Determinants of Long-Term Neurological Recovery Patterns Relative to Hospital Discharge Among Cardiac Arrest Survivors

Association of hyperosmolar therapy with cerebral oxygen extraction after cardiac arrest

BACKGROUND

Elevated jugular bulb venous oxygen saturation (SjvO2) after cardiac arrest may be due to diffusion-limited oxygen extraction secondary to perivascular edema. Treatment with hyperosmolar solution (HTS) may decrease this edema and thus the barrier to oxygen diffusion. Alternatively, SjvO2 may rise when cerebral metabolic rate declines due to irreversible cellular injury, which would not be affected by HTS. Electroencephalography (EEG) may differentiate between these etiologies of elevated SjvO2. We hypothesized SjvO2 would be lower after treatment with HTS and EEG could identify treatment responders.

METHODS

We conducted a retrospective observational cohort study including comatose survivors of cardiac arrest who had at least one elevated SjvO2 (>75 %) and were EEG-monitored. We quantified the change in consecutive SjvO2 values within a sample pair using a multivariable mixed-effects regression, treating HTS as a fixed effect, adjusting for mean arterial pressure, partial pressure of arterial oxygen, and partial pressure of carbon dioxide. We classified pretreatment EEG patterns as benign or indicative of potential metabolic failure and tested for an interaction of EEG pattern with HTS.

RESULTS

Our primary adjusted analysis showed an independent association of HTS treatment with change in SjvO2 (β -2.2; 95% confidence interval [CI], -4.0 to -0.3%). In our interaction model, the effect of treatment differed by EEG pattern (β for interaction term -10.9%, 95% CI -17.9 to -3.9%). HTS was associated with a significant change in SjvO2 among those with benign pre-treatment EEG patterns (-12.4%, 95% CI -18.4 to -6.4%) but was not associated with a change in SjvO2 in those with ominous pre-treatment EEG patterns (-1.6%, 95% CI -3.6 to 0.4%).

CONCLUSIONS

HTS was independently associated with decreased SjvO2 in patients resuscitated from cardiac arrest, and this effect was limited to patients with benign pretreatment EEG patterns. Our results suggest diffusion-limited oxygen extraction secondary to modifiable perivascular edema as the etiology of elevated SjvO2, and EEG pattern may be useful to identify treatment responders.

Prospective evaluation of the relationship between cognition and recovery outcomes after cardiac arrest

PURPOSE

Cognitive function is often impaired for cardiac arrest (CA) survivors due to hypoxic-ischemic brain injury. Whether cognitive impairment at hospital discharge is associated with recovery defined as functional status and fatigue measured at 1-month post-discharge is not known.

METHODS

Consecutive CA patients admitted at an academic center (May 14, 2021-June 23, 2023) were assessed for cognitive impairment (modified Telephone Interview for Cognitive Status, TICS-m < 33) and depressive symptoms (8-item Patient Health Questionnaire) at hospital discharge. Poor functional status (primary outcome; modified Rankin Scale, mRS > 3) and fatigue severity (patient-reported outcome; Modified Fatigue Impact Scale) were assessed 1-month post-discharge. Hierarchical regressions tested associations of cognitive function with outcomes.

RESULTS

Of 112 participants (mean age 54.4 ± 14.8; 38% female; 43% White race, 20% Black race, 29% Hispanic ethnicity) completing discharge TICS-m, 63 (56%) had indicated cognitive impairment, and 68 (61%) had poor 1-month functional outcome. Worse discharge cognitive function was independently associated with a higher risk of poor 1-month functional outcome (OR = 0.88, 95% CI [0.79, 0.98], p = 0.02) after adjusting for age, education, sex, race, ethnicity, length of hospital stay, comorbidities, and depressive symptoms. Fatigue severity lacked significant associations with cognitive function, but was associated with depressive symptoms (B = 1.03 [0.00, 2.05], p = 0.04).

CONCLUSION

Cognitive function at discharge after CA was significantly and independently associated with functional outcome 1 month after hospital discharge. Psychological distress contributed to fatigue severity. This highlights the need for screening and addressing cognitive and emotional problems pre-hospital discharge.

Barriers and Facilitators of Center-Based Cardiac Rehabilitation Utilization in South Asian Ethnic Minorities: A META-SYNTHESIS

AIM

The aim of this review was to synthesize literature on the perceptions of South Asian ethnic minorities of the barriers and facilitators to center-based, phase II cardiac rehabilitation (CR).

METHODS

A meta-synthesis approach was used, and findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was conducted from database inception dates to July 2022 using the following databases: MEDLINE, EMBASE, APA PsycINFO, Cochrane Database of Systematic Review, CINAHL, Scopus, and Web of Science. The inclusion criteria were studies that examined the barriers and/or facilitators of structured center-based CR among South Asian adult ethnic minorities. Critical appraisal of the included studies was conducted using the Mixed Methods Appraisal Tool. Findings were synthesized using a thematic synthesis approach.

RESULTS

Among the 7110 records initially retrieved only nine studies conducted in the United Kingdom or Canada met the inclusion criteria. More barriers than facilitators were studied and reported. Key barriers were the English language difficulty, fatalistic beliefs, previous bad interactions with and negative perception of health care professionals, transportation problems, work schedule conflict, safety issues, and long-distance CR centers. The facilitators included patient-preferred environment, presence of family members during exercise, family and friends support, and encouragement to change lifestyle and enroll in a CR program.

CONCLUSION

The review findings revealed that South Asian ethnic minorities encounter various barriers and facilitators to enroll and complete CR. The findings can inform researchers and clinicians in the development of interventions that are tailored to their cultural needs.

PRACTICE IMPLICATIONS

The findings can be valuable to health care professionals and policy makers in designing customized CR programs for South Asian minorities.

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.

Bayesian Outcome Prediction After Resuscitation From Cardiac Arrest

BACKGROUND AND OBJECTIVES

Postarrest prognostication research does not typically account for the sequential nature of real-life data acquisition and interpretation and reports nonintuitive estimates of uncertainty. Bayesian approaches offer advantages well suited to prognostication. We used Bayesian regression to explore the usefulness of sequential prognostic indicators in the context of prior knowledge and compared this with a guideline-concordant algorithm.

METHODS

We included patients hospitalized at a single center after cardiac arrest. We extracted prospective data and assumed these data accrued over time as in routine practice. We considered predictors demographic and arrest characteristics, initial and daily neurologic examination, laboratory results, therapeutic interventions, brain imaging, and EEG. We fit Bayesian hierarchical generalized linear multivariate models predicting discharge Cerebral Performance Category (CPC) 4 or 5 (poor outcomes) vs 1-3 including sequential clinical and prognostic data. We explored outcome posterior probability distributions (PPDs) for individual patients and overall. As a comparator, we applied the 2021 European Resuscitation Council and European Society of Intensive Care Medicine (ERC/ESICM) guidelines.

RESULTS

We included 2,692 patients of whom 864 (35%) were discharged with a CPC 1-3. Patients' outcome PPDs became narrow and shifted toward 0 or 1 as sequentially acquired information was added to models. These changes were largest after arrest characteristics and initial neurologic examination were included. Using information typically available at or before intensive care unit admission, sensitivity predicting poor outcome was 51% with a 0.6% false-positive rate. In our most comprehensive model, sensitivity for poor outcome prediction was 76% with 0.6% false-positive rate (FPR). The ERC/ESICM algorithm applied to 547 of 2,692 patients and yielded 36% sensitivity with 0% FPR.

DISCUSSION

Bayesian models offer advantages well suited to prognostication research. On balance, our findings support the view that in expert hands, accurate neurologic prognostication is possible in many cases before 72 hours postarrest. Although we caution against early withdrawal of life-sustaining therapies, rapid outcome prediction can inform clinical decision making and future clinical trials.

Sex-Based Differences in 30-Day Readmissions After Cardiac Arrest: Analysis of the Nationwide Readmissions Database

Background There are limited data on the sex-based differences in the outcome of readmission after cardiac arrest. Methods and Results Using the Nationwide Readmissions Database, we analyzed patients hospitalized with cardiac arrest between 2010 and 2015. Based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, we identified comorbidities, therapeutic interventions, and outcomes. Multivariable logistic regression was performed to assess the independent association between sex and outcomes. Of 835 894 patients, 44.4% (n=371 455) were women, of whom 80.7% presented with pulseless electrical activity (PEA)/asystole. Women primarily presented with PEA/asystole (80.7% versus 72.4%) and had a greater comorbidity burden than men, as assessed using the Elixhauser Comorbidity Score. Thirty-day readmission rates were higher in women than men in both PEA/asystole (20.8% versus 19.6%) and ventricular tachycardia/ventricular fibrillation arrests (19.4% versus 17.1%). Among ventricular tachycardia/ventricular fibrillation arrest survivors, women were more likely than men to be readmitted because of noncardiac causes, predominantly infectious, respiratory, and gastrointestinal illnesses. Among PEA/asystole survivors, women were at higher risk for all-cause (adjusted odds ratio [aOR], 1.07; [95% CI, 1.03-1.11]), cardiac-cause (aOR, 1.15; [95% CI, 1.06-1.25]), and noncardiac-cause (aOR, 1.13; [95% CI, 1.04-1.22]) readmission. During the index hospitalization, women were less likely than men to receive therapeutic procedures, including coronary angiography and targeted therapeutic management. While the crude case fatality rate was higher in women, in both ventricular tachycardia/ventricular fibrillation (51.8% versus 47.4%) and PEA/asystole (69.3% versus 68.5%) arrests, sex was not independently associated with increased crude case fatality after adjusting for differences in baseline characteristics. Conclusions Women are at increased risk of readmission following cardiac arrest, independent of comorbidities and therapeutic interventions.

Cardiac arrest in spontaneous subarachnoid hemorrhage and associated outcomes

OBJECTIVE

The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition.

METHODS

This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014.

RESULTS

A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p < 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p < 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status.

CONCLUSIONS

In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients.

Hispanic/Latino-Serving Hospitals Provide Less Targeted Temperature Management Following Out-of-Hospital Cardiac Arrest

Background Variation exists in outcomes following out-of-hospital cardiac arrest, but whether racial and ethnic disparities exist in postarrest provision of targeted temperature management (TTM) is unknown. Methods and Results We performed a retrospective analysis of a prospectively collected cohort of patients who survived to admission following out-of-hospital cardiac arrest from the Cardiac Arrest Registry to Enhance Survival, whose catchment area represents ≈50% of the United States from 2013 to 2019. Our primary exposure was race or ethnicity and primary outcome was utilization of TTM. We built a mixed-effects model with both state of arrest and admitting hospital modeled as random intercepts to account for clustering. Among 96 695 patients (24.6% Black patients, 8.0% Hispanic/Latino patients, and 63.4% White patients), a smaller percentage of Hispanic/Latino patients received TTM than Black or White patients (37.5% versus 45.0% versus 43.3%, P<0.001) following out-of-hospital cardiac arrest. In the mixed-effects model, Black patients (odds ratio [OR], 1.153 [95% CI, 1.102-1.207], P<0.001) and Hispanic/Latino patients (OR, 1.086 [95% CI, 1.017-1.159], P<0.001) were slightly more likely to receive TTM compared with White patients, perhaps because of worse neurological status on admission. We did find community- level disparity because Hispanic/Latino-serving hospitals (defined as the top decile of hospitals that cared for the highest proportion of Hispanic/Latino patients) provided less TTM (OR, 0.587 [95% CI, 0.474-0.742], P<0.001). Conclusions Reassuringly, we did not find evidence of intrahospital or interpersonal racial or ethnic disparity in the provision of TTM. However, we did find interhospital, community-level disparity. Hispanic/Latino-serving hospitals provided less guideline-recommended TTM after out-of-hospital cardiac arrest.

Women receive less targeted temperature management than men following out-of-hospital cardiac arrest due to early care limitations - A study from the CARES Investigators

BACKGROUND

Women experience worse neurological outcomes following out-of-hospital cardiac arrest (OHCA). It is unknown whether sex disparities exist in the use of targeted temperature management (TTM), a standard of care treatment to improve neurological outcomes.

METHODS

We performed a retrospective study of prospectively collected patients who survived to hospital admission following OHCA from the Cardiac Arrest Registry to Enhance Survival from 2013 through 2019. We compared receipt of TTM by sex in a mixed-effects model adjusted for patient, arrest, neighborhood, and hospital factors, with the admitting hospital modeled as a random intercept.

RESULTS

Among 123,419 patients, women had lower rates of shockable rhythms (24.4 % vs. 39.2%, P < .001) and lower rates of presumed cardiac aetiologies for arrest (74.3% vs. 81.1%, P < .001). Despite receiving a similar rate of TTM in the field (12.1% vs. 12.6%, P = .02), women received less TTM than men upon admission to the hospital (41.6% vs. 46.4%, P < .001). In an adjusted mixed-effects model, women were less likely than men to receive TTM (Odds Ratio 0.91, 95% Confidence Interval 0.89 to 0.94). Among the 27,729 patients with data indicating the reason for not using TTM, a higher percentage of women did not receive TTM due to Do-Not-Resuscitate orders/family requests (15.1% vs. 11.4%, p < .001) and non-shockable rhythms (11.1% vs. 8.4%, p < .001).

CONCLUSIONS

We found that women received less TTM than men, likely due to early care limitations and a preponderance of non-shockable rhythms.

Increased 5-year risk of stroke, atrial fibrillation, acute coronary syndrome, and heart failure in out-of-hospital cardiac arrest survivors compared with population controls: A nationwide registry-based study

AIM

Long-term risks of stroke, atrial fibrillation, or flutter (AF), acute coronary syndrome (ACS), and heart failure (HF) among survivors of out-of-hospital cardiac arrest (OHCA) are unknown. We aimed to examine 5-year risks of these outcomes among 30-day survivors of OHCA.

METHODS

Thirty-day survivors of OHCA without a prior (or within 30 days after cardiac arrest) history of stroke, AF, ACS, or HF and population controls without a prior history of these conditions were identified using Danish nationwide registries. Five-year risks of stroke, AF, ACS, and HF standardized to the distributions of age, sex, and comorbidities among OHCA survivors and controls were obtained using multivariable regression.

RESULTS

Of 4,362 30-day OHCA-survivors, 1,051 were stroke-, AF-, ACS-, and HF-naïve and matched with controls using age, sex, and time of OHCA event. Absolute five-year risks for OHCA survivors vs. controls were for stroke: 6.3% [95% confidence interval (CI) 4.1-8.5] vs. 2.0% [1.6-2.5], AF: 7.9% [5.7-10.2] vs. 2.6% [2.1-3.1], ACS: 5.0% [3.2-6.8] vs. 1.5% [1.1-1.9], and HF: 12.7% [10.1-15.4] vs. 1.2% [0.9-1.6], respectively. Corresponding relative risks were 3.18 [95% CI 1.76-4.61] for stroke, 3.03 [1.93-4.14] for AF, 3.23 [1.69-4.77] for ACS, and 10.40 [6.57-14.13] for HF.

CONCLUSION

When compared with population controls, OHCA survivors had significantly increased five-year risks of incident stroke, AF, ACS, and HF.

Rehabilitation outcomes of survivors of cardiac arrest admitted to ICUs in Australia and New Zealand (ROSC ANZ): A data linkage study

INTRODUCTION

Rehabilitation outcomes in cardiac arrest survivors are largely unknown, with no data comparing out-of-hospital cardiac arrests (OHCA) and in-hospital cardiac arrests (IHCA). This study aimed to describe and compare inpatient rehabilitation outcomes in these patients who were admitted from intensive care units (ICU).

METHODS

A retrospective linkage and analysis of cardiac arrest patients in the Australian and New Zealand Intensive Care Society Adult Patient Database and the Australasian Rehabilitation Outcomes Centre inpatient dataset discharged to inpatient rehabilitation between January 2017 and June 2018. Primary outcome was the functional improvement during rehabilitation (difference between the Functional Independence Measurement (FIM) score on admission and discharge). Multivariate regression analyses were performed to determine factors associated with functional improvement.

RESULTS

In the 240 (84 OHCA and 156 IHCA) patients included, the median length of inpatient rehabilitation was 15 days [1st-3rd quartile (Q1-Q3): 9-24]. OHCA patients were more likely to be admitted to rehabilitation for neurological issues (41.7%) and IHCA for medical reasons (51.9%). Median (Q1-Q3) change in total FIM scores was similar between the two groups (24.5[10-37]) vs 21[11-31], adjusted p = 0.20), with most of the FIM change seen in the motor items, and this was only associated with a lower admission FIM score. The majority of OHCA and IHCA patients were discharged home (91.5% and 89.7%, respectively), although with an increased need for a carer at home compared to baseline (27.2% to 55.6%).

CONCLUSION

Patients discharged from ICU following OHCA and IHCA achieved reasonable and similar functional improvement during inpatient rehabilitation.

Predicting early recovery of consciousness after cardiac arrest supported by quantitative electroencephalography

OBJECTIVE

To determine the ability of quantitative electroencephalography (QEEG) to improve the accuracy of predicting recovery of consciousness by post-cardiac arrest day 10.

METHODS

Unconscious survivors of cardiac arrest undergoing daily clinical and EEG assessments through post-cardiac arrest day 10 were studied in a prospective observational cohort study. Power spectral density, local coherence, and permutation entropy were calculated from daily EEG clips following a painful stimulus. Recovery of consciousness was defined as following at least simple commands by day 10. We determined the impact of EEG metrics to predict recovery when analyzed with established predictors of recovery using partial least squares regression models. Explained variance analysis identified which features contributed most to the predictive model.

RESULTS

367 EEG epochs from 98 subjects were analyzed in conjunction with clinical measures. Highest prediction accuracy was achieved when adding QEEG features from post-arrest days 4-6 to established predictors (area under the receiver operating curve improved from 0.81 ± 0.04 to 0.86 ± 0.05). Prediction accuracy decreased from 0.84 ± 0.04 to 0.79 ± 0.04 when adding QEEG features from post-arrest days 1-3. Patients with recovery of command-following by day 10 showed higher coherence across the frequency spectrum and higher centro-occipital delta-frequency spectral power by days 4-6, and globally-higher theta range permutation entropy by days 7-10.

CONCLUSIONS

Adding quantitative EEG metrics to established predictors of recovery allows modest improvement of prediction accuracy for recovery of consciousness, when obtained within a week of cardiac arrest. Further research is needed to determine the best strategy for integration of QEEG data into prognostic models in this patient population.

Hyperarousal Symptoms in Survivors of Cardiac Arrest Are Associated With 13 Month Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

BACKGROUND

Key dimensions of cardiac arrest-induced posttraumatic stress disorder (PTSD) symptoms include reexperiencing, avoidance, numbing, and hyperarousal. It remains unknown which dimensions are most predictive of outcome.

PURPOSE

To determine which dimensions of cardiac arrest-induced PTSD are predictive of clinical outcome within 13 months posthospital discharge.

METHODS

PTSD symptoms were assessed in survivors of cardiac arrest who were able to complete psychological screening measures at hospital discharge via the PTSD Checklist-Specific scale, which queries for 17 symptoms using five levels of severity. Responses on items for each symptom dimension of the four-factor numbing model (reexperiencing, avoidance, numbing, and hyperarousal) were converted to Z-scores and treated as continuous predictors. The combined primary endpoint was all-cause mortality (ACM) or major adverse cardiovascular events (MACE; hospitalization for myocardial infarction, unstable angina, heart failure, emergency coronary revascularization, or urgent defibrillator/pacemaker placements) within 13 months postdischarge. Four bivariate Cox proportional hazards survival models evaluated associations between individual symptom dimensions and ACM/MACE. A multivariable model then evaluated whether significant bivariate predictors remained independent predictors of the primary outcome after adjusting for age, sex, comorbidities, premorbid psychiatric diagnoses, and initial cardiac rhythm.

RESULTS

A total of 114 patients (59.6% men, 52.6% white, mean age: 54.6 ± 13 years) were included. In bivariate analyses, only hyperarousal was significantly associated with ACM/MACE. In a fully adjusted model, 1 standard deviation increase in hyperarousal symptoms corresponded to a two-times increased risk of experiencing ACM/MACE.

CONCLUSIONS

Greater level of hyperarousal symptoms was associated with a higher risk of ACM/MACE within 13 months postcardiac arrest. This initial evidence should be further investigated in a larger sample.

Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes

OBJECTIVES

To evaluate racial and ethnic disparities in postcardiac arrest outcomes in patients undergoing targeted temperature management.

DESIGN

Retrospective study.

SETTING

ICUs in a single tertiary care hospital.

PATIENTS

Three-hundred sixty-seven patients undergoing postcardiac arrest targeted temperature management, including continuous electroencephalogram monitoring.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical variables examined in our clinical cohort included race/ethnicity, age, time to return of spontaneous circulation, cardiac rhythm at time of arrest, insurance status, Charlson Comorbidity Index, and time to withdrawal of life-sustaining therapy. CT at admission and continuous electroencephalogram monitoring during the first 24 hours were used as markers of early injury. Outcome was assessed as good (Cerebral Performance Category 1-2) versus poor (Cerebral Performance Category 3-5) at hospital discharge. White non-Hispanic ("White") patients were more likely to have good outcomes than white Hispanic/nonwhite ("Non-white") patients (34.4 vs 21.7%; p = 0.015). In a multivariate model that included age, time to return of spontaneous circulation, initial rhythm, combined electroencephalogram/CT findings, Charlson Comorbidity Index, and insurance status, race/ethnicity was still independently associated with poor outcome (odds ratio, 3.32; p = 0.003). Comorbidities were lower in white patients but did not fully explain outcomes differences. Nonwhite patients were more likely to exhibit signs of early severe anoxic changes on CT or electroencephalogram, higher creatinine levels and receive dialysis, but had longer duration to withdrawal of lifesustaining therapy. There was no significant difference in catheterizations or MRI scans. Subgroup analysis performed with patients without early electroencephalogram or CT changes still revealed better outcome in white patients.

CONCLUSIONS

Racial/ethnic disparity in outcome persists despite a strictly protocoled targeted temperature management. Nonwhite patients are more likely to arrive with more severe anoxic brain injury, but this does not account for all the disparity.

Modifiable provider-patient relationship factors and illness perceptions are associated with quality of life in survivors of cardiac arrest with good neurologic recovery

Aim

To evaluate associations between provider-patient communication, readiness for discharge, and patients' illness perceptions with post-arrest quality of life (QoL).

Methods

We distributed an online survey to survivors of cardiac arrest who were members of the Sudden Cardiac Arrest Foundation. Survivors completed the Questionnaire for the Quality of Provider-Patient Interactions (QQPPI), Readiness for Hospital Discharge Scale (RHDS), and the Brief Illness Perception Questionnaire (B-IPQ). When completing the QQPPI and RHDS, survivors were asked to think back to their hospitalization and discharge. QoL domains (physical, psychological, social) were measured via the WHO-QOL BREF. Three multiple regression models examined associations between QQPPI, RHDS, and B-IPQ scores with QoL domains, adjusted for age, sex, months since arrest, self-reported understanding of cardiac arrest and potential post-arrest symptoms at discharge, self-reported memory at discharge, and functional status as defined by the Lawton Instrumental Activities of Daily Living scale.

Results

A total of 163 survivors (mean age: 50.1 years, 50.3% women, 95.5% white, mean time since arrest: 63.9 months) provided complete survey data. More threatening illness perceptions (β: -0.45, p ​< ​0.001) and lower readiness for discharge (β: 0.21, p ​= ​0.01) were associated with worse physical QoL. More threatening illness perceptions (β: -0.47, p ​< ​0.001) was associated with worse psychological QoL. More threatening illness perceptions (β: -0.28, p ​= ​0.001) and poor provider-patient communication (β: 0.35, p ​< ​0.001) were associated with worse social QoL.

Conclusions

Modifiable provider-patient relationship factors and illness perceptions were associated with quality of life in survivors of cardiac arrest with good neurologic recovery.

Cardiac Arrest and Subsequent Hospitalization-Induced Posttraumatic Stress Is Associated With 1-Year Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

OBJECTIVES

To compare 1-year all-cause mortality and major adverse cardiovascular events in cardiac arrest survivors with and without posttraumatic stress disorder symptomatology at hospital discharge.

DESIGN

Prospective, observational cohort.

SETTING

ICUs at a tertiary-care center.

PATIENTS

Adults with return of spontaneous circulation after in-hospital or out-of-hospital cardiac arrest between September 2015 and September 2017. A consecutive sample of survivors with sufficient mental status to self-report cardiac arrest and subsequent hospitalization-induced posttraumatic stress disorder symptoms (cardiac arrest-induced posttraumatic stress symptomatology) at hospital discharge were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The combined primary endpoint was all-cause mortality or major adverse cardiovascular event-hospitalization for nonfatal myocardial infarction, unstable angina, congestive heart failure, emergency coronary revascularization, or urgent implantable cardio-defibrillators/permanent pacemaker placements within 12 months of discharge. An in-person posttraumatic stress disorder symptomatology was assessed at hospital discharge via the Posttraumatic Stress Disorder Checklist-Specific scale; a suggested diagnostic cutoff of 36 for specialized medical settings was adopted. Outcomes for patients meeting (vs not meeting) this cutoff were compared using Cox-hazard regression models. Of 114 included patients, 36 (31.6%) screened positive for cardiac arrest-induced posttraumatic stress symptomatology at discharge (median 21 d post cardiac arrest; interquartile range, 11-36). During the follow-up period (median = 12.4 mo; interquartile range, 10.2-13.5 mo), 10 (8.8%) died and 29 (25.4%) experienced a recurrent major adverse cardiovascular event: rehospitalizations due to myocardial infarction (n = 4; 13.8%), unstable angina (n = 8; 27.6%), congestive heart failure exacerbations (n = 4; 13.8%), emergency revascularizations (n = 5, 17.2%), and urgent implantable cardio-defibrillator/permanent pacemaker placements (n = 8; 27.6%). Cardiac arrest-induced posttraumatic stress symptomatology was associated with all-cause mortality/major adverse cardiovascular event in univariate (hazard ratio, 3.19; 95% CI, 1.7-6.0) and in models adjusted for age, sex, comorbidities, preexisting psychiatric condition, and nonshockable initial rhythm (hazard ratio, 3.1; 95% CI, 1.6-6.0).

CONCLUSIONS

Posttraumatic stress disorder symptomatology is common after cardiac arrest, and cardiac arrest-induced posttraumatic stress symptomatology was associated with significantly higher risk of death and cardiovascular events. Further studies are needed to better understand the underlying mechanisms.

Cardiac arrest: An interdisciplinary review of the literature from 2018

OBJECTIVES

The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest (CA). The goals of the review are to illustrate best practices and help reduce knowledge silos by disseminating clinically relevant advances in the field of CA across disciplines.

METHODS

An electronic search of PubMed using keywords related to CA was conducted. Title and abstracts retrieved by these searches were screened for relevancy, separated by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and importance. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors and reviewer scores were assessed using Wilcoxon signed-rank test.

RESULTS

A total of 9119 articles were identified on initial search; of these, 1214 were scored after screening for relevance and deduplication, and 80 underwent full critique. Prognostication & Outcomes category comprised 25% and Epidemiology & Public Health 17.5% of fully reviewed articles. There were no differences between editor and reviewer scoring.

CONCLUSIONS

The total number of articles demonstrates the need for an accessible source summarizing high-quality research findings to serve as a high-yield reference for clinicians and scientists seeking to absorb the ever-growing body of CA-related literature. This may promote further development of the unique and interdisciplinary field of CA medicine.

Dimensional structure of posttraumatic stress disorder symptoms after cardiac arrest

BACKGROUND

Considerable evidence suggests that posttraumatic stress disorder (PTSD) is a heterogeneous construct despite often being treated as a homogeneous diagnostic entity. PTSD in response to cardiac arrest is common and may differ from PTSD following other medical traumas. Most patients are amnesic from the cardiac event, and it is unclear if and how certain PTSD symptoms may manifest.

METHODS

We examined the latent structure of PTSD symptoms in 104 consecutive cardiac arrest survivors who were admitted to Columbia University Medical Center. PTSD symptoms were assessed via the PTSD Checklist-Specific at hospital discharge. We performed a confirmatory factor analysis (CFA) to compare 4-factor dysphoria, 4-factor numbing, and 5-factor dysphoric arousal models of PTSD with our data.

RESULTS

The CFA showed that each of the models had good fit. We chose the 4-factor numbing model (χ² (113) = 151.59, p < .01, CFI = 0.94, RMSEA = 0.057, 90% CI: [0.032, 0.081]) as most representative of the data, after considering a between-factor correlation of 0.99 in the 5-factor dysphoric arousal model, and greater fit statistics than the 4-factor dysphoria model.

LIMITATIONS

Certain factors were defined by only two items. Additionally, PTSD was assessed at discharge (median = 21 days); those assessed before 30 days could be displaying symptoms of acute stress disorder.

CONCLUSIONS

Our findings suggest that PTSD symptoms after cardiac arrest are best represented by a 4-factor numbing model of PTSD. PTSD assessment and intervention efforts for cardiac arrest survivors should consider the underlying dimensions of PTSD.

Variability in functional outcome and treatment practices by treatment center after out-of-hospital cardiac arrest: analysis of International Cardiac Arrest Registry

PURPOSE

Functional outcomes vary between centers after out-of-hospital cardiac arrest (OHCA) and are partially explained by pre-existing health status and arrest characteristics, while the effects of in-hospital treatments on functional outcome are less understood. We examined variation in functional outcomes by center after adjusting for patient- and arrest-specific characteristics and evaluated how in-hospital management differs between high- and low-performing centers.

METHODS

Analysis of observational registry data within the International Cardiac Arrest Registry was used to perform a hierarchical model of center-specific risk standardized rates for good outcome, adjusted for demographics, pre-existing functional status, and arrest-related factors with treatment center as a random effect variable. We described the variability in treatments and diagnostic tests that may influence outcome at centers with adjusted rates significantly above and below registry average.

RESULTS

A total of 3855 patients were admitted to an ICU following cardiac arrest with return of spontaneous circulation. The overall prevalence of good outcome was 11-63% among centers. After adjustment, center-specific risk standardized rates for good functional outcome ranged from 0.47 (0.37-0.58) to 0.20 (0.12-0.26). High-performing centers had faster time to goal temperature, were more likely to have goal temperature of 33 °C, more likely to perform unconscious cardiac catheterization and percutaneous coronary intervention, and had differing prognostication practices than low-performing centers.

CONCLUSIONS

Center-specific differences in outcomes after OHCA after adjusting for patient-specific factors exist. This variation could partially be explained by in-hospital management differences. Future research should address the contribution of these factors to the differences in outcomes after resuscitation.

The impact of psychological distress on long-term recovery perceptions in survivors of cardiac arrest

PURPOSE

To determine the association of depressive and PTSD symptoms with cardiac arrest survivors' long-term recovery perceptions, after accounting for cognitive status, functional independence, and medical comorbidities.

METHODS

Perceived recovery of 78 cardiac arrest survivors at 6-months post-hospital discharge was assessed through the question, "Do you feel that you have made a complete recovery from your arrest?" Psychological symptoms were measured using the Center for Epidemiological Studies-Depression scale (CES-D) and the PTSD Checklist-Specific (PCLS). Logistic regression was utilized to assess the association between psychological symptoms with positive and negative recovery perceptions, adjusting for demographics, cognitive impairment, functional dependence, and medical comorbidities.

RESULTS

At 6 months, 53% of patients (n = 41) had negative recovery perceptions. 32.1% (n = 25) of patients screened for depression and 28.2% (n = 22) for PTSD. Patients with higher CES-D scores were significantly more likely to have negative recovery perceptions in both unadjusted and adjusted analyses (OR: 1.10, 95% CI [1.03, 1.16], p < .01). PCL-S scores were significantly associated with negative recovery perceptions in an unadjusted model (OR: 1.05, 95% CI [1.01, 1.10], p < .01), but not after adjustment of covariates.

CONCLUSIONS

In contrast with cognitive and functional measures, depressive symptoms were strongly associated with cardiac arrest survivors' negative recovery perceptions at 6-months post-discharge.

Posttraumatic stress and depressive symptoms characterize cardiac arrest survivors' perceived recovery at hospital discharge

OBJECTIVE

To test the hypothesis that posttraumatic stress and depressive symptoms, not cognitive or functional impairment, are associated with cardiac arrest survivors' negative recovery perceptions at hospital discharge.

METHODS

Prospective observational cohort of cardiac arrest patients admitted between 9/2015-5/2017. Survival to discharge with sufficient mental status to complete a psychosocial interview was the main inclusion criterion. Perceived recovery was assessed through the question, "Do you feel that you have made a complete recovery from your arrest?" The following measures were examined as potential correlates of perceived recovery: Repeatable Battery for Assessment of Neuropsychological Status, Modified Lawton Physical Self-Maintenance Scale, Barthel Index, Modified Rankin Scale, Cerebral Performance Category, Center for Epidemiological Studies-Depression (CES-D), and PTSD Checklist-Specific (PCL-S). Logistic regression evaluated associations between perceived recovery and potential correlates of recovery.

RESULTS

64/354 patients (58% men, 48% white, mean age 52 ± 17) were included. 67% (n = 43) had a negative recovery perception. There were no differences among patients' cognitive and functional domains. In individual models, patients with higher PCL-S and CES-D scores were more likely to have a negative recovery perception after adjusting for age and gender (OR: 1.2, 95% CI [1.1, 1.4], p = 0.003) and (OR: 1.1, 95% CI [1.0, 1.1], p = 0.05).

CONCLUSIONS

Within one month after a cardiac arrest event, survivors' negative recovery perceptions are associated with psychological distress.