Effectiveness of rehabilitation interventions on the secondary consequences of surviving a cardiac arrest: a systematic review and meta-analysis

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.

Benefits and harms of structured outdoor physical activity for people with somatic or mental diseases: A systematic review and meta-analysis

OBJECTIVE

To examine the benefits and harms of structured outdoor physical activity (PA) for people living with one or more somatic or mental diseases.

METHODS

We identified articles from inception until Marts 2023 in MEDLINE, EMBASE, CINAHL and CENTRAL and citation tracking in Web of Science. We included randomized controlled trials (RCTs) and observational studies examining structured outdoor PA reporting physical function, health-related quality of life (HRQOL), pain or mental outcomes. We used random-effect meta-analyses and investigated heterogeneity in subgroups, sensitivity and meta-regression analyses. Observational studies and studies with insufficient data were summarized narratively. Certainty of evidence was assessed with GRADE.

RESULTS

From 4098 hits, 20 studies (19 RCTs and 1 cohort) were included (n: 1759 participants). Studies varied in type of disease and intervention. End of intervention results suggested a small effect on HRQOL (k = 10, SMD = 0.45, 95%CI: 0.19 to 0.71) and physical function (k = 14, SMD = 0.39, 95%CI: 0.13 to 0.64), while effects were moderate on mental outcomes (k = 13, SMD = -0.52, 95%CI: -0.82 to -0.23) favoring the outdoor intervention over comparators (no intervention, usual care, indoor PA or outdoor intervention without exercise). We were not able to conclude on outdoor interventions' effect on pain. Four studies reported adverse events including non-serious (pain, falls, fatigue) and serious (hospitalization, pneumonia). Certainty of evidence was overall very low.

CONCLUSION

Structured outdoor PA may improve HRQOL and physical function, as well as mental health outcomes. The very low certainty of evidence calls for high quality RCTs to determine benefits and harms of structured outdoor PA.

A multidisciplinary guideline-based approach to improving the sudden cardiac arrest care pathway: The Copenhagen framework

Although recommended in the European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) Guidelines, a framework for delivering post-cardiac arrest care in a systematic manner in dedicated high-volume cardiac arrest centers is lacking in the existing literature. To our knowledge, the Copenhagen Framework is the only established framework of its kind. The framework comprises management of out-of-hospital cardiac arrest (OHCA) survivors, and follow-up, and rehabilitation. The framework also incorporates research projects on cardiac arrest survivors and their close family members. The overall aim of this paper is to describe a framework made in order to bridge the gaps between international recommendations and delivering high-quality post-resuscitation clinical care, improving the continuity of care for OHCA survivors, access to post-CA rehabilitation, a seamless transition to everyday life, and ultimately patient outcomes in the future.

The ROCK trial-a multidisciplinary Rehabilitation intervention for sudden Out-of-hospital Cardiac arrest survivors focusing on return-to-worK: a pragmatic randomized controlled trial protocol

INTRODUCTION

Most cardiac arrest survivors are classified with mild to moderate cognitive impairment; roughly, 50% experience long-term neurocognitive impairment. Postarrest challenges complicate participation in society and are associated with social issues such as failure to resume social activities and impaired return to work. The effectiveness of rehabilitation interventions for out-of-hospital cardiac arrest survivors are sparsely described, but the body of evidence describes high probabilities of survivors not returning to work, returning to jobs with modified job descriptions, returning to part-time employment, and often in combination with extensive unmet rehabilitation needs. Hence, there is a need to develop and test a pragmatic individual targeted intervention to facilitate return to work (RTW) in survivors of OHCA. The overall aim of the ROCK trial is to evaluate the effectiveness of a comprehensive individually tailored multidisciplinary rehabilitation intervention for survivors of OHCA on RTW compared to usual care.

METHODS AND ANALYSIS

The ROCK trial is a two-arm parallel group multicentre investigator-initiated pragmatic randomized controlled superiority trial with primary endpoint measured 12 months after the cardiac arrest. Adult survivors who were part of the labour force prior to the OCHA and had at least 2 years until they are qualified to receive retirement state pensions are eligible for inclusion. Survivors will be randomized 1:1 to usual care group or usual care plus a comprehensive tailored rehabilitation intervention focusing on supporting RTW. After comprehensive assessment of individual rehabilitation needs, the intervention is ongoingly coordinated within a multidisciplinary rehabilitation team, and the intervention can be delivered for up until 12 months. Data for the primary outcome will be obtained from the national register on social transfer payments. The primary outcome will be analysed using logistic regression assessing RTW status at 12 months adjusting for the intervention and age at OHCA, sex, marital status, and occupation prior to OHCA.

DISCUSSION

The ROCK trial is the first RCT to investigate the effectiveness of a rehabilitation intervention focusing on return to work after cardiac arrest.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05173740. Registered on May 2018.

Cardio-Oncology: Managing Cardiovascular Complications of Cancer Therapies

This narrative review explores the complex relationship between cancer medicines and cardiovascular health in the junction of oncology and cardiology, known as cardio-oncology. The study examines the historical development of cancer treatments and highlights the growing importance of cardiovascular problems in patient care. This text delves into the topic of cardiotoxicity, examining both conventional chemotherapeutic drugs like anthracyclines and more recent tyrosine kinase and immune checkpoint inhibitors. The complex molecular and cellular mechanisms that control cardiovascular problems are explained, including an understanding of how genetic predisposition influences an individual's sensitivity. The narrative expands into the crucial realm of risk stratification and evaluation, revealing advanced instruments for identifying cardiovascular risk in cancer patients. The importance of non-invasive imaging methods and biomarkers in early detection and continuous monitoring is emphasized. The prioritization of preventive tactics emphasizes the need to take proactive measures incorporating therapies to protect the heart throughout cancer treatment. It also highlights the significance of making lifestyle improvements to reduce risk factors. The narrative emphasizes the changing collaborative treatment environment, advocating for merging oncologists and cardiologists in a coordinated endeavor to maximize patient outcomes. In addition to clinical factors, the review explores the critical domain of patient education and support, acknowledging its crucial role in promoting informed decision-making and improving overall patient well-being. The latter portions of the text anticipate and consider upcoming treatments and existing research efforts that offer the potential for the future of cardio-oncology. This review seeks to provide a detailed viewpoint on the intricate connection between cancer treatments and cardiovascular well-being. Its objective is to encourage a more profound comprehension of the subject and prompt careful contemplation regarding the comprehensive care of cancer patients who confront the intricate difficulties presented by their treatment plans.

Rehabilitation interventions for young adult cancer survivors: A scoping review

OBJECTIVE

To map existing research concerning rehabilitation interventions for young adult cancer survivors (YACS) that address at least one factor from the biopsychosocial health model.

DESIGN

Scoping review.

DATA SOURCES

Searches were performed in EMBASE, MEDLINE, PsycINFO, CINAHL and Cochrane in January 2022 and updated in March 2023, and grey literature between February and April 2022.

METHODS

The review followed Joanna Briggs Institute's methodology for scoping reviews. Quantitative, qualitative and mixed methods studies evaluating interventions for YACS of any cancer who had completed primary treatment and were between 18 and 39 years old at diagnosis were included. Two authors independently screened studies for eligibility, and standardised forms were used for data extraction. Descriptive statistics, narrative summaries and thematic analysis were used to analyse the data.

RESULTS

The search revealed 5706 records, of which 70 were full-text screened. The 20 included studies represented a heterogeneous group of 444 young adults with different cancer types, mean age above 25, and an overrepresentation of females. Most studies were feasibility and pilot studies. The 20 studies consisted of 14 unique interventions focusing primarily on one dimension of the biopsychosocial health model like biological or psychological factors. In the 14 interventions, the most frequent intervention element was peer-to-peer support (n = 12). The interventions were often delivered online (n = 9), lasting 3-12 months (n = 8). A wide variety of theories, providers and outcome measures were used.

CONCLUSION

The results show that current research on multicomponent, biopsychosocial and age-specific rehabilitation for YACS remains at an early stage.

Revolutionizing Cardiac Care: A Comprehensive Narrative Review of Cardiac Rehabilitation and the Evolution of Cardiovascular Medicine

Cardiovascular disease (CVD) stands as a global health crisis, with its complex web of conditions, including coronary artery disease, heart failure, hypertension, and stroke, continuing to exact a heavy toll on individuals and healthcare systems worldwide. Despite substantial advances in medical technology and pharmaceutical interventions, CVD remains a formidable adversary, necessitating innovative prevention, management, and rehabilitation approaches. In tracing the historical trajectory of CVD, the narrative reveals the antiquated practices of early 20th-century medicine, marked by extended bed rest as the primary modality for heart-related conditions. It underscores the critical juncture when exercise was first recognized as a therapeutic tool for cardiac health, setting the stage for the evolution of cardiac rehabilitation (CR). CR programs have transcended their initial focus on exercise, expanding to encompass dietary guidance, psychosocial support, and comprehensive risk factor modification. These holistic interventions enhance physical recovery and address the psychosocial and lifestyle aspects of CVD management, ultimately improving patients' overall well-being. CR programs increasingly leverage advanced technologies and personalized strategies to tailor interventions to individual patient needs, ultimately enhancing outcomes and reducing the burden of CVD. In conclusion, this narrative review illuminates the transformative journey of cardiac care, with a particular spotlight on the indispensable role of CR in reshaping the landscape of cardiovascular medicine. By evolving from historical practices to comprehensive, patient-centered interventions, CR has made significant strides in improving the prognosis, quality of life, and holistic well-being of individuals grappling with the complexities of CVD. Understanding this historical context and the contemporary advancements is paramount for healthcare professionals and policymakers as they navigate the intricate terrain of cardiovascular medicine and endeavor to mitigate the impact of this pervasive disease.

Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review

Background

There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies.

Methods

We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers.

Results

In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services.

Conclusions

The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access.

Limitations

Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified.

Future work

High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward.

Funding

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health.

Study registration

The study protocol is registered with PROSPERO [CRD42022309214].

The aftermath of surviving a sudden cardiac arrest for young exercisers - a qualitative study in Norway

BACKGROUND

When surviving a sudden cardiac arrest (SCA), physical, cognitive, and emotional effects of surviving may be present for months or years. The survivors' family and colleagues are also highly affected by the incident. There is little knowledge about experiences of surviving SCA in individuals who prior to the incident were young and reported to exercise regularly. Consequently, the aim of this study was to explore the aftermath of surviving a SCA in young, regular exercisers.

METHODS

The study had a qualitative design, conducting in-depth individual interviews with SCA survivors < 50 years of age reporting to exercise ≥ 5 h/week and/or who suffered SCA during or less than 60 min after exercise. The data were analysed using systematic text condensation in-line with recommendations from Malterud.

RESULTS

18 of 31 eligible participants were included in the study. Through analysis we identified 'Establishing a new everyday life' as superordinate category, with subordinate categories a) being part of my surroundings, b) expecting normality but facing a new reality and c) lucky to be alive!

CONCLUSION

This study adds knowledge about young and regular exercisers' experiences after surviving a SCA. The obligations of everyday life in young survivors of SCA often imply a high work load and complex tasks, e.g. due to being in the beginning of their career or even still studying. Healthcare personnel, as well as the society, need to acknowledge that although lucky to be alive and apparently well-functioning, young survivors of SCA may have persistent challenges that cause frustration and reduced quality of life.

Psychological Distress After Sudden Cardiac Arrest and Its Impact on Recovery

PURPOSE OF REVIEW

To summarize the prevalence, correlates, and health consequences of poor mental health in the increasingly sizable population of survivors of Sudden cardiac arrest (CA) and to describe current intervention research in this area.

RECENT FINDINGS

After CA many patients report high psychological distress, including depression, generalized anxiety, and posttraumatic stress. Emerging evidence suggests that distressed patients' attention may narrow such that anxious awareness of afferent cardiac signals e.g., changes in heart rate or blood pressure, becomes predominant and a cause for concerned, constant monitoring. This cardiac-specific anxiety followed by behavioral avoidance and physiological hyperreactivity may increase patients' already high risk of secondary cardiovascular disease and undermine their health-related quality of life (HRQoL). Unlike other cardiovascular diseases, no clinical practice guidelines exist for assessing or treating psychological sequelae of CA. Future research should identify modifiable psychological targets to reduce secondary cardiovascular disease risk and improve HRQoL.

Surviving cardiac arrest - what do we know about recovery & survivorship?

PURPOSE OF REVIEW

There has been increasing interest in examining how cardiac arrest survivors and their families experience life after sudden cardiac arrest (SCA). Understanding their experiences provides a basis to study tools and interventions to improve short- and long-term recovery and rehabilitation.

RECENT FINDINGS

Qualitative interview and survey-style studies explored the lived experience of SCA survivors and revealed common themes (e.g., need for recovery expectations and long-term follow-up resources). A heightened awareness for the unique needs of family and loved ones of survivors led to qualitative studies focusing on these members as well. Methodology papers published portend prospective assessment and follow-up cohort studies. However, no investigations evaluating discharge processes or specific interventions directed at domain impairments common after SCA were identified in the review period. International work continues to identify patient and family-centered priorities for outcome measurement and research.

SUMMARY

In line with increased recognition of the importance for recovery and rehabilitation after SCA, there has been a commensurate increase in investigations documenting the needs of survivors and families surviving SCA. Pediatric and underserved populations continue to be understudied with regards to recovery after SCA.

Promising results from a residential rehabilitation intervention focused on fatigue and the secondary psychological and physical consequences of cardiac arrest: The SCARF feasibility study

AIMS

This study investigated the feasibility and potential effect of SCARF (Survivors of Cardiac ARest focused on Fatigue) a multidisciplinary residential rehabilitation intervention focused on fatigue and the secondary psychological and physical consequences of cardiac arrest (CA).

METHODS

This was a prospective one-armed feasibility study. Six progression criteria were identified related to the feasibility of the intervention and viability of a future effect study in terms of: participant recruitment (1), participant retention (2,3,4), and completeness of outcomes (5,6). Data on participant/clinician satisfaction with the intervention was also collected along with self-reported outcomes: fatigue, quality of life, anxiety, depression, function and disability, and physical activity (at baseline, 12 weeks and 6 months) and physical capacity (baseline and 12 weeks).

RESULTS

Four progression criteria were met including retention (87.5%) and completion of baseline outcomes (97.5%). Two criteria were not met: recruitment rate was 2.9 participants per month (estimated rate needed 6.1) and completion of final outcomes was 65% (estimated proportion needed 75%). Participant/clinician satisfaction with the intervention was high. Three months after the SCARF intervention small to moderate effect size changes of r=0.18-0.46 were found for self-reported fatigue, quality of life, anxiety, depression and disability and for two of the physical capacity tests (d=0.46-0.52).

CONCLUSION

SCARF was found to be a feasible intervention with high participant/clinician satisfaction, high participant retention and the possible potential to improve self-reported and physical capacity outcomes. Procedures for study recruitment and collection of final outcomes should be modified before a fully powered randomised controlled trial is conducted.