Resuscitation 85 (2014) 157–158

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Editorial

Life after cardiac arrest: Better with time

Although the chances of surviving a cardiac arrest (CA) are historically dismal – less than 10% – survival rates are improving, and today they approximate 40–60% in some populations.1,2 Because of recent emphasis on high-quality and timely cardiopulmonary resuscitation (CPR), increased availability of public defibrillators, induced therapeutic hypothermia (TH), and standardized postresuscitation protocols, the number of survivors is increasing.3 Thus, the neurological and functional state of postresuscitation survivors is of growing importance. Many studies on CA sequelae have relied on relatively crude outcome measures. For example, in one of the influential trials that contributed to the eventual widespread implementation of TH for “neuroprotection”, a good outcome was defined as discharge home or to a rehabilitation facility.4 A potentially more meaningful outcome measure – quality of life – is difficult to measure given its subjective nature, particularly in a population in which cognitive abilities are often impaired.5–7 Cognitive status, along with fatigue, ability to perform instrumental daily life activities, and anxiety/depression are key factors that determine quality of life after CA.8 Despite the fairly frequent occurrence of mild cognitive impairment (affecting predominantly memory and frontal lobe executive functions), most survivors of CA are functionally independent and have a reasonable quality of life.5,6,7,9,10 In this issue of Resuscitation, Larsson et al. prospectively studied 26 CA survivors who underwent TH and measured self-reported health-related quality of life (QOL), anxiety, and depression levels at three time points: hospital discharge, 1 month, and 6 months.11 QOL was measured by the questionnaires EQ-5D and SF-12 which assess various domains including mobility, pain, mood, self-care, and daily activities. In this small study, there was improvement in QOL, but not in levels of anxiety/depression. Mobility problems were present in 54% at discharge, which was reduced to 31% by 6 months. A moderate-to-low QOL for the mental component of the SF-12 was reported in 31% of patients at discharge, 27% at 1 month, and 11% at 6 months. For the physical component, moderate-tolow QOL was reported in 69% at discharge, 73% at 1 month, and 38% at 6 months. While there was no significant improvement in self-reported anxiety/depression levels over time, there was a fairly strong negative correlation between anxiety/depression and QOL at six months. These results provide new insights into the recovery process for CA survivors and confirm that improvements continue to be made for several months out of the hospital – and even at a faster rate during the latter months. The substantial clinical improvements seen during the first 6 months should be kept in mind when interpreting 0300-9572/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.11.012

results of studies with shorter-term endpoints. The strengths of this small study include its prospective nature and uniform follow-up evaluations using standardized and validated measurement tools. It is limited, however, by the possibility of selection and reporting biases. During this 4 year time period in the same Swedish hospitals, a total of 242 patients were admitted to intensive care units after CA and 63 patients still included in the study survived. Nearly half of survivors (28 patients) were excluded from the analysis because they did not complete the questionnaires at all 3 time points. These excluded patients had a higher prevalence of asystole and longer time to ROSC, factors that have been associated with poorer outcomes. While this would not necessarily impact the recovery process of those who ultimately do recover, it may lead to falsely optimistic averages of perceived QOL and levels of functional outcomes. It is possible that only those patients who were more motivated filled the questionnaires, also a potential source of bias. Furthermore, as many patients who survive CA have some degree of cognitive impairment, the potential for lack of insight into their true level of disability may exist and self-reporting may not be fully reliable. A discrepancy between patient reporting and care-giver reporting of disability after CA is known.12 However, the alternative of using a surrogate to report QOL for another person is not a valid option. This study had no comparator group, and thus we cannot draw conclusions about the specific effect of TH on QOL or cognitive recovery from this study. Nevertheless, the results are informative and they enhance our knowledge about the course of CA survivors who recover. Also importantly, these results can help us guide patients and families in discussions about the potential for further improvements with time. The findings that anxiety/depression levels did not improve over time along with the negative correlation seen between anxiety/depression and QOL suggest that routine screening for psychiatric comorbidities may be important to help patients recover optimally. This could be achieved by a multidisciplinary assessment of both physical and mental abilities after cardiac arrest, which could assist providers in planning and administering appropriate post-hospitalization rehabilitation therapies and follow-up evaluations. Thus, given the dynamic recovery process suggested in this study, perhaps rather than being regarded as “cardiac patients”, some patients who survive CA may also benefit from routine brain rehabilitation therapies. Conflict of interest statement Dr. Jennifer Fugate and Dr. Alejandro Rabinstein report no conflicts of interest.

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Editorial / Resuscitation 85 (2014) 157–158

Funding None. References 1. Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database. Anaesthesia 2007;62:1207–16. 2. Reinikainen M, Oksanen T, Leppanen P, Torppa T, Niskanen M, Kurola J. Mortality in out-of-hospital cardiac arrest patients has decreased in the era of therapeutic hypothermia. Acta Anaesthesiol Scand 2012;56:110–5. 3. Fugate JE, Brinjikji W, Mandrekar JN, et al. Post-cardiac arrest mortality is declining: a study of the US National Inpatient Sample 2001 to 2009. Circulation 2012;126:546–50. 4. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557–63. 5. Cronberg T, Lilja G, Rundgren M, Friberg H, Widner H. Long-term neurological outcome after cardiac arrest and therapeutic hypothermia. Resuscitation 2009;80:1119–23. 6. Fugate JE, Moore SA, Knopman DS, et al. Cognitive outcomes of patients undergoing therapeutic hypothermia after cardiac arrest. Neurology 2013;81:40–5. 7. Mateen FJ, Josephs KA, Trenerry MR, et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: a population-based study. Neurology 2011;77:1438–45. 8. Moulaert VR, Wachelder EM, Verbunt JA, Wade DT, van Heugten CM. Determinants of quality of life in survivors of cardiac arrest. J Rehabil Med 2010;42:553–8.

9. Elliott VJ, Rodgers DL, Brett SJ. Systematic review of quality of life and other patient-centred outcomes after cardiac arrest survival. Resuscitation 2011;82:247–56. 10. Alexander MP, Lafleche G, Schnyer D, Lim C, Verfaellie M. Cognitive and functional outcome after out of hospital cardiac arrest. J Int Neuropsychol Soc 2011;17:364–8. 11. Larsson I, Wallin E, Rubertsson S, Kristofferzon M. Health-related quality of life improves during the first six months after cardiac arrest and hypothermia treatment. Resuscitation 2014;85:215–20. 12. Pusswald G, Fertl E, Faltl M, Auff E. Neurological rehabilitation of severely disabled cardiac arrest survivors. Part II. Life situation of patients and families after treatment. Resuscitation 2000;47:241–8.

Jennifer E. Fugate ∗ Alejandro A. Rabinstein Division of Critical Care Neurology, Mayo Clinic, Rochester, MN 55905, United States ∗ Corresponding

author at: Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States. E-mail address: [email protected] (J.E. Fugate) 17 November 2013

Life after cardiac arrest: better with time.

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