

Of those patients with ROSC admitted to ICU, survival to hospital discharge (any CPC) was 33/69 (48%) with 26/33 survivors in CPC 1-2 at hospital discharge. Cost per survivor to hospital discharge (including total cost of survivors and non-survivors) was £50,000, cost per CPC 1-2 survivor was £65,000. Cost and length of stay of CPC 1-2 patients was considerably lower than CPC 3-4 patients. The majority of the costs (69%) related to intensive care. Estimated cost per CPC 1-2 survivor per QALY was £16,000.

CONCLUSIONS

The costs of in-hospital patient care for ICU admissions following ROSC after OOHCA are considerable but within a reasonable threshold when assessed from a QALY perspective.

Cerebral performance category at hospital discharge predicts long-term survival of cardiac arrest survivors receiving targeted temperature management*

OBJECTIVE

Despite recent advancements in post-cardiac arrest resuscitation, the optimal measurement of postarrest outcome remains unclear. We hypothesized that Cerebral Performance Category score can predict the long-term outcome of postarrest survivors who received targeted temperature management during their postarrest hospital care.

DESIGN

Retrospective chart review.

SETTING

Two academic medical centers from May 2005 to December 2012.

PATIENTS

The medical records of 2,417 out-of-hospital and in-hospital patients post cardiac arrest were reviewed to identify 140 of 582 survivors who received targeted temperature management.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The Cerebral Performance Category scores at hospital discharge were determined by three independent abstractors. The 1-month, 6-month, and 12-month survival of these patients was determined by reviewing hospital records and querying the Social Security Death Index and by follow-up telephone calls. The association of unadjusted long-term survival and adjusted survival with Cerebral Performance Category was calculated. Of the 2,417 patients who were identified to have undergone cardiac arrest, 24.1% (582/2,417) were successfully resuscitated, of whom 24.1% (140/582) received postarrest targeted temperature management. Overall, 42.9% of patients (60/140) were discharged with Cerebral Performance Category 1, 27.1% (38/140) with Cerebral Performance Category 2, 18.6% (26/140) with Cerebral Performance Category 3, and 11.4% (16/140) with Cerebral Performance Category 4. Cerebral Performance Category 1 survivors had the highest long-term survival followed by Cerebral Performance Categories 2 and 3, with Cerebral Performance Category 4 having the lowest long-term survival (p < 0.001, log-rank test). We found that Cerebral Performance Category 3 (hazard ratio = 3.62, p < 0.05) and Cerebral Performance Category 4 (hazard ratio = 12.73, p < 0.001) remained associated with worse survival after adjusting for age, gender, race, shockable rhythm, time to targeted temperature management initiation, total duration of resuscitation, withdrawal of care, and location of arrest.

CONCLUSION

Patients with different Cerebral Performance Category scores at discharge have significantly different survival trajectories. Favorable Cerebral Performance Category at hospital discharge predicts better long-term outcomes of survivors of cardiac arrest who received targeted temperature management than those with less favorable Cerebral Performance Category scores.

Long-term outcomes in elderly survivors of in-hospital cardiac arrest

BACKGROUND

Little is known about the long-term outcomes in elderly survivors of in-hospital cardiac arrest. We determined rates of long-term survival and readmission among survivors of in-hospital cardiac arrest and examined whether these outcomes differed according to demographic characteristics and neurologic status at discharge.

METHODS

We linked data from a national registry of inpatient cardiac arrests with Medicare files and identified 6972 adults, 65 years of age or older, who were discharged from the hospital after surviving an in-hospital cardiac arrest between 2000 and 2008. Predictors of 1-year survival and of readmission to the hospital were examined.

RESULTS

One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ≥85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P=0.03), and among black patients than among white patients (52.5% vs. 60.4%, P=0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P=0.35).

CONCLUSIONS

Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. Survival and readmission rates differed according to the demographic characteristics of the patients and neurologic status at discharge. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.).

Family-Witnessed Resuscitation: Perceptions of Nurses and Doctors Working in an Australian Emergency Department

Inconsistencies abound in the literature regarding staff attitudes and perceptions toward family-witnessed resuscitation. Our study builds on previous research by using a validated tool to investigate emergency department staff perceptions of family-witnessed resuscitation. A cross-sectional survey was distributed to 221 emergency department doctors' and nurses'. We found few differences between doctors and nurses perceptions toward family-witnessed resuscitation. Both nurses and doctors who held a specialty certification, who were more highly qualified, who had more experience with family presence during resuscitation, and who had a personal preference for having family members present during their own resuscitation perceived more benefits and fewer risks, as well as more confidence in their ability to manage these events. However, nurses more than doctors want patients to provide advanced directives for family presence. The findings will enable clinicians, educators, and hospital management to provide better support to all stakeholders through these events.

Design and Development of a Cardiopulmonary Resuscitation Mattress

This study introduces the design and construction of a mattress insert to produce more effective cardiopulmonary resuscitation (CPR). The mattress insert deflates, making the mattress insert a rigid surface. Using a device that administers a constant compression depth onto a manikin, we were able to show that our mattress insert more effectively directed the compressive force to the manikin compared to the current practice of using a headboard on top of a mattress. The mattress insert produced a statistically significant increase in the compression efficiency when compared to the current practice of using the headboard (81% vs. 53%). Because the mattress insert starts deflating immediately after the vacuum is turned on, 1 person is needed to initiate chest compressions. Compression begins while the mattress deflates. Running compression tests at incremental time periods, we found that our design reaches and surpasses the compression efficiency when using a headboard in 10 seconds.

Long-term outcome of bystander-witnessed out-of-hospital cardiac arrest in Estonia from 1999 to 2002

OBJECTIVE

To assess the long-term outcome of bystander-witnessed out-of-hospital cardiac arrest victims in Estonia by using the survival rate and quality of life assay.

METHODS

All resuscitation attempts made from 01.01.1999 to 31.12.2002 in Estonia were retrospectively screened for bystander-witnessed adult out-of-hospital cardiac arrests of cardiac origin. The patients who survived hospital discharge were included in the study. Their long-term survival data were retrieved from Estonian Population Registry on March 15, 2004. Quality of life was assessed by RAND-36 questionnaire. Comparisons were made with population norms, and patients suffering from myocardial infarction or angina pectoris.

RESULTS

854 bystander-witnessed resuscitation attempts were made in four years. 91 patients (10.7%) survived to hospital discharge. Their one-year survival rate was 77.0% and five-year survival rate 64.3%. 44 patients responded to quality of life questionnaire, sent 16-62 months after out-of-hospital cardiac arrest (response rate 77.2%). Respondents rated their quality of life significantly worse than general population in five out of eight categories. The out-of-hospital cardiac arrest survivors with known cardiovascular disease in history (n=30) had quality of life similar to patients suffering from myocardial infarction or angina pectoris who had not required resuscitation.

CONCLUSION

In Estonia majority of bystander-witnessed out-of-hospital cardiac arrest victims who survive hospital discharge are alive one and also more than three years after resuscitation. Their quality of life is worse than that of general population.

Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest

Introduction

The purpose of this study was to investigate the costs and health status outcomes of intensive care unit (ICU) admission in patients who present after sudden cardiac arrest with in-hospital or out-of-hospital cardiopulmonary resuscitation.

Methods

Five-year survival, health-related quality of life (Medical Outcome Survey Short Form-36 questionnaire, SF-36), ICU costs, hospital costs and post-hospital health care costs per survivor, costs per life year gained, and costs per quality-adjusted life year gained of patients admitted to a single ICU were assessed.

Results

One hundred ten of 354 patients (31%) were alive 5 years after hospital discharge. The mean health status index of 5-year survivors was 0.77 (95% confidence interval 0.70 to 0.85). Women rated their health-related quality of life significantly better than men did (0.87 versus 0.74; P < 0.05). Costs per hospital discharge survivor were 49,952 €. Including the costs of post-hospital discharge health care incurred during their remaining life span, the total costs per life year gained were 10,107 €. Considering 5-year survivors only, the costs per life year gained were calculated as 9,816 € or 14,487 € per quality-adjusted life year gained. Including seven patients with severe neurological sequelae, costs per life year gained in 5-year survivors increased by 18% to 11,566 €.

Conclusion

Patients who leave the hospital following cardiac arrest without severe neurological disabilities may expect a reasonable quality of life compared with age- and gender-matched controls. Quality-adjusted costs for this patient group appear to be within ranges considered reasonable for other groups of patients.

Do patient characteristics or factors at resuscitation influence long-term outcome in patients surviving to be discharged following in-hospital cardiac arrest?

INTRODUCTION

Few studies have focused on factors influencing long-term outcome following in-hospital cardiac arrest. The present study assesses whether long-term outcome is influenced by difference in patient factors or factors at resuscitation.

METHODS

An analysis of cardiac arrest data collected from one Swedish tertiary hospital and from five Finnish secondary hospitals supplemented with data on 1 year survival. Multiple logistic regression analysis was used to identify factors associated with survival at 12 months.

RESULTS

A total of 441 patients survived to hospital discharge following in-hospital cardiac arrest and 359 (80%) were alive at 12 months. Factors independently associated with survival [odds ratio (OR) >1 indicates increased survival and <1 decreased survival] at 12 months were; age [OR 0.95, 95% confidence interval (CI) 0.93-0.98], renal disease (OR 0.3, CI 0.1-0.9), good functional status at discharge (OR 4.9, CI 1.3-18.9), arrest occurring at (compared with arrests on general wards) emergency wards (OR 4.7, CI 1.4-15.3), cardiac care unit (OR 2.8, CI 1.2-6.4), intensive care unit (OR 2.4, CI 1.1-5.7), ward for thoracic surgery (OR 10.2, CI 2.6-40.1) and unit for interventional radiology (OR 13.3, CI 3.4-52.0). There was no difference in initial rhythm, delay to defibrillation or delay to return of spontaneous circulation between survivors and nonsurvivors.

CONCLUSION

Several patient factors, mainly age, functional status and co-morbid disease, influence long-term survival following cardiac arrest in hospital. The location where the arrest occurred also influences survival, but initial rhythm, delay to defibrillation and to return of spontaneous circulation do not.

Increasing compression depth during manikin CPR using a simple backboard

BACKGROUND

The quality of external chest compressions (ECC) is influenced by the surface supporting the patient. The aim of this study was to compare chest compression depth with and without a rigid backboard. The authors hypothesized that the presence of a backboard would result in an increased depth of chest compressions.

METHODS

A randomized, double-blinded, cross-over trial. We simulated in-hospital cardiac arrest using a resuscitation manikin placed in a standard hospital bed. In total, 23 hospital orderlies were randomly assigned to perform ECC for 2 min on two identical ResusciAnne manikins, under one of which a rigid backboard had been placed. Data were recorded using the Laerdal PC-Skill Reporting System.

RESULTS

Mean chest compression depth increased from 43 to 48 mm (P < 0.0001) when a backboard was present (mean difference 5 mm, 95% CI 3.6-7.5 mm, SD 4.6). There was a significant increase in mean proportion of compressions >40 mm when using a backboard Mean 92% vs. 69%, P= 0.0007). No difference was found between the two groups in the following variables: duty cycle, compression rate, mean proportion of compressions of correct depth (40-50 mm) or proportion of compressions with incomplete release.

CONCLUSIONS

Applying a backboard significantly increases depth of chest compressions during cardiopulmonary resuscitation when performed on a manikin model.

Clinical review: beyond immediate survival from resuscitation-long-term outcome considerations after cardiac arrest

A substantial body of literature concerning resuscitation from cardiac arrest now exists. However, not surprisingly, the greater part concerns the cardiac arrest event itself and optimising survival and outcome at relatively proximal time points. The aim of this review is to present the evidence base for interventions and therapeutic strategies that might be offered to patients surviving the immediate aftermath of a cardiac arrest, excluding components of resuscitation itself that may lead to benefits in long-term survival. In addition, this paper reviews the data on long-term impact, physical and neuropsychological, on patients and their families, revealing a burden that is often underestimated and underappreciated. As greater numbers of patients survive cardiac arrest, outcome measures more sophisticated than simple survival are required.