Resuscitation 85 (2014) 585–586
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Life after death
Through a variety of public health efforts and medical advances, the incidence of out-of-hospital cardiac arrest and other forms of cardiovascular disease has declined in some parts of the world.1 However, the burden of out-of-hospital cardiac arrest is still substantial – claiming hundreds of thousands of lives worldwide each year; and this burden is likely to increase as many developing societies successfully address mortality from infectious disease.2,3 In these developing societies, mortality from heart disease often increases as death from infectious causes decreases.3 Thus resuscitation is likely to remain an important systems-based health intervention where improvement in care can favorably affect public health. Resuscitation stakeholders have understandably focused on efforts to treat the acute condition of cardiac arrest. Several timesensitive, often interdependent strategies influence the chances that the arrest victim can achieve return of spontaneous pulses and ultimately be discharged alive following hospitalization. These strategies – termed the links in the chain of survival – provide the framework for successful resuscitation.4 Even with this understanding, a meaningful increase in resuscitation success has historically been elusive in most communities.5 Evidence is now accumulating that survival to hospital discharge following out-of-hospital cardiac arrest can improve; and this improvement extends to a broad and diverse set of communities.6,7 The improvement appears to be built on measurement and benchmarking, and then system-specific efforts to improve. These efforts likely derive from a combination of evidence-based clinical science and local common sense and determination.8 Although in-hospital resuscitation constitutes a different set of challenges and solutions, a similar temporal improvement has been observed in the hospital setting.9 On the surface, this improvement would seem like a welcome development, one that suggests a new momentum in effective clinical translation of resuscitation science. One persisting concern however, is that those who survive to hospital discharge are substantially disabled, most often from neurological injury. The perception by some is that the patient admitted with coma following resuscitation will have a poor long-term prognosis characterized by dependence and inferior quality of life, even if they were to survive to leave the hospital.10 Fortunately we are beginning to provide a more informed and comprehensive context regarding long-term prognosis of patients who survive to be discharged from the hospital. In this issue of Resuscitation, Linder and colleagues provide useful insights
http://dx.doi.org/10.1016/j.resuscitation.2014.02.027 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
regarding long-term survival.11 The study adds to a collection of contemporary experiences that support a meaningful long-term survival following hospital discharge.12,13 The Stavanger survivor cohort experienced a 5-year survival following discharge of 76%. Long-term survival in the study cohort did not achieve that of an age- and sex-matched healthy cohort, but is comparable or exceeds long-term prognosis of other life-threatening, acute-illness cohorts who survive to hospital discharge.14 Moreover, the impressive long-term survival was achieved in a community where short-term survival is quite high, suggesting that improvements in acute resuscitation care will translate to subsequent life-years. Other findings from the Stavanger experience are also worthy of notice. The results of the current investigation – in the context of other published studies – indicate that long-term survival following resuscitation appears to be improving over time.15 Survivors today enjoy a better prognosis than arrest survivors from prior decades. The study also reports useful information regarding rhythm-specific long-term prognosis. Five-year survival was 78% for those presenting with a shockable rhythm and 67% for those presenting with a non-shockable rhythm. An increasing number of arrests and to a lesser extent an increasing number of survivors present with a non-shockable rhythm.12 Although long-term prognosis is not as favorable in the non-shockable cohort, still twothirds are alive approximately 5 years following the arrest. The goal of course is to achieve survival with good prognosis and satisfactory quality of life.16 To this end, the current study did not assess quality of life during long-term follow-up period. In the general population of older adults, longevity is associated with favorable quality of life and vice versa.17 The large majority of the Stavanger cohort enjoyed fairly good functional status based on assessment at hospital discharge. Those with favorable functional status at discharge have a better prognosis following cardiac arrest and resuscitation.18 These relationships suggest that many of the long-term survivors likely experienced a reasonable quality of life. Ongoing efforts should determine what acute or convalescent characteristics influence long-term outcome. As the authors acknowledged, such a comprehensive evaluation was not possible in the current study. Given the strong prognostic influence of heart function and neurological status, treatment strategies that optimize cardiac recovery and brain protection may provide important long-term benefits.19 To this end, links in the chain of survival can be expected to influence long-term prognosis.20 Convalescent treatment with implantable defibrillators in patients surviving ventricular fibrillation arrest can provide survival benefits.21 However
586
Editorial / Resuscitation 85 (2014) 585–586
there is still much to learn about what acute and convalescent characteristics influence long-term prognosis. There appears to be a growing momentum in resuscitation science and community translation. There is an established, ongoing North American resuscitation research network that has conducted multiple well-powered randomized trials that have direct clinical implications.22,23 Hard work has forged large and growing national, population-based registries that provide for benchmarking and improvement.6,24 And there is a growing grass roots effort that empowers stakeholders to implement locally effective programs with the appreciation that successful resuscitation can be achieved in many communities.8 And the findings from Stavanger should only encourage the positive momentum. There is life after death. . .and lots of it. Conflict of interest Dr. Rea and Dr. Dumas do not have any relevant conflicts of interest related to this editorial. Acknowledgements Dr. Rea receives support from the Medtronic Foundation, the Laerdal Foundation, and the Life Sciences Discovery Fund. None of these organizations had a role in this editorial. References 1. Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2014;129:399–410. 2. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479–87. 3. Jammison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013;382:1898–955. 4. Nolan JP, Hazinski MF, Billi JE, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2010;81:e1–25. 5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63–81. 6. Kitamura T, Iwami T, Kawamura T, et al. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circulation 2012;126: 2834–43. 7. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310: 1377–84. 8. van Diepen S, Abella BS, Bobrow BJ, et al. Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue project. Am Heart J 2013;166:647–53. 9. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012;367:1912–20.
10. Gold B, Puertas L, Davis SP, et al. Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early? Resuscitation 2014;85:211–4. 11. Linder TW, Vossius C, Torunn MW, Soreide E. Life years saved, standardised mortality rates and causes of death after hospital discharge in out-of-hospital cardiac arrest. Resuscitation 2014;85:671–5. 12. Dumas F, Rea TD. Long-term prognosis following resuscitation from outof-hospital cardiac arrest: role of aetiology and presenting arrest rhythm. Resuscitation 2012;83:1001–5. 13. Bunch TJ, White RD, Gersh BJ, et al. Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. N Engl J Med 2003;348:2626–33. 14. Barnato AE, Albert SM, Angus DC, Lave JR, Degenholtz HB. Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med 2011;183:1037–42. 15. Rea TD, Crouthamel M, Eisenberg MS, Becker LJ, Lima AR. Temporal patterns in long-term survival after resuscitation from out-of-hospital cardiac arrest. Circulation 2003;108:1196–201. 16. Becker LB, Aufderheide TP, Geocadin RG, Callaway CW, Lazar RM, Donnino MW, et al. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association. Circulation 2011;124:2158–77. 17. Diehr P, Johnson LL, Patrick DL, Psaty B. Methods for incorporating death into health-related variables in longitudinal studies. J Clin Epidemiol 2005;58:1115–24. 18. Phelps R, Dumas F, Maynard C, Silver J, Rea T. Cerebral performance category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med 2013;41:1252–7. 19. Dumas F, White L, Stubbs BA, Cariou A, Rea TD. Long-term prognosis following resuscitation from out of hospital cardiac arrest: role of percutaneous coronary intervention and therapeutic hypothermia. J Am Coll Cardiol 2012;60: 21–7. 20. Stiell I, Nichol G, Wells G, et al. Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation. Circulation 2003;108:1939–44. 21. Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study. Eur Heart J 2000;21: 2071–8. 22. Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med 2011;365:798–806. 23. Stiell IG, Nichol G, Leroux BG, et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med 2011;365:787–97. 24. McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance – Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010. MMWR Surveill Summ 2011;60:1–19.
Thomas Rea ∗ University of Washington School of Medicine, United States Florence Dumas a,b Cochin Hospital, Paris, France b Paris Sudden Death Expertise Center-Inserm U970 Paris Descartes University, France a
∗ Corresponding author. E-mail address: [email protected] (T. Rea)
21 February 2014
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Life after death
Through a variety of public health efforts and medical advances, the incidence of out-of-hospital cardiac arrest and other forms of cardiovascular disease has declined in some parts of the world.1 However, the burden of out-of-hospital cardiac arrest is still substantial – claiming hundreds of thousands of lives worldwide each year; and this burden is likely to increase as many developing societies successfully address mortality from infectious disease.2,3 In these developing societies, mortality from heart disease often increases as death from infectious causes decreases.3 Thus resuscitation is likely to remain an important systems-based health intervention where improvement in care can favorably affect public health. Resuscitation stakeholders have understandably focused on efforts to treat the acute condition of cardiac arrest. Several timesensitive, often interdependent strategies influence the chances that the arrest victim can achieve return of spontaneous pulses and ultimately be discharged alive following hospitalization. These strategies – termed the links in the chain of survival – provide the framework for successful resuscitation.4 Even with this understanding, a meaningful increase in resuscitation success has historically been elusive in most communities.5 Evidence is now accumulating that survival to hospital discharge following out-of-hospital cardiac arrest can improve; and this improvement extends to a broad and diverse set of communities.6,7 The improvement appears to be built on measurement and benchmarking, and then system-specific efforts to improve. These efforts likely derive from a combination of evidence-based clinical science and local common sense and determination.8 Although in-hospital resuscitation constitutes a different set of challenges and solutions, a similar temporal improvement has been observed in the hospital setting.9 On the surface, this improvement would seem like a welcome development, one that suggests a new momentum in effective clinical translation of resuscitation science. One persisting concern however, is that those who survive to hospital discharge are substantially disabled, most often from neurological injury. The perception by some is that the patient admitted with coma following resuscitation will have a poor long-term prognosis characterized by dependence and inferior quality of life, even if they were to survive to leave the hospital.10 Fortunately we are beginning to provide a more informed and comprehensive context regarding long-term prognosis of patients who survive to be discharged from the hospital. In this issue of Resuscitation, Linder and colleagues provide useful insights
http://dx.doi.org/10.1016/j.resuscitation.2014.02.027 0300-9572/© 2014 Elsevier Ireland Ltd. All rights reserved.
regarding long-term survival.11 The study adds to a collection of contemporary experiences that support a meaningful long-term survival following hospital discharge.12,13 The Stavanger survivor cohort experienced a 5-year survival following discharge of 76%. Long-term survival in the study cohort did not achieve that of an age- and sex-matched healthy cohort, but is comparable or exceeds long-term prognosis of other life-threatening, acute-illness cohorts who survive to hospital discharge.14 Moreover, the impressive long-term survival was achieved in a community where short-term survival is quite high, suggesting that improvements in acute resuscitation care will translate to subsequent life-years. Other findings from the Stavanger experience are also worthy of notice. The results of the current investigation – in the context of other published studies – indicate that long-term survival following resuscitation appears to be improving over time.15 Survivors today enjoy a better prognosis than arrest survivors from prior decades. The study also reports useful information regarding rhythm-specific long-term prognosis. Five-year survival was 78% for those presenting with a shockable rhythm and 67% for those presenting with a non-shockable rhythm. An increasing number of arrests and to a lesser extent an increasing number of survivors present with a non-shockable rhythm.12 Although long-term prognosis is not as favorable in the non-shockable cohort, still twothirds are alive approximately 5 years following the arrest. The goal of course is to achieve survival with good prognosis and satisfactory quality of life.16 To this end, the current study did not assess quality of life during long-term follow-up period. In the general population of older adults, longevity is associated with favorable quality of life and vice versa.17 The large majority of the Stavanger cohort enjoyed fairly good functional status based on assessment at hospital discharge. Those with favorable functional status at discharge have a better prognosis following cardiac arrest and resuscitation.18 These relationships suggest that many of the long-term survivors likely experienced a reasonable quality of life. Ongoing efforts should determine what acute or convalescent characteristics influence long-term outcome. As the authors acknowledged, such a comprehensive evaluation was not possible in the current study. Given the strong prognostic influence of heart function and neurological status, treatment strategies that optimize cardiac recovery and brain protection may provide important long-term benefits.19 To this end, links in the chain of survival can be expected to influence long-term prognosis.20 Convalescent treatment with implantable defibrillators in patients surviving ventricular fibrillation arrest can provide survival benefits.21 However
586
Editorial / Resuscitation 85 (2014) 585–586
there is still much to learn about what acute and convalescent characteristics influence long-term prognosis. There appears to be a growing momentum in resuscitation science and community translation. There is an established, ongoing North American resuscitation research network that has conducted multiple well-powered randomized trials that have direct clinical implications.22,23 Hard work has forged large and growing national, population-based registries that provide for benchmarking and improvement.6,24 And there is a growing grass roots effort that empowers stakeholders to implement locally effective programs with the appreciation that successful resuscitation can be achieved in many communities.8 And the findings from Stavanger should only encourage the positive momentum. There is life after death. . .and lots of it. Conflict of interest Dr. Rea and Dr. Dumas do not have any relevant conflicts of interest related to this editorial. Acknowledgements Dr. Rea receives support from the Medtronic Foundation, the Laerdal Foundation, and the Life Sciences Discovery Fund. None of these organizations had a role in this editorial. References 1. Go AS, Mozaffarian D, Roger VL, et al. Executive summary: heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2014;129:399–410. 2. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479–87. 3. Jammison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013;382:1898–955. 4. Nolan JP, Hazinski MF, Billi JE, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2010;81:e1–25. 5. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-ofhospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63–81. 6. Kitamura T, Iwami T, Kawamura T, et al. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circulation 2012;126: 2834–43. 7. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310: 1377–84. 8. van Diepen S, Abella BS, Bobrow BJ, et al. Multistate implementation of guideline-based cardiac resuscitation systems of care: description of the HeartRescue project. Am Heart J 2013;166:647–53. 9. Girotra S, Nallamothu BK, Spertus JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med 2012;367:1912–20.
10. Gold B, Puertas L, Davis SP, et al. Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early? Resuscitation 2014;85:211–4. 11. Linder TW, Vossius C, Torunn MW, Soreide E. Life years saved, standardised mortality rates and causes of death after hospital discharge in out-of-hospital cardiac arrest. Resuscitation 2014;85:671–5. 12. Dumas F, Rea TD. Long-term prognosis following resuscitation from outof-hospital cardiac arrest: role of aetiology and presenting arrest rhythm. Resuscitation 2012;83:1001–5. 13. Bunch TJ, White RD, Gersh BJ, et al. Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. N Engl J Med 2003;348:2626–33. 14. Barnato AE, Albert SM, Angus DC, Lave JR, Degenholtz HB. Disability among elderly survivors of mechanical ventilation. Am J Respir Crit Care Med 2011;183:1037–42. 15. Rea TD, Crouthamel M, Eisenberg MS, Becker LJ, Lima AR. Temporal patterns in long-term survival after resuscitation from out-of-hospital cardiac arrest. Circulation 2003;108:1196–201. 16. Becker LB, Aufderheide TP, Geocadin RG, Callaway CW, Lazar RM, Donnino MW, et al. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association. Circulation 2011;124:2158–77. 17. Diehr P, Johnson LL, Patrick DL, Psaty B. Methods for incorporating death into health-related variables in longitudinal studies. J Clin Epidemiol 2005;58:1115–24. 18. Phelps R, Dumas F, Maynard C, Silver J, Rea T. Cerebral performance category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med 2013;41:1252–7. 19. Dumas F, White L, Stubbs BA, Cariou A, Rea TD. Long-term prognosis following resuscitation from out of hospital cardiac arrest: role of percutaneous coronary intervention and therapeutic hypothermia. J Am Coll Cardiol 2012;60: 21–7. 20. Stiell I, Nichol G, Wells G, et al. Health-related quality of life is better for cardiac arrest survivors who received citizen cardiopulmonary resuscitation. Circulation 2003;108:1939–44. 21. Connolly SJ, Hallstrom AP, Cappato R, et al. Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg. Canadian Implantable Defibrillator Study. Eur Heart J 2000;21: 2071–8. 22. Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med 2011;365:798–806. 23. Stiell IG, Nichol G, Leroux BG, et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med 2011;365:787–97. 24. McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance – Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010. MMWR Surveill Summ 2011;60:1–19.
Thomas Rea ∗ University of Washington School of Medicine, United States Florence Dumas a,b Cochin Hospital, Paris, France b Paris Sudden Death Expertise Center-Inserm U970 Paris Descartes University, France a
∗ Corresponding author. E-mail address: [email protected] (T. Rea)
21 February 2014
