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Functional outcome, cognition and quality of life after out-of-hospital cardiac arrest and therapeutic hypothermia: Data from a randomized controlled trial

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  • Faculty of Medicine, University of Helsinki; Rehabilitation Foundation

Abstract and Figures

Background To study functional neurologic and cognitive outcome and health-related quality of life (HRQoL) in a cohort of patients included in a randomised controlled trial on glucose control following out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation (VF) treated with therapeutic hypothermia.Methods Patients alive at 6 months after being discharged from the hospital underwent clinical neurological and extensive neuropsychological examinations. Functional outcome was evaluated with the Cerebral Performance Category scale, the modified Rankin scale and the Barthel Index. Cognitive outcome was evaluated by neuropsychological test battery including two measures of each cognitive function: cognitive speed, execution, memory, verbal skills and visuospatial performance. We also assessed quality of life with a HRQoL 15D questionnaire.ResultsOf 90 OHCA-VF patients included in the original trial, 57 were alive at 6 months. Of these, 52 (91%) were functionally independent and 54 (95%) lived at their previous home. Focal neurological deficits were scarce. Intact cognitive performance was observed in 20 (49%), mild to moderate deficits in 14 (34%) and severe cognitive deficits in 7 (17%) of 41 patients assessed by a neuropsychologist. Cognitive impairments were most frequently detected in executive and memory functions. HRQoL of the CA survivors was comparable to that of age- and gender matched population.Conclusions Functional outcome six months after OHCA and therapeutic hypothermia was good in the great majority of the survivors, and half of them were cognitively intact. Of note, the HRQoL of CA survivors did not differ from that of age- and gender matched population.
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O R I G I N A L R E S E A R C H Open Access
Functional outcome, cognition and quality of life
after out-of-hospital cardiac arrest and therapeutic
hypothermia: data from a randomized controlled
trial
Marjaana Tiainen
1*
, Erja Poutiainen
1,2
, Tuomas Oksanen
3
, Kirsi-Maija Kaukonen
3
, Ville Pettilä
3
, Markus Skrifvars
3
,
Tero Varpula
3
and Maaret Castrén
4,5
Abstract
Background: To study functional neurologic and cognitive outcome and health-related quality of life (HRQoL) in a
cohort of patients included in a randomised controlled trial on glucose control following out-of-hospital cardiac arrest
(OHCA) from ventricular fibrillation (VF) treated with therapeutic hypothermia.
Methods: Patients alive at 6 months after being discharged from the hospital underwent clinical neurological and
extensive neuropsychological examinations. Functional outcome was evaluated with the Cerebral Performance
Category scale, the modified Rankin scale and the Barthel Index. Cognitive outcome was evaluated by
neuropsychological test battery including two measures of each cognitive function: cognitive speed, execution,
memory, verbal skills and visuospatial performance. We also assessed quality of life with a HRQoL 15D questionnaire.
Results: Of 90 OHCA-VF patients included in the original trial, 57 were alive at 6 months. Of these, 52 (91%) were
functionally independent and 54 (95%) lived at their previous home. Focal neurological deficits were scarce. Intact
cognitive performance was observed in 20 (49%), mild to moderate deficits in 14 (34%) and severe cognitive deficits in 7
(17%) of 41 patients assessed by a neuropsychologist. Cognitive impairments were most frequently detected in executive
and memory functions. HRQoL of the CA survivors was comparable to that of age- and gender matched population.
Conclusions: Functional outcome six months after OHCA and therapeutic hypothermia was good in the great majority
of the survivors, and half of them were cognitively intact. Of note, the HRQoL of CA survivors did not differ from that of
age- and gender matched population.
Keywords: Cardiac arrest, Neurological outcome, Cognition, Quality of life, Hypothermia
Background
The prognosis of patients resuscitated from out-of-hospital
cardiac arrest (OHCA) with ventricular fibrillation (VF) as
the initial rhythm has improved, as up to 55% of
hypothermia-treated OHCA-VF patients may achieve good
outcome [1-3]. Long-term mortality among patients dis-
charged alive after OHCA does not differ markedly from
that of myocardial infarct (MI) patients without OHCA
[4]. In a recent study of Lindner and colleagues, the five-
year survival rate for OHCA patients discharged from hos-
pital alive was 75%, and the mean potential life-years saved
per patient was 22.8 years [5]. However, not only survival
but also functional outcome and quality of life are import-
ant long-term outcomes.
Neurologic outcome after CA is commonly evaluated by
Glasgow-Pittsburgh Cerebral Performance Categories
(CPC) [6,7]. This five-step category classification is simple,
but it has a limited value in discriminating between mild
and moderate brain injury [8]. Cognitive deficits may
markedly impair the functional status of CA survivors
and their quality of life. Regrettably, the CPC classification
does not comprise cognitive impairment in conscious
* Correspondence: marjaana.tiainen@hus.fi
1
Department of Neurology, Helsinki University Hospital, Haartmaninkatu 4,
Helsinki 00029, Finland
Full list of author information is available at the end of the article
© 2015 Tiainen et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
(2015) 23:12
DOI 10.1186/s13049-014-0084-9
subjects, unless the impairment is severe. The increased
survival of OHCA-VF patients in the hypothermia-era
does not seem to be associated with decrease in survivors
with clinically significant cognitive deficits [9,10]. Compre-
hensive data on functional outcome of OHCA patients is
still limited. As the number of CA survivors is increasing,
there is clearly a need for data of their functional outcome
and quality of life.
Accordingly, we aimed to evaluate the functional
neurologic and cognitive outcome of hypothermia treated
OHCA-VF survivors and their quality of life in a cohort of
OHCA-VF patients included in a randomised controlled
trial on strict versus moderate glucose control.
Methods
This study protocol was approved by the ethics commit-
tee of the Helsinki University Central Hospital (HUCH).
All postresuscitation patients in the HUCH area with
witnessed OHCA caused by VF and admitted to the two
participating intensive care units (ICU) from November
2004 to December 2006 were screened for the SUGAR-
trial. The inclusion criteria were VF of presumed cardiac
origin, witnessed arrest, age 18 years, basic life support
(BLS) delay less than 15 min, return of spontaneous cir-
culation (ROSC) less than 35 min and unconsciousness
at hospital admission. Exclusion criteria were persistent
hypotension (mean arterial pressure below 65 mmHg for
over 30 min) despite therapy, pregnancy, terminal ill-
ness, pre-arrest illness limiting follow-up (eg. dementia),
or a do not attempt resuscitation order. After obtaining
informed consent from a close relative, patients were
randomized into a strict (46 mmol/l) or a moderate
(68 mmol/l) glucose control group for the first 48 hours
of treatment in the ICU. Short-acting insulin was used
in both groups as needed. All patients received thera-
peutic hypothermia of 33°C for 24 hours induced with
an intravascular cooling device (CoolGard, Zoll Medical
Corporation), followed by slow warming (warming rate
not exceeding 0.5°C per hour) to normothermia. General
treatment of the patients was conducted according to
the ICUs written standard protocols. The delay from
discontinuation of sedative medication to recovery of
consciousness (defined as ability to obey verbal com-
mands) was recorded. The cause of CA was classified as
acute MI, myocardial ischemia without infarction, pri-
mary arrhythmia, or other. The short-term outcome of
the SUGAR-trial has been published previously [11].
Evaluation of outcome
All patients alive 6 months after CA were contacted and in-
vited for a follow-up visit. The evaluation at follow-up visit
included an interview and standard neurologic examination
performed by the same board certified neurologist (MT).
For institutionalized patients the assessment included also
an interview with the nearest relatives and/or with nursing
staff. The neurological outcome was also assessed by modi-
fied Rankin Scale (mRs) [12], Barthel Index (BI) [13], and
National Institutes of Health stroke scale (NIHSS) [14].
Cognitive outcome was evaluated by neuropsychological
examination including two measures of each cognitive
function: cognitive speed, execution, memory, verbal skills
and visuospatial performance. Health-related quality of life
(HRQoL) was assessed by the 15D questionnaire [15]. The
neurologist and the neuropsychologist performing the eval-
uationswereunawareofthepatients glucose treatment
group. If a patient was not able or not willing to attend a
follow-up visit, a telephone interview was performed, with
evaluation of CPC, BI and mRs.
Modified Rankin scale is a widely applied measure of
global disability and handicap after stroke [12]. The scores
for patients alive range from 0 (no symptoms) to 5 (bed-
ridden, incontinent, and requires constant nursing care
and attention). Favourable outcome in stroke studies is de-
fined as mRs 0-2 (0 = no symptoms at all, 1 = no signifi-
cant disability despite symptoms, 2 = slight disability;
independent but unable to carry out all previous activ-
ities). The Barthel Index is a measure to assess an individ-
ual's ability to perform activities of daily living related to
self-care and mobility; for example, transfers, stairs, feed-
ing, dressing, personal care and bathing [13]. The range of
functionally independent outcome is 95 to 100. BI score
90-55 indicates moderate dependency, and score 50-0 in-
dicates full dependency. NIHSS is a widely used instru-
ment for the evaluation of neurologic impairment after
stroke [14]. A 15-item scale provides a quantitative meas-
ure of the key components of a standard neurologic exam-
ination, with higher scores indicating greater impairment.
Neuropsychological examination was designed to esti-
mate cognitive functions sensitive to CA related cogni-
tive deficits. Different cognitive functions were measured
by the Similarities, Block Design and Digit Symbol sub-
tests of the Wechsler Adult Intelligence Scale-Revised
(WAIS-R), and by the Logical Passages subtask of the
Wechsler Memory Scale-Revised (WMS-R) and the List
Learning task of the WMS-III [15-17]. Furthermore, the
Trail-Making Test (Parts A and B), the Interference and
naming subtasks of the modified Stroop Test, semantic
fluency task (animal names) and visual search task were
used [18,19]. A patients test performance was catego-
rized as normal or impaired using the cut point of one
standard deviation (SD) below the mean of the Finnish
normative sample. If among the 10 tests none or only
one (10%) was impaired a subjects cognitive perform-
ance was considered intact. When two to four tests (11-
49%) were below 1 SD cut point a cognitive functioning
was scored as mildly to moderately defective, and when
at least half of the tests (50%) were impaired it was
scored as severely defective.
Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:12 Page 2 of 7
15D is a generic, standardized, non-disease-specific
self-administered multidimensional measure of HRQoL
[20]. It has 15 dimensions: mobility, vision, hearing,
breathing, sleeping, eating, speech, elimination, usual
activities, mental function, discomfort and symptoms,
depression, distress, vitality and sexual activity. Each
dimension is divided into five grades of severity. The
15D can be used both as a profile and single index score
measure. The single index score, 15D score on a 01
scale, represents the overall HRQoL, and is calculated
from the health state descriptive system by using a set of
population-based preference or utility weights. The max-
imum score is 1 (no problems on any dimensions) and
the minimum score 0 (being dead). The minimal clinic-
ally significant difference in 15D is 0.03 [20]. The 15D
instrument has been tested in various states of illness,
e.g. in invasive treatment of coronary artery disease [21]
and stroke [22,23].
Statistical analysis
We present categorical variables as counts and percent-
ages, and non-normally distributed continuous data as
median and range, compared with the Mann-Whitney
U-test. We compared binary outcome data by Fishers
exact test. Correlations were analyzed by Spearmansrho-
test. Cognitive functions were analyzed using means and
standard deviations. P values < 0.05 were considered
statistically significant. We used the Statistica data
analysis software system® (StatSoft, Tulsa, OK, USA) to
analyze the data.
Results
At six months after CA, 57 patients (63%) of 90 patients
included in the study were alive and were contacted.
Outcome was assessed on a follow-up visit for 49 pa-
tients and by a phone interview for eight patients who
had no possibility for a visit (two living at a remote loca-
tion, three not willing to attend a visit, two patients not
being able to attend a visit due to other serious medical
conditions, one patient not speaking Finnish, Swedish
nor English interviewed by a translator). Figure 1 pre-
sents the flow-chart of study patients. The surviving pa-
tients were evaluated six to eight months (median
7.0 months) after the CA. Their clinical and demograph-
ical data are presented in Table 1. Diagnostic cardiologic
examinations and therapeutic interventions were com-
monly performed during the initial hospital stay. Coron-
ary angiography had been performed on 51 (89%)
patients, percutaneous coronary intervention (PCI) on
21 (37%) patients and coronary artery bypass grafting
(CABG) on 7 (12%) patients. Electrophysiological testing
had been performed on 17 (30%) patients and an im-
plantable cardioverter defibrillator (ICD) had been im-
planted in 19 (33%) of the 57 patients.
No difference was observed in the delay to recovery of
consciousness, CPC, cognitive outcome, NIHSS, mRs, BI
outcome or HRQoL between the strict and moderate
glucose groups (data not shown). Therefore we present
the outcome data as one group.
At evaluation after CA, CPC 1 outcome had been
achieved by 38 patients (42%), CPC 2 by 12 patients
(13%), and CPC 3 by 7 patients (8%). None of the pa-
tients were in persistent vegetative state (CPC 4), and 33
(37%) had died (CPC 5). Two patients with CPC 2 out-
come had already pre-arrest CPC of 2, and post-arrest
CPC 3 patients included one patient with a pre-arrest
CPC level of 3 and two patients with pre-arrest CPC of
2. Thus, favourable outcome after CA (CPC 1 or 2) was
observed in 50 (88% of 57 survivors and 56% of all 90
randomized patients). See Table 2 for additional data on
functional outcome.
The distribution of CPC, mRs, BI and NIHSS scores
among the survivors are presented as Figure 2. Median
[IQR] mRs score was 0 [0-2], median BI score 100 [100-
100] and median NIHSS score 0 [0-0]. Of 57 survivors,
the outcome was good in 52 (91%) by Barthel Index
(BI 95-100), and in 50 (88%) by mRS (mRS 0-2).
90 patients randomized to
SUGAR-trial
58 patients (64%) discharged
fro m hosp ital
32 patients (36%)
died during hospital
stay; six w ith
recovery of
consciousness
1 patient died before
six months
57 patients (63%) alive and
contacted six months after cardiac
arrest
8 patients with no
possibility to visit
evaluated by
telephone
49 patients attended
follow-up visit
41 patients attended
neuropsychological
examination
8 patients excluded
from
neuropsychological
examination:
3 refused, 5 with
interfer ing cond itions
Figure 1 Flow-chart of study patients.
Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:12 Page 3 of 7
Neurological sequels of CA were relatively few. Two
patients suffered also an ischemic stroke during the
hospitalization for CA, and one of them presented with
aphasia and apraxia with NIHSS score of 12. One patient
had been diagnosed with post-arrest epilepsy (secondar-
ily generalized seizures) and used antiepileptic medica-
tion with good seizure-control. Another patient had
experienced focal myoclonic jerks, which had spontan-
eously declined over time.
Neuropsychological examination could be performed
to 41 of the 49 patients attending follow-up visit (72% of
all 57 patients alive). Reasons for exclusion were chronic
conditions affecting cognitive skills (N = 4; two patients
with mental retardation, one patient with chronic
schizophrenia and one patient with frontal infarct not
able to co-operate), refusal (N = 3) and poor general con-
dition (N = 1). Of 41, 20 (49%) were cognitively intact,
14 (34%) had mild to moderate cognitive deficits and
severe cognitive deficits were found in 7 patients (17%).
Cognitive deficits were predominantly detected in execu-
tive and memory functions.
The 15D profile of studied patients compared to age-
and gender matched normal population sample (N = 5689)
is presented in Figure 3. The 15D total score of studied pa-
tients did not differ from the score of age- and gender
matched general population (0.883 vs 0.904, p = 0.112).
The scores for two dimensions, usual activities and sexual
activities, were significantly lower, whereas the score for
one dimension, discomfort and symptoms, was signifi-
cantly better than the respective scores in the general
population sample matched with the gender and age distri-
bution of the patients. Both mRs and CPC scores and clas-
sification by cognition correlated with self-assessed 15D
total score (for CPC r = -0.425, for mRs r = -0.574, for cog-
nition r = -0.317, p < 0.05). The 15D total score differed
significantly between patients with mRs 0 and 1 (me-
dian score 0.952 vs 0.851, p = 0.012), between mRs 0
and 2 (median score 0.952 vs 0.730, p = 0.003) and be-
tween 0 and 1-2 (median score 0.952 vs 0.840, p < 0.001).
The 15D total score difference was also significant be-
tween patients with CPC 1 and 2 (median score 0.939 vs
0.824, p = 0.017). However, the 15D total score did not dif-
fer between cognitively intact subjects and those with mild
to moderate cognitive deficits (0.952 vs 0.885, p = 0.323).
Discussion
We found that 91% of OHCA-VF patients surviving six
months after CA were functionally independent and
95% of survivors had been able to return to their home.
Table 1 Clinical and demographical data on patients alive
six months after out-of-hospital cardiac arrest (N = 57)
Age, years 59 (24-78)
Male 44 (77%)
Bystander initiated CPR 38 (67%)
BLS, min 8 (2-14)
ACLS, min 14.5 (6-100)
ROSC, min 17 (7-33)
Length of ICU stay, days 7 (3-38)
Serum NSE at 24 hours, mmol/L 16.0 (8.6-41.2)
Serum NSE at 48 hours, mmol/L 14.8 (6.8-33.1)
Delay to recovery of consciousness, days 1 (0-7)
The aetiology of cardiac arrest
Acute myocardial infarction 21 (37%)
Myocardial ischemia without infarction 11 (19%)
Arrhythmia 22 (39%)
Other 3 (5%)*
Pre-arrest medical history of
Coronary heart disease 13 (23%)
Acute myocardial infarction 10 (18%)
Ventricular tachycardia or ventricular fibrillation 2 (4%)
Cardiac insufficiency 11 (19%)
Hypertension 23 (40%)
Diabetes 7 (12%)
Hyperlipidemia, medication prescribed 13 (23%)
Smoker/ex-smoker 18 / 11 (32/19%)
Data are given as absolute numbers (percentage) or as median and range.
CPR = cardiopulmonary resuscitation, BLS = basic life support, ACLS = advanced
cardiac life support, ROSC = restoration of spontaneous circulation, ICU =
intensive care unit, NSE = neuron specific enolase. Delay to rec overy of
consciousness has been counted from the withdrawal of sedative medication.
*Other aetiology of cardiac arrest: unknown for one subject, technical failure
of an implantable cardioverter defibrillator in one subject, and myocardial
sarcoidosis in one subject.
Table 2 Functional outcome of patients alive six months
after cardiac arrest (N = 57)
Lives at home 52 (91%)
Lives with family 46 (81%)
Lives alone 6 (11%)
Receives some help from family members 8 (15%)
Receives some help from social home-care system* 1 (2%)
Institutional care 5 (9%)
Sheltered home** 2 (4%)
Nursing home 1 (2%)
Long-term hospital 2 (4%)
Employed at the time of cardiac arrest 26 (46%)
Returned to previous employment 16 (61%)
On sick-leave, returned to work later on 3 (12%)
Retired from previous work due to the event 7 (27%)
Data are given as absolute numbers (percentage). *One alone-living patient
received help from a home-care nurse once a week with medication dispensing.
**These two patients had already lived in a sheltered home before
cardiac arrest.
Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:12 Page 4 of 7
Furthermore, the HRQoL of CA survivors did not differ
from that of age- and sex-matched normal population.
The proportion of independent patients in this study
was higher than the previously reported 65% one year
after CA from the pre-hypothermia era [24], and
comparable to that of hypothermia-treated patients re-
ported by Cronberg et al [25]. Focal neurological senso-
motor deficits among CA survivors are relatively
scarce, which was also reflected in the low NIHSS
scores among our study patients. The CPC outcome in
NIHSS ou tcome
0
5
10
15
20
25
30
35
40
45
50
NIHSS 0 NIHSS 1-4 NIHSS 5-10 NIHSS 10-12 NIHSS >12
stneitapforebmun
CPC outcome
0
5
10
15
20
25
30
35
40
CPC 1 CPC 2 CPC 3 CPC 4
s
t
n
ei
tapf
o
rebmuN
modifie d Rankin scale outc ome
0
5
10
15
20
25
30
35
mRs 0 mRs 1 mRs 2 mRs 3 mRs 4 mRs 5
stneit
a
pfor
e
b
m
un
Barthel Index outcome
0
10
20
30
40
50
60
BI 95-100 BI 55-90 BI 0-50
stneitapforebmun
Figure 2 CPC, Modified Rankin, Barthel Index and NIHSS six months after cardiac arrest. y-axis shows the percentage of patients.
0,6
0,65
0,7
0,75
0,8
0,85
0,9
0,95
1
Mobility
Vison
Hearing
Breathing
Sleeping
Eating
Speech
Elimination
Usual acti vitie s
Mentalfunction
Discomfort
Depression
Distress
Vitality
Sex ual a ctivity
Dimensions
Level val ue
Population
Patients
15D score
Population 0.904
Patients 0.883
* p=0.001, ** p=0.01
*
*
**
Figure 3 Self-assessed health-related quality of life by 15D in cardiac arrest survivors at six months compared to age- and gender
matched population.
Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:12 Page 5 of 7
our study was comparable to that of our Hypothermia
After Cardiac Arrest -study patients [26]. In resuscita-
tion studies it is usually assumed that all CA patients
have a pre-arrest CPC level of 1, which is not the case
in clinical settings. Thus, measuring change from as-
sumed pre-arrest CPC level in addition to the achieved
CPC level could reflect more accurately the clinical
outcome.
Recent large prospective multicenter study reported
that in medical and surgical ICU patients one out of four
patients had cognitive impairment 12 months after crit-
ical illness, similar in severity to that of patients with
mild Alzheimers disease; and that neurocognitive dys-
function occurred both in young and old patients [27].
Neuropsychological deficits are common in survivors of
CA, ranging from mild deficits in memory and executive
functions to severe amnestic syndrome. In the present
study half of studied survivors were cognitively intact at
six months after CA. As in previous studies with detailed
cognitive testing [9,25,28], the most frequent cognitive
deficits were found in memory and executive functions.
Extensive neuropsychological testing is not routinely of-
fered for all CA survivors, and studies concentrating on
predictors of cognitive outcome would be of great import-
ance in order to detect survivors needing further cognitive
evaluation and rehabilitation. Mild or moderate cognitive
impairments do not necessarily translate to deficits in the
activities in the daily living or threaten independency, but
especially in the current demanding work life even subtle
cognitive deficits may severely impair the personsworking
capacity. Recognition of cognitive defects would thus be
important, as awareness of limitations enables the use of
compensating strategies. In our study 73% of survivors
employed at the time of CA returned to work. This high
percentage could be related to the relatively small number
of patients, but in previous studies this number has also
been quite high, between 42-79% [25,29-31].
In the study of Hsu et al, the CPC score at hospital
discharge correlated poorly with all categories of the
QoL measurements performed at least 6 months later
[32]. In our study the HRQoL score correlated well with
CPC and mRs assessed by a neurologist at six-months
after CA. Of note, for both CPC and mRs, there were
significant differences in HRQoL between outcome clas-
ses generally regarded as good outcome (CPC 1-2 and
mRs 0-2). It seems that even mild residual symptoms are
reflected as lower self-assessed QoL. On the other hand,
mild to moderate cognitive deficits did not result in sig-
nificantly lower self-assessed HRQoL. A possible explan-
ation for this is that 15D emphasizes physical symptoms,
compared to cognitive complaints. It is also possible that
patients with mild cognitive decline manage quite well in
familiar environment, adapt to their deficits, or alterna-
tively are unaware of their cognitive deficits. Further
studies examining the association of cognition and quality
of life using methods sensitive to symptoms caused by
cognitive deficits would be of importance.
Previous studies have suggested that most survivors of
out-of-hospital CA present a satisfactory quality of life
comparable to that of age- and disease-matched controls
[33-38]. In the study of Cronberg et al, CA survivors
had a slightly lower HRQoL measured by the EQ-5D
Visual Analogue Scale than an age-adjusted healthy co-
hort [25]. In our study the HRQoL of CA survivors did
not differ from that of age- and sex-matched control
population. In fact, their overall HRQoL measured by
the 15D single index score (median 0.883) was higher
than previously published scores for patients with coron-
ary artery disease six months after CABG (mean 0.858,
SD 0.110) or PCI (mean 0.847, SD 0.105) [21] and higher
than after stroke (median 0.86 [22], mean 0.801 [23]).
This study has some important limitations. First, 28% of
patients did not attend the neuropsychological examin-
ation. It is possible that subjects with cognitive deficits
were more prone to refuse the neuropsychological exam-
ination which may have caused bias. Second, we cannot
exclude the possibility that some of the noticed cognitive
deficits existed already before CA, although we tried to ex-
clude patients with pre-existing major cognitive impair-
ment. Third, due to the strict inclusion and exclusion
criteria, the results cannot be generalized to all OHCA
patients treated in the ICU with hypothermia. Finally, the
number of patients was inadequate to find any differences
between standard and intensive glucose control, if present.
Therefore, we analyzed the patients as one group.
Conclusions
In this study the functional outcome six months after
CA and therapeutic hypothermia was good (CPC1-2) in
88% of the survivors, and half of them were cognitively
intact. 95% of survivors had been able to return to their
home, and 73% of patients employed at the time of CA
had returned to work. Those who survived to six
months after CA had quality of life comparable to
age- and gender-matched population.
Competing interests
The authors declare that they have no competing interests.
Authorscontributions
MT, EP, TO, VP and TV obtained the data. MT, EP, TO and VP researched data.
MT and EP wrote the manuscript. MS, KMK and MC reviewed and edited the
manuscript. All authors read and approved the final manuscript.
Acknowledgements
The authors would like to thank professor Harri Sintonen, University of
Helsinki, for his help in analyzing 15D data. Marjaana Tiainen has received
support from the Maire Taponen foundation.
Author details
1
Department of Neurology, Helsinki University Hospital, Haartmaninkatu 4,
Helsinki 00029, Finland.
2
Institute of Behavioral Sciences, University of
Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:12 Page 6 of 7
Helsinki, Helsinki, Finland.
3
Intensive Care Units, Department of
Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital,
Helsinki, Finland.
4
Karolinska Institutet, Institution of Clinical Science and
Education and Stockholm, Stockholm, Sweden.
5
Helsinki University and
HUCH Emergency Care, Helsinki University Hospital, Helsinki, Finland.
Received: 22 August 2014 Accepted: 30 December 2014
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Tiainen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2015) 23:12 Page 7 of 7
... Unter Überlebenden nach Kreislaufstillstand, die mit einem guten Ergebnis eingestuft wurden, können sich die Auswirkungen einer hypoxischischämischen Hirnschädigung auf den Alltag auswirken. Die am häufigsten gemeldeten neurologischen Folgen sind neurokognitive Beeinträchtigungen für alle Überlebenden in der frühen Phase [146] und in etwa 40-50 % langfristig [147][148][149][150][151]. Die meisten Verbesserungen der Wahrnehmung treten in den ersten drei Monaten auf [152,153], es wurden jedoch bis zu einem Jahr später noch Verbesserungen beschrieben [152]. ...
... In einer spanischen Studie hatte die Hälfte der Überlebenden (n = 79) drei Jahre nach dem Ereignis eine kognitive Beeinträchtigung [147]. Eine kognitive Beeinträchtigung in der chronischen Phase ist meist leicht bis mittelschwer, bei 20 bis 26 % der Überlebenden wird jedoch eine mittelschwere bis schwere Beeinträchtigung festgestellt [149,151,154]. Zu den am häufigsten betroffenen kognitiven Domänen gehören: episodisches/Langzeitgedächtnis [147,[149][150][151]154]; Aufmerksamkeits-/ Verarbeitungsgeschwindigkeit [147,149,150,154] und ausführende Funktionen [147,150,151,153,154]. ...
... Eine kognitive Beeinträchtigung in der chronischen Phase ist meist leicht bis mittelschwer, bei 20 bis 26 % der Überlebenden wird jedoch eine mittelschwere bis schwere Beeinträchtigung festgestellt [149,151,154]. Zu den am häufigsten betroffenen kognitiven Domänen gehören: episodisches/Langzeitgedächtnis [147,[149][150][151]154]; Aufmerksamkeits-/ Verarbeitungsgeschwindigkeit [147,149,150,154] und ausführende Funktionen [147,150,151,153,154]. Es wurden auch Beeinträchtigungen in anderen Domänen beschrieben [148,154]. ...
Article
In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in- and out-of-hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to provide support for health system planning and responses to cardiac arrest.
... B. der Cerebral Performance Categories (CPC), der modifizierten Rankin Scale (mRS) oder der Glasgow Outcome Scale/Extended (GOS/E; [293,414,[434][435][436]). Diese Skalen sind jedoch nicht sensitiv genug, um die Probleme zu erfassen, mit denen viele Überlebende konfrontiert sind, einschließlich kognitiver, emotionaler und physischer Probleme und Müdigkeit [437][438][439]. Tatsächlich haben ungefähr 40-50 % der Überlebenden langfristige kognitive Beeinträchtigungen [232,440,441]. Beeinträchtigungen sind meist leicht bis mittelschwer, und obwohl alle kognitiven Bereiche betroffen sein können, treten die meisten Probleme im Gedächtnis, in der Aufmerksamkeit, in der Verarbeitungsgeschwindigkeit und bei sog. ...
... exekutiven Funktionen auf (z. B. Planung, Organisation, Initiierung, Flexibilität; [232,437,[440][441][442]). Im Allgemeinen erfolgt der Großteil der kognitiven Erholung in den ersten 3 Monaten nach dem Kreislaufstillstand [443][444][445]. ...
... Nach der Entlassung können die meisten Überlebenden nach Hause zurückkehren und nur ein kleiner Prozentsatz (1-10 %) muss in eine Langzeitpflegeeinrichtung verlegt werden [446,456,457]. Die große Mehrheit (82-91 %) ist in ihren grundlegenden Aktivitäten des täglichen Lebens (ATL) unabhängig [231,440,453,456]. Obwohl die meisten Überlebenden in der Lage sind, ihre Aktivitäten von vor dem Kreislaufstillstand wieder aufzunehmen, erleben sie mehr Einschrän-kungen der sozialen Kontakte im Vergleich zu Patienten mit Myokardinfarkt [446,452]. ...
Article
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation phase guidelines for adults, which are based on the 2020 International Liaison Committee on Resuscitation consensus on cardiopulmonary resuscitation.The topics covered include post-cardiac arrest syndrome, the differential diagnosis of the causes of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
... However, these measures are not sufficiently sensitive to capture the problems that many of the survivors experience, including cognitive, emotional and physical problems and fatigue [435][436][437]. In fact, approximately 40-50% of the survivors have long-term cognitive impairments [229,438,439]. Impairments are mostly mild to moderate and, although all cognitive domains can be affected, most problems are seen in memory, attention, processing speed and executive functioning (e.g. ...
... Impairments are mostly mild to moderate and, although all cognitive domains can be affected, most problems are seen in memory, attention, processing speed and executive functioning (e.g. planning, organisation, initiation, flexibility) [229,435,[438][439][440]. In general, most cognitive recovery occurs during the first 3 months after the cardiac arrest [441][442][443]. ...
... After discharge, most survivors are able to return home and only a small percentage (1-10%) need to be admitted to a long-term care facility [444,454,455]. The large majority (82-91%) are independent in their basic activities of daily living (ADL) [228,438,451,454]. Although most survivors are able to resume their pre-arrest activities, they experience more restrictions in societal participation compared with myocardial infarction patients [444,450]. ...
Article
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
... 435À437 In fact, approximately 40 À50% of the survivors have long-term cognitive impairments. 229,438,439 Impairments are mostly mild to moderate and, although all cognitive domains can be affected, most problems are seen in memory, attention, processing speed and executive functioning (e.g. planning, organisation, initiation, flexibility). ...
... 444,454,455 The large majority (82À91%) are independent in their basic activities of daily living (ADL). 228,438,451,454 Although most survivors are able to resume their pre-arrest activities, they experience more restrictions in societal participation compared with myocardial infarction patients. 444,450 Cognitive impairments, depression, fatigue and restricted mobility are negative predictors for future participation. ...
Article
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
... In the latter, HRQOL of cardiac arrest survivors is described as moderately impaired compared to population norms [4][5][6]. However, the vast majority of cardiac arrest survivors included in these observational studies were resuscitated from initial shockable rhythm [7,8] ; this could constitute a bias as brain injury is different in terms of pathogenesis and impairment in these patients compared to those resuscitated from non-shockable cardiac arrest [9]. ...
Article
Full-text available
Background Intensive care has a strong impact on health-related quality of life (HRQOL). The specific impact of cardiac arrest in non-shockable rhythm is poorly known. Patients and methods We gathered patients included in two randomized controlled trials (AWARE and HYPERION). The HYPERION trial included ICU-treated non-shockable cardiac arrest patients. The AWARE study included ICU patients requiring mechanical ventilation. We compared the 3-months HRQOL of these patients to those of a large sample of the French general population. Physical and mental dimension were compared. Multivariable linear regression was used to pick up factors associated with HRQOL. Results 72 and 307 patients of the HYPERION and the AWARE studies were compared to 20,574 French controls. ICU patients evidenced lower scores in all the SF-36 dimensions compared to the controls. Similar scores were observed in both HYPERION and AWARe trials. The physical component score was lower in patients from the HYPERION trial compared to those from the AWARE trials and to controls (38.6 [29.6-47.8], 35.4 [27.5-46.4] vs. 53.0 [46.0-56.7], $$\hbox {p}<0.001$$ p < 0.001 ). After adjustment for age and gender, HYPERION and AWARE trial status were associated wit lower physical component score. Conclusion Health-related quality of life of unshockable cardiac arrest survivors evaluated at 3 months was similar to ICU survivors and significantly lower than in individuals from general population, especially in the physical dimensions.
... 1,2 There is mounting evidence of persistent long-term difficulties following OHCA, affecting different physical, cognitive and psychosocial domains. These include but are not limited to fatigue 3 , difficulties with memory and other cognitive abilities, 4,5 difficulties in returning to work/driving/other activities of daily living, 6,7 pain, 8 and significant levels of anxiety, depression, and Post Traumatic Stress Disorder (PTSD). 9 The reported incidence and prevalence of these difficulties vary in the scientific literature, possibly due in part to the variable timing of the follow-up, as some issues tend to manifest themselves in different ways at different points in time 10 A recent scientific statement from the American Heart Association highlighted these challenges and the knowledge gaps around survivorship care. ...
Article
Full-text available
Background and objectives Cognitive and physical difficulties are common in survivors of out-of-hospital cardiac arrest (OHCA); both survivors and close family members are also at risk of developing mood disorders. In the UK, dedicated follow-up pathways for OHCA survivors and their family are lacking. A cohort of survivors and family members were surveyed regarding their experience of post-discharge care and their recommended improvements. Method 123 OHCA survivors and 39 family members completed questionnaires during an educational event or later online. Questions addressed both the actual follow-up offered and the perceived requirements for optimal follow-up from the patient and family perspective, including consideration of timing, professionals involved, involvement of family members and areas they felt should be covered. Results Outpatient follow-up was commonly arranged after OHCA (77%). This was most often conducted by a cardiologist alone (80%) but survivors suggested that other professionals should also be involved (e.g. psychologist/counsellor, 64%). Topics recommended for consideration included cardiac arrest-related issues (heart disease; cause of arrest) mental fatigue/sleep disturbance, cognitive problems, emotional problems and daily activities. Most survivors advocated an early review (<1month; 61%). Most family members reported some psychological difficulties (95%); many of them (95%) advocated a dedicated follow-up appointment for family members of survivors. Conclusions The majority of OHCA survivors advocated an early follow-up following hospital discharge and a holistic, multidimensional assessment of arrest sequelae. These results suggest that current OHCA follow-up often fails to address patient-centred issues and to provide access to professionals deemed important by survivors and family members.
... It is associated with a lower quality of life. [224][225][226][227][228][229] After intensive care, muscle weakness, gait impairment, dysphagia, and cardiopulmonary impairment are also common. 230 Therefore, we recommend that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurological, cardiopulmonary, and cognitive impairments before hospital discharge. ...
Article
Objective Time is critical with any out of hospital cardiac arrest (OHCA). The possibility of brain cell death increases, and the likelihood of a “good” outcome decreases with time. The most prominent impairments involve memory and attentional difficulties. Limited research and few cases have shown positive cognitive results following an OHCA to the extent that this case study depicts. Method The current case study presents a right-handed male in his late 40s, with master’s and law degrees, and a high-level functioning in the workplace who experienced an OHCA. He was treated for his OHCA and subsequently underwent neuropsychological testing less than 2 months following his hospital discharge. Results Expected results suggest impairments in key cognitive areas; however, a neuropsychological exam less than 2-months post-incident, testing pre-morbid IQ, overall cognitive ability, processing speed, attention, executive functioning, language, visuospatial abilities, and memory; each showing normal or better results. Additionally, self and collateral report questionnaires examining cognitive and emotional functioning reported no difficulties and no major changes since his cardiac arrest. Conclusions We speculate that this patient’s exceptional outcome might be due to his cognitive reserve, and the immediateness of his intervention (5–10 min of CPR and return-of-spontaneous-circulation from an AED shock) and use of a saline cooling procedure upon arrival to the hospital. Overall, we highlight a patient with a remarkable cognitive outcome, utilizing data from neuropsychological testing within 2-months post-incident, and propose protective factors in neuropsychological functioning following an OHCA.
Article
Objectives: The primary aim of this review was to investigate neurocognitive outcomes following out-of-hospital cardiac arrest (OHCA). Specifically, the focus was on identifying the different neurocognitive domains that are assessed, the measures used, and the level of, and criteria for, impairment. Design and review methods: A systematic review of the literature from 2006 to 2021 was completed using Medline, Cinahl and Psychinfo. Criteria for inclusion were studies with participants over the age of 18, OHCA and at least one neurocognitive function measure. Qualitative and case studies were excluded. Reviewers assessed criteria and risk of bias using a modified version of Downs and Black. Results: Forty-three studies were identified. Most studies had a low risk of bias (n=31) or moderate risk of bias (n=11) and one had a high risk; however, only six reported effect sizes or power analyses. Multiple measures of neurocognitive outcomes were used (>50) and level of impairment criteria varied considerably. Memory impairments were frequently found and were also more likely to be impaired followed by executive function and processing speed. Discussion: This review highlights the heterogeneity of measures and approaches used to assess neurocognitive outcomes following OHCA as well as the need to improve risk of bias concerning generalizability. Improved understanding of the approaches used for assessment and the subsequent findings will facilitate a standardized evaluation of neurocognitive outcomes following OHCA.
Article
Background. Abnormalities of cellular calcium homeostasis have been implicated in the pathophysiology of postischemic encephalopathy. Calcium-entry—blocking drugs inhibit the influx of calcium into cells and have been shown to mitigate postischemic encephalopathy in animal models. Methods. Five hundred twenty patients with cardiac arrest who remained comatose after the restoration of spontaneous circulation were randomly assigned to receive three doses of lidoflazine, an experimental calcium-entry blocker, or a placebo and were followed for six months. Four patients were lost to follow-up. Treated patients received an intravenous loading dose (1 mg per kilogram of body weight) of lidoflazine and two subsequent doses (0.25 mg per kilogram) 8 and 16 hours after resuscitation. The investigators were blinded to treatment assignment. Results. There was no statistically significant difference between the lidoflazine group (n = 259) and the placebo group (n = 257) in the proportion of patients who died during the six-month follow-up (82 vs. 83 percent), who survived with good cerebral recovery (15 vs. 13 percent), or who survived with severe neurologic deficit (1.2 vs. 1.9 percent). Analysis of the best level of recovery achieved at any time during follow-up also did not show a difference between the treatment groups: 24 percent of those given lidoflazine and 23 percent of those given placebo recovered good cerebral function (normal or only moderately disabled cerebral performance) at some time. Conclusions. The administration of lidoflazine after cardiac arrest was not found to be beneficial. Our data do not support the routine use of this calcium-entry—blocking drug in comatose survivors of cardiac arrest. (N Engl J Med 1991;324:1225–31.)
Article
Background Cardiac arrest with widespread cerebral ischemia frequently leads to severe neurologic impairment. We studied whether mild systemic hypothermia increases the rate of neurologic recovery after resuscitation from cardiac arrest due to ventricular fibrillation. Methods In this multicenter trial with blinded assessment of the outcome, patients who had been resuscitated after cardiac arrest due to ventricular fibrillation were randomly assigned to undergo therapeutic hypothermia (target temperature, 32°C to 34°C, measured in the bladder) over a period of 24 hours or to receive standard treatment with normothermia. The primary end point was a favorable neurologic outcome within six months after cardiac arrest; secondary end points were mortality within six months and the rate of complications within seven days. Results Seventy-five of the 136 patients in the hypothermia group for whom data were available (55 percent) had a favorable neurologic outcome (cerebral-performance category, 1 [good recovery] or 2 [moderate disability]), as compared with 54 of 137 (39 percent) in the normothermia group (risk ratio, 1.40; 95 percent confidence interval, 1.08 to 1.81). Mortality at six months was 41 percent in the hypothermia group (56 of 137 patients died), as compared with 55 percent in the normothermia group (76 of 138 patients; risk ratio, 0.74; 95 percent confidence interval, 0.58 to 0.95). The complication rate did not differ significantly between the two groups. Conclusions In patients who have been successfully resuscitated after cardiac arrest due to ventricular fibrillation, therapeutic mild hypothermia increased the rate of a favorable neurologic outcome and reduced mortality.
Article
Aim of the study: Out-of-hospital cardiac arrest (OHCA) accounts for many unexpected deaths in Europe and the survival rates in different regions vary considerably. We have previously reported excellent survival to discharge rates in the Stavanger region. We now describe the long-term outcome of OHCA victims in our region. Methods: In this retrospective observational study, we followed all OHCA hospital discharge survivors between 01.07.2002 and 30.06.2011 (n=213) for a minimum of 1 year and up to 10 years. Based on the national death statistics stratified for gender and age, we could calculate the potential life years saved, standardised mortality rates (SMR) and delineate the causes of death after hospital discharge. Results: Of the 213 patients who were discharged from the hospital, 91% had a cardiac origin of their OHCA. The mean potential life years saved per patient was 22.8 years. The observed five-year survival rate was 76%. The overall SMR in our study cohort was 2.3 when compared to the age- and gender-matched population. Cardiac disease was a prominent cause of late deaths, with the specific SMR for cardiac disease-related deaths being as high as 42 in males and 140 in females. Conclusion: Resuscitation of OHCA victims lead to a significant long-term benefit with respect to life years saved. Cardiac disease was the main cause of death after hospital discharge. More studies are needed to identify the potential of therapeutic interventions and rehabilitation efforts that may further enhance the long-term outcomes in OHCA hospital discharge survivors.
Article
Aim of the study To describe differences over time in outcome, physical and cognitive function among survivors of cardiac arrest treated with hypothermia and to examine survivors’ life satisfaction 6 months after cardiac arrest as well as gender differences. Methods The study was prospective and included 45 cardiac arrest survivors admitted to three Swedish hospitals between 2008 and 2012. Participants were followed from intensive care unit discharge to one and six months after cardiac arrest. In addition to cerebral performance category (CPC), participants were asked to complete questionnaires regarding activities in daily life (Barthel Index), cognitive function (Mini Mental State Examination) and life satisfaction (LiSat-11). Results Outcome measured using CPC scores improved over time. At 6 months, all participants were classified as having a good outcome. At one month, participants were impaired but improved over time in their activities in daily life and cognitive function. At 6 months satisfaction with “life as a whole” was seen in 70%. Conclusions Cardiac arrest survivors are satisfied with life as a whole despite a severe illness that has impaired their physical and cognitive function, which seemed to improve over time. Predicting patients’ functional outcome in early stages is difficult, and the CPC score alone is not sufficient to assess patients’ function. It is a need to reach a consensus to which instruments best reflect physical and cognitive function as well as to specify a rehabilitation plan
Article
Background Mortality after out-of-hospital cardiac arrest from ventricular fibrillation is high. Programs focusing on early defibrillation have improved the rate of survival to hospital discharge. We conducted a population-based analysis of the long-term outcome and quality of life of survivors. Methods All patients who had an out-of-hospital cardiac arrest between November 1990 and January 2001 who received early defibrillation for ventricular fibrillation in Olmsted County, Minnesota, were included. The survival rate was compared with that of an age-, sex-, and disease-matched (2:1) control population of residents who had not had an out-of-hospital cardiac arrest and with that of age- and sex-matched controls from the general U.S. population. The quality of life was assessed with use of the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and compared with U.S. population norms. Results Of 200 patients who presented with an out-of-hospital cardiac arrest with ventricular fibrillat...