A change of perspective? An explorative study on why patients may not subjectively report cognitive impairments after a cardiac arrest.

AIM: Cardiac arrest survivors are at risk of long-term cognitive impairment. Patients with cognitive impairments do not always have cognitive complaints and vice versa. Not reporting cognitive complaints could be caused by a lack of awareness. We hypothesized that caregivers report more cognitive failures than patients, indicating patients' lack of insight into cognitive functioning. METHODS: This is a secondary analysis of the Activity and Life After Survival of Cardiac Arrest study on survivors of cardiac arrest and their caregivers. They were assessed at two weeks, three months, and one year after cardiac arrest. At each time point, the patient and the caregiver filled out the cognitive failure questionnaire (CFQ) regarding the patient. We analysed the correlation, intraclass correlation, and self-proxy discrepancy between patients and caregivers on the CFQ over time. RESULTS: One-hundred-and-nineteen cardiac arrest survivors (mean age = 60, 85 % male) and their caregivers were included. The CFQ scores of the patients and caregivers were equally low. The correlation (T1 r = 0.31; T2 r = 0.40; T3 r = 0.55) and intraclass correlation (T1 r = 0.48; T2 r = 0.56; T3 r = 0.71) between patient and caregiver increased over time. CONCLUSION: This study does not support a lack of awareness of cognitive impairments by long-term cardiac arrest survivors. Future research may focus on alternative explanations for why patients have less cognitive complaints than expected based on the frequency of cognitive impairments. Possible explanations include a response shift.

European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care.

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.

European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care.

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.

Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation.

More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.

Care After REsuscitation: Implementation of the United Kingdom's First Dedicated Multidisciplinary Follow-Up Program for Survivors of Out-of-Hospital Cardiac Arrest.

Survival rates after cardiac arrest (CA) are increasing, with more patients and their families living with the psychological consequences of surviving a sudden CA. The currently available neuropsychological assessment tools and therapies were not designed for CA, and may be inadequate. The Essex Cardiothoracic Centre set up the United Kingdom's first dedicated multidisciplinary "Care After REsuscitation" (CARE) service, offering CA survivors and their caregivers systematic psychological, cognitive, and specialized medical support for the first 6 months after CA. Twenty-one patients were recruited into the CARE pilot service evaluation. Patients' health at hospital discharge was poor; however, by 6 months all components (except general health) had improved significantly, and were close to that experienced by "healthy" individuals. Five (26%) required referral to a psychiatrist, with all 5 (26%) subsequently being diagnosed with moderate-to-severe depression, and 3 (16%) with comorbid post-traumatic stress disorder. Our study demonstrates a large unmet clinical need in general and neuropsychological assessment, and our results suggest that offering appropriate and prompt specialist diagnosis and therapies leads to an improvement in health at 6 months.

Out-of-hospital cardiac arrest survivors need both cardiological and neurological rehabilitation!

PURPOSE OF REVIEW: Most survivors of out-of-hospital cardiac arrest (OHCA) suffer from cardiologic symptoms and approximately half of them experience cognitive problems because of hypoxic brain damage. Symptoms of anxiety and depression are also common. This review aims to give an overview of recent literature on rehabilitation treatment aiming at improvement of quality of life after OHCA. RECENT FINDINGS: Existing cognitive screening tools are now validated for OHCA survivors. OHCA patients with cognitive deficits may have lower exercise capacity. Cardiac rehabilitation seems to be well tolerated for OHCA survivors, with outcomes comparable to myocardial infarction patients. Many caregivers suffer from posttraumatic stress disorder and emotional stress. Interventions for them are available. Implementation of integrated programs covering both cognitive and cardiac rehabilitation is hampered by lack of knowledge and organizational barriers. SUMMARY: OHCA survivors should be routinely screened for cognitive and emotional problems. When patients with mild cognitive deficits participate in cardiac rehabilitation, their program should be adjusted to their cognitive abilities. For patients with severe cognitive or emotional problems, individualized rehabilitation seems favorable. Integrated rehabilitation treatment between cardiac and cognitive rehabilitation departments is recommended. Attention should be paid to the burden of caregivers.

Long-term quality of life of caregivers of cardiac arrest survivors and the impact of witnessing a cardiac event of a close relative.

BACKGROUND: The incidence of cardiac arrest is high, with a poor survival rate of 8-14%. Currently, only limited evidence is available about long-term consequences of cardiac arrest on quality of life of caregivers. AIMS: First, to determine the level of daily functioning and quality of life in caregivers of cardiac arrest survivors two years after the cardiac arrest. Second, to study the long-term impact of witnessing the event of a cardiac arrest. METHODS: A longitudinal cohort study including caregivers of cardiac arrest survivors. Participants received a questionnaire at home. Outcome variables were instrumental daily activities(FAI), emotional functioning(HADS), fatigue(FSS), caregiver strain(CSI), impact of event(IES), and quality of life(SF36). RESULTS: 57 caregivers (89% female, age 56,9 ±â€¯12 years) participated. Two years after the cardiac arrest, quality of life of caregivers equals that of the general population, although almost 30% still scored high on the Impact of Events Scale. Mean IES-, FSS-, CSI and FAI-scores were increased as compared to the general population (P < 0.001). Two years after the cardiac arrest, caregivers that witnessed the resuscitation (IES = 23.6 ±â€¯14.9) still experienced significantly more trauma related stress than caregivers that did not witness the resuscitation (11.9 ±â€¯12.5; p < 0.01). CONCLUSIONS: Two years after the cardiac arrest, quality of life of caregivers is quite good, but almost one third of the caregivers still experience a high level of trauma-related stress, especially in those that witnessed the resuscitation. Future research will have to focus on the effectiveness of support programs for caregivers of survivors of cardiac arrest.

Factors predicting quality of life and societal participation after survival of a cardiac arrest: A prognostic longitudinal cohort study.

AIM: For those patients who suffer unfavourable outcome after survival of cardiac arrest, it is important to know whether this can be predicted at an early stage. Support can subsequently be provided. This study aimed to identify early prognostic factors of quality of life (QOL) and societal participation at one year post-cardiac arrest. METHODS: The design was a prospective longitudinal cohort study following cardiac arrest survivors up to one year. Prognostic personal, injury-related, function-related and subjective outcome factors were selected and entered into a hierarchical regression model to assess whether they were predictive of QOL and societal participation at one year post-cardiac arrest. RESULTS: Hundred and ten cardiac arrest survivors were included. Not having a partner, more functional limitations (at two weeks) and cognitive complaints were significantly predictive of lower physical QOL, while higher levels of anxiety and depression symptoms (at three months) were significant predictors of mental QOL. A neurological history and higher levels of anxiety and depression symptoms were significantly predictive of lower brain injury-specific QOL. Societal participation was only predicted by premorbid functioning. CONCLUSION: This study identified prognostic factors of QOL and societal participation one year after survival of cardiac arrest. Screening of these factors in early stages can identify those survivors with possibly unfavourable QOL at one year post cardiac arrest. For those survivors, preventive and targeted interventions may be offered.

Cognitive impairments and subjective cognitive complaints after survival of cardiac arrest: A prospective longitudinal cohort study.

BACKGROUND: Cardiac arrest can lead to hypoxic brain injury, which can affect cognitive functioning. OBJECTIVE: To investigate the course of objective and subjective cognitive functioning and their association during the first year after cardiac arrest. METHODS: A multi-centre prospective longitudinal cohort study with one year follow-up (measurements at two weeks, three months and one year). Cognitive functioning was measured with a neuropsychological test battery and subjective cognitive functioning with the Cognitive Failures Questionnaire. RESULTS: 141 cardiac arrest survivors participated. Two weeks post cardiac arrest 16% to 29% of survivors were cognitively impaired varying on the different tests, at three months between 9% and 23% and at one year 10%-22% remained impaired with executive functioning being affected most. Significant reduction of cognitive impairments was seen for all tests, with most recovery during the first three months after cardiac arrest. Subjective cognitive complaints were present at two weeks after cardiac arrest in 11%, 12% at three months and 14% at one year. There were no significant associations between cognitive impairments and cognitive complaints at any time point. CONCLUSIONS: Cognitive impairments are common in cardiac arrest survivors with executive functioning being mostly affected. Most recovery is seen in the first three months after cardiac arrest. After one year, a substantial number of patients remain impaired, especially in executive functioning. Because of absence of associations between impairments and complaints, cognitive testing using a sensitive test battery is important and should be part of routine follow-up after a cardiac arrest.

Long-term Outcome After Survival of a Cardiac Arrest: A Prospective Longitudinal Cohort Study.

BACKGROUND: A cardiac arrest can lead to hypoxic brain injury, which can affect all levels of functioning. OBJECTIVE: To investigate 1-year outcome and the pattern of recovery after surviving a cardiac arrest. METHODS: This was a multicenter, prospective longitudinal cohort study with 1 year of follow-up (measurements 2 weeks, 3 months, 1 year). On function level, physical/cardiac function (New York Heart Association Classification), cognition (Cognitive Log [Cog-log], Cognitive Failures Questionnaire), emotional functioning (Hospital Anxiety and Depression Scale, Impact of Event Scale), and fatigue (Fatigue Severity Scale) were assessed. In addition, level of activities (Frenchay Activities Index, FAI), participation (Community Integration Questionnaire [CIQ] and return to work), and quality of life (EuroQol 5D, EuroQol Visual Analogue Scale, SF-36, Quality of Life after Brain Injury) were measured. RESULTS: In this cohort, 141 cardiac arrest survivors were included. At 1 year, 14 (13%) survivors scored below cutoff on the Cog-log. Both anxiety and depression were present in 16 (15%) survivors, 29 (28%) experienced posttraumatic stress symptoms and 55 (52%), severe fatigue. Scores on the FAI and the CIQ were, on average, respectively 96% and 92% of the prearrest scores. Of those previously working, 41 (72%) had returned to work. Most recovery of cognitive function and quality of life occurred within the first 3 months, with further improvement on some domains of quality of life up to 12 months. CONCLUSIONS: Overall, long-term outcome in terms of activities, participation, and quality of life after cardiac arrest is reassuring. Nevertheless, fatigue is common; problems with cognition and emotions occur; and return to work can be at risk.

The impact of cardiac arrest on the long-term wellbeing and caregiver burden of family caregivers: a prospective cohort study.

OBJECTIVE: The purpose was to gain insight in the functioning of caregivers of cardiac arrest survivors at 12 months after a cardiac arrest. Secondly, the course of the wellbeing of the caregivers during the first year was studied. Finally, factors that are associated with a higher care burden at 12 months after the cardiac arrest were investigated. SUBJECTS: A total of 195 family caregivers of cardiac arrest survivors were included. MAIN MEASURES: Quality of life (SF-36, EuroQol-VAS), caregiver strain (CSI) and emotional functioning (HADS, IES) were measured at two weeks, three months and one year after the cardiac arrest. Thereby, the caregiver was asked to fill out the cognitive failure questionnaire (CFQ) to evaluate their view on the cognitive status of the patient. RESULTS: Caregiver strain was high in 16 (15%) of the caregivers at 12 months. Anxiety was present in 33 (25%) caregivers and depression in 18 (14%) caregivers at 12 months. The repeated measures MANOVA showed that during the first year the following variables improved significantly: SF-36 domains social and mental health, role physical, role emotional and vitality, caregiver strain, HADS and IES ( P<0.001). At 12 months caregiver strain correlated significantly (explained variance 63%, P=0.03) with caregiver HADS ( P=0.01), EuroQol-VAS ( P=0.02), and the CFQ ( P<0.001), all measured at 12 months after the cardiac arrest. CONCLUSIONS: Overall wellbeing of the caregivers improves during the first year up to normal levels, but caregivers with emotional problems or perceived cognitive problems at 12 months are at risk for developing a higher care burden.

Early neurologically focused follow-up after cardiac arrest is cost-effective: A trial-based economic evaluation.

OBJECTIVE: To evaluate the cost-effectiveness of an early intervention service for cardiac arrest survivors called 'Stand still …, and move on' from a societal perspective. INTERVENTION: This concise nursing intervention consists of screening for cognitive and emotional problems, information provision and support, self-management promotion, and further referral if necessary. Earlier research confirmed the feasibility of the intervention and its effectiveness in improving emotional functioning and quality of life. METHODS: In this multicentre randomized controlled trial with one year follow-up 185 patients were included between April 2007 and December 2010. The experimental group received the intervention, the control group received care-as-usual. Intervention costs, other direct healthcare costs (e.g. hospital care, rehabilitation, medication, home care) and indirect costs (productivity loss) were measured during ten months using monthly cost-diaries. The economic evaluation comprised a cost-utility analysis (SF-36) and a cost-effectiveness analysis (QOLIBRI) using bootstrapping (5000 replications) to quantify uncertainty concerning the incremental cost effectiveness ratio (ICER), and the probability of the intervention being cost-effective was estimated. To check the robustness of the findings, two sensitivity analyses were performed using the EQ-5D and the complete cases respectively. RESULTS: Of 136 (74%) participants sufficient data concerning costs were collected to be included in this economic evaluation. Intervention costs were on average €127 (SD 85). No significant differences between groups were found with regard to overall costs. The ICERs of the cost-utility and the cost-effectiveness analyses supported the cost-effectiveness of the intervention. The probability of the intervention being cost-effective was 54-76% for the SF-36 and 94% for the QOLIBRI. Findings were robust. CONCLUSION: The intervention 'Stand still …, and move on' has positive societal economic effects and has a high probability to be cost-effective. Implementation in regular healthcare is recommended. TRIAL REGISTRATION: ISRCTN74835019.

European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.

The European Resuscitation Council and the European Society of Intensive Care Medicine have collaborated to produce these post-resuscitation care guidelines, which are based on the 2015 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. Recent changes in post-resuscitation care include: (a) greater emphasis on the need for urgent coronary catheterisation and percutaneous coronary intervention following out-of-hospital cardiac arrest of likely cardiac cause; (b) targeted temperature management remains important but there is now an option to target a temperature of 36 °C instead of the previously recommended 32-34 °C; (c) prognostication is now undertaken using a multimodal strategy and there is emphasis on allowing sufficient time for neurological recovery and to enable sedatives to be cleared; (d) increased emphasis on rehabilitation after survival from a cardiac arrest.

Early neurologically-focused follow-up after cardiac arrest improves quality of life at one year: A randomised controlled trial.

BACKGROUND: Survivors of a cardiac arrest frequently have cognitive and emotional problems and their quality of life is at risk. We developed a brief nursing intervention to detect cognitive and emotional problems, provide information and support, promote self-management, and refer them to specialised care if necessary. This study examined its effectiveness. METHODS: Multicentre randomised controlled trial with measurements at two weeks, three months and twelve months after cardiac arrest. 185 adult cardiac arrest survivors and 155 caregivers participated. Primary outcome measures were societal participation and quality of life of the survivors at one year. Secondary outcomes were the patient's cognitive functioning, emotional state, extended daily activities and return to work, and the caregiver's well-being. Data were analysed using 'intention to treat' linear mixed model analyses. RESULTS: After one year, patients in the intervention group had a significantly better quality of life on SF-36 domains Role Emotional (estimated mean differences (EMD)=16.38, p=0.006), Mental Health (EMD=6.87, p=0.003) and General Health (EMD=8.07, p=0.010), but there was no significant difference with regard to societal participation. On the secondary outcome measures, survivors scored significantly better on overall emotional state (HADS total, EMD=-3.25, p=0.002) and anxiety (HADS anxiety, EMD=-1.79, p=0.001) at one year. Furthermore, at three months more people were back at work (50% versus 21%, p=0.006). No significant differences were found for caregiver outcomes. CONCLUSION: The outcomes of cardiac arrest survivors can be improved by an intervention focused on detecting and managing the cognitive and emotional consequences of a cardiac arrest. TRIAL REGISTRATION: Current controlled trials, ISRCTN74835019.

'Stand still , and move on' , an early neurologically-focused follow-up for cardiac arrest survivors and their caregivers: a process evaluation.

BACKGROUND: A cardiac arrest can lead to hypoxic-ischaemic brain injury which can result in cognitive and emotional impairments and may negatively affect daily functioning, participation in society and quality of life. Furthermore, the impact on the family of the patient can be high. We designed an intervention called 'Stand still …, and move on', which is a concise, individualised, semi-structured intervention for survivors of cardiac arrest and their caregivers, consisting of between one and six face-to-face consultations provided by a trained nurse. The intervention is directed at early detection of cognitive and emotional problems, provision of information, promotion of self-management and referral to specialised care if necessary. The effectiveness of the intervention is being examined in a randomised controlled trial [ISRCTN74835019]. Alongside this trial we performed a process evaluation which aims to investigate the feasibility of the intervention by assessing: 1) the attendance and dose delivered; 2) performance according to protocol; and 3) the opinion of patients, caregivers and nurses on the intervention. METHODS: Participants of this process evaluation were 97 patients allocated to the intervention group of the RCT, their 91 caregivers, and six nurses who conducted the intervention. Measurement instruments used were evaluation forms for patients and caregivers, registration and evaluation forms for nurses, and semi-structured interviews with nurses. RESULTS: Seventy-nine of the patients (81%) allocated to the intervention group and 65 caregivers (71%) participated in the intervention. The mean (SD) number of consultations per patient was 1.8 (1.0), and most consultations were conducted at the patients' home. The intervention was performed largely according to protocol, except that the intervention usually started later than intended, consultations were longer than expected, and the topic of self-management was not regularly addressed. Patients marked the quality of the intervention with a mean score of 7.5 and the performance of the nurse with an 8.0 out of ten. Overall, the intervention was positively evaluated by patients, caregivers and nurses. CONCLUSIONS: The intervention 'Stand still …, and move on' is a promising intervention which was performed largely according to protocol and seems feasible for implementation after some adaptations, if it is found to be effective.