h
a
anaesth. scand. 1979, 23, 211-216
Long- and Short-Term Mortality Rates in Patients who Primarily Survive Cardiac Arrest Compared with a Normal Population M. WERNBERC and A. THOMASSEN Departments of Anaesthesiology and Clinical Neurophysiology, University Hospital, Aarhus, Denmark
This is a follow-up study of 180 survivors after cardiac arrest outside intensive care and coronary care units. The follow-up extended over 0.5 to 8.5 years (average 4.3 years) after the primary cardiac arrest. Of the patients, 72 (40%) were discharged from hospital, 13 with anoxic brain damage. Thirty-one per cent of the discharged patients died within the first year; death had occurred in 43% after 2 years, and in 50% after 3 years. After that time, the mortality was similar to that of a comparable normal population. At the end of the study, 34 patients were still alive, including eight with neurological sequelae. Their present cardiac function was satisfactory in the majority (59%) of the patients falling into group I or I1 of the American Heart Association classification. Their social situation, however, left much to be desired, as only 50% had fully or partly regained their previous level of activity. Received I1 August, accepted f o r publication 10 October 1978
Since the introduction of external thoracic mental state (DOBSONet al. 1971), and compression in 1960, the treatment of cardiac (4) their general social situation (DYBDAHL arrest has been systematized, resulting in the et al. 1978). survival of more patients following successful The present study is a follow-up of all resuscitation. The introduction of mobile primarily successful resuscitations outside emergency care systems, intensive care, and intensive care and coronary care units during coronary care units has further contributed an 8-year period. The prognosis is evaluated to the improved prognosis after cardiac by comparing the mortality of the patients arrest. with that of a normal population with the The long-term prognosis for survival has same sex and age distribution (HORWITZ been examined in several studies, which 1978). report that about 25% of resuscitated patients die within the first year of discharge MATERIAL AND METHODS & -JOHNSON 1972, RAUMet al. 1974, (LEMIRE The study comprised 180 patients who during the coBB et al. 1975, D~~~~~~ et al. 1978). 8-year period from April 1 1969 to March 31 1977 had addition to the Of the discharged been resuscitated from cardiac arrest and survived for patients, the following items have been a t least 24 h. studied: (1) their cardiac function (DUPONT Children under 16 years of age and patients with primary cerebral diseases, severe traumata or poisoning et al. 1969, LAWRIE1969, LEMIRE& JOHNSON 1972, FABRICIUS-BJERRE et al. 1974), (2) their were The follow-up was terminated on October 1 1977, working capacity (GEDDES et ADCEy which was from 0.5 to 8.5 years (average 4.3 years) et al. 1969, LAWRIE1969, FABRICIUS-BJERRE after cardiac arrest. et al. 1974, DYBDAHL et al. 1978), (3) their Diagnosis, hospital course, and state at discharge 0001-5172/79/030211-06$02.50/0
0 1979 The
Scandinavian Society of Anaesthesiologists
212
M . WERNBERG AND A . THOMASSEN
were ascertained from a review of the hospital records. RESULTS Follow-up data were obtained from hospital records of later admissions and from replies to questionnaires sent The 180 patients consisted of 120 men and to surviving patients. In cases of death after discharge, 60 women, whose ages ranged from 20 to 92 death certificates were obtained, and if an autopsy had years (average 64 years). been performed, the autopsy records were also studied. Resuscitation had occurred outside hospital The survival rates were computed and compared (107 cases), in general wards (57 cases), and with those of a comparable normal population by during ambulance transport to the emergency means of special programmes which have been developed at the Danish Institution of Clinical Epidemi- room (1 6 cases). ology (HORWITZ 1978). Using this method, the progThe diagnosis was arteriosclerotic heart nosis was assessed in three different ways: disease in 148 cases, including 103 with acute (1) The niortality rates (%) during the specific follow-up myocardial infarction. Acute asphyxia was periods, i.e. days, weeks, months or years after the found in 16, while other diagnoses were made cardiac arrest; (2) The number ofdeaths that had occurred among 100 in 16. new cases at the end of a specific follow-up period; Of the patients, 108 died in hospital, while (3) The death area, indicating the fractinn of the lifespan 72 were discharged alive; 38 patients died lost because of death during the follow-up period. after discharge during the follow-up period. The mortality of the patients was related to their age Table 1 shows the duration of follow-up at the time of cardiac arrest and to the original cause and of survival for each patient, as well as the of cardiac arrest. The quality of life of surviving patients was assessed mortality rates and deaths in 100 new from their day-to-day activities, which might be limited patients at the end of a specific follow-up mainly by anoxic mental impairment or cardiac period, and the same parameters in a comdisability. Their cardiac function was classified according to the principles of the NEWYORKHEARTASSOCI- parable normal population with the same sex and age distribution. ATION (1964).
Table 1 Mortality rates and survival table for patients with cardiac arrest compared with corresponding data from a normal popuiation with the same sex and age distribution. Number of patients
Mortality rate
(5:)
Deaths:
-
Time after cardiac arrest
Alive*
Dead?
Observation ceased?
1 day 2 days 3 days 7 days 14 clays 1 month 2 months 3 months 6 months 1 year 2 years 3 years 4 years 5 years
180 175 160 130 103 80 70 64 55 39 25 13 8 6
0 5 15 30 27 23 10 6 9 6 8 6
0
0 1
0 0 0 0 0 0 0 0 10 6 6 5 1
Paticntst
2.78 8.75 18.75 20.77 22.33 12.50 8.57 14.06 12.04 2 1.86 28.60
14.18
* Refers to the time in question. ? Refers to the immediately preceding period.
3 Percentage of deaths in
100 new cases in a specific period.
(x)
Normal?
Patients*
Normal
0.01 0.01 0.01 0.04 0.07 0.15 0.25 0.26 0.77 1.43 2.62 2.31 2.32 2.96
2.78 11.11 27.78 42.78 55.56 61.11 64.44 69.44 73.12 79.00 85.01 85.01 87.13
0.01 0.02 0.03 0.07 0.13 0.28 0.57 0.85 1.70 3.45 6.97 10.57 14.26 17.99
MORTALIlY RATES A F l E R CARDIAC ARREST
It appears that 55 patients were followed for more than 6 months, 39 for more than 1 year, 25 for more than 2 years, and 13 for more than 3 years. It should be noted that the mortality rate after cardiac arrest was greatest during the first few weeks, as nearly 25:l0 of the patients died within 1 week, approximately 43% within 2 weeks, and about 55% within the first month after cardiac arrest. After this time a definite decrease in mortality was seen, but the mortality rate was still many times greater than that of the normal population: it was 10 times as great 1, 2 and 3 years after cardiac arrest. After 3 years, only a limited mortality was seen, and none of the six patients who were followed for more than 5 years died during the follow-up period. Figure 1 illustrates the death area of the patients, which corresponds to the percentage of the total possible lifespan during the follow-up period which is lost due to death. For comparison, the death area of a comparable normal population is superimposed upon that of the patients. After 5 years of observation, the total death area of the patients made up 78.96% of the possible total, while it was only 8.850,/, for the normal population.
0area
Furthermore, the figure illustrates the area corresponding to the duration of the primary hospital stay, which lasted from 3 to 365 days, averaging 28 days and totalling 51 13 days. Owing to the special graduation of the abscissa, the hospitalization area is not as large as it appears in Figure 1 (it is actually 1.54% of the total area). The total time of survival after discharge corresponds to the white area, which represents 19.500,:. After discharge, 38 patients died 1-48 months (average 11.2 months) after cardiac arrest. Table 2 shows the relation between the original diagnosis and mortality. Note that the mortality after discharge was evenly distributed between patients with the two main diagnoses, i.e. occlusive and nonocclusive arteriosclerotic heart disease. However, the risk of sudden cardiac death was greatest in arteriosclerotic heart disease without acute infarction. Among the patients who died after discharge, five had sequelae of anoxic brain damage, severe in one, but only of moderate degree in four. The importance of age in the prognosis is
af t h e l i v i n g d i s c h a r g e d p a t i e n t s
t h e d e a t h area of normal personii t h e d e a t h a r e a o f p a t i e n t s a f t e r c a r d i a c arrest a r e a of t h e primary h o s p i t a l i z a t i o n after c,ii-diac a r r P 5 t
days
'
montt1s
'
time since c a r d i a c a r r e s t
213
yCL3rS
Fig. 1. Areas oldeatli, hospitalization and survival after discharge.
214
M . WERNDERG AN11 A . THOMASSEN
Table 2 Outcome related to the original cause of cardiac arrest.
Total number
Discharged alive
Still alive
Died after discharge
Cardiac death
Sudden cardiac death*
Acute myocardial infarction Arteriosclerotic heart disease without infarction Acute asphyxia Other diagnoses
103
37
17
20
17
8
45 16 16
21
9
12
7 7
5 3
2
9 1
4
2
0 1
Total
180
72
34
38
29
15
Cause of cardiac arrest
G
* Includes deaths only after discharge from hospital. illustrated in Figure 2. The younger patients seem to have better chances of survival, but the differences are not statistically significant. At the termination of the follow-up, 34 patients were still alive after observation periods varying from 7 months to 8.2 years (average 2.7 years) after cardiac arrest. The present conditions of these patients are shown in Table 3. I n most of the patients, cardiac function was classified as group 1 or 2. No drugs were given to 11 patients, while heart medicine was administered in 15 and diuretics in 16. The patients who, in spite of good cardiac
I -19
I /
, 1 1 1 1
1
1
function, were still convalescent or far frorn having regained previous activity were mainly disabled by sequelae of anoxic brain damage. A total of eight patients had mental impairment, one to such a n extent that he was permanently institutionalized. The others could manage at home, although four of them were a considerable burden to their families. Furthermore, troublesome nervous symptoms developed in two after their cardiac arrest. Many of the patients had later been repeatedly admitted to hospital because of their heart disease, one as often as 40 times.
>
and survival arrest.
after
cardiac
MORTALITY RATES AFTER CARDIAC ARREST
215
Table 3 Conditions of 34 patients still alive.
1
Bedridden or convalescent Far from having regained the same activity level as before cardiac arrest Having partly regained the same activity level as before Having fully regained the same activity level as before Total
* According to the New York
Heart function group* 2 3
4
Total
1
1
1
3
7
2
0
8
0
10
1
6
1
0
8
G
3
0
0
9
10
10
11
3
34
Heart Association.
up to 3 years after cardiac arrest, most pronounced in the first year. After 3 years the The majority of patients who primarily mortality rate of the patients approached survive cardiac arrest die in hospital. The that of the normal population. A similar figure in our series was SO%, which agrees decrease was found by LEMIRE& JOHNSON with other reports (LUND& SKULBERC 1971, (1972), but as in our study they had only a LIRERTHSON et al. 1974, DYBDAHL et al. limited number of patients with a sufficiently long time of observation. 1978). About half of the patients (15 out of 29) Studies on the mortality of patients discharged after cardiac arrest show that whose death was due to cardiac causes after 24-30% die within the first year, while death discharge died suddenly outside hospital, had occurred in 38-430/, after 2 years and in which is in accordance with earlier reports et al. 1969, BAUMet al. 1974, CORB 49% after 3 years (LEMIRE &JOHNSON 1972, (DUPONT et al. 1978). The risk BAUMet al. 1974, COBBet al. 1975, DYBDAHL et al. 1975, DYBDAHL et al. 1978). T h e corresponding figures in our oflater sudden cardiac death was most prostudy were 31%, 43%, and 50%, respectively. nounced if the primary arrest had been However, we reckoned the duration of sur- caused by arteriosclerotic heart disease withvival from the time of cardiac arrest and not out infarction. This difference between occlufrom the day of discharge. The long-term sive and non-occlusive arteriosclerotic heart prognosis after cardiac arrest in relation to a disease has previously been observed by mild coronary attack has been found to be GDTZSGHE & LYSCAARD (1968), BAUMet al. approximately the sameas that fo!lowing acute (1974) and COBBet al. (1975), but not by et al. (1969). A possible explanation myocardial infarction without cardiac arrest DUPONT (GEDDES et al. 1967). of this is that while the risk of cardiac arrest However, it does not seem reasonable to due to acute coronary occlusion is of relatively assess the severity of a disease by comparing short duration, non-occlusive arteriosclerotic it with another serious illness. We found it heart disease is a chronic progressing disease more illustrative to relate the mortality of in which myocardial fibrosis is probably the patients after cardiac arrest with that exciting cause of cardiac arrest. Like DYBDAHL et al. (1978), we found a occurring in a comparable normal population. By so doing, we found that the patients tendency to a lower mortality rate in younger had a significantly increased mortality rate patients. DISCUSSION
216
hl. CVERNEERG AND A. TIIOMASSEN
The Datients who were still alive at the end of the following study mainly had satisfactory cardiac function; 59% were in group I or 11. These findings are in accordance with those of DUPONTet al. (1969), LAWRIE(1969), LEMIRE& JOHNSON (1972), and FABRICIUS-RJERRE et al. (1974). However, the day-to-day activities and the social situation of many of the patients left a good deal to be desired, as only 9 (27%) had fully and 8 (24%) partly regained their previous level of activity. I n addition to a poor cardiac state, this was caused by neurological sequelae, especially mental impairment, which was found in 13 (180/,) of the discharged patients. Eight of these were still alive at the end of the study. Tlius, the mortality rate does not seem to be increased by anoxic brain damage iri discharged patients. Consequent to cardiac arrest, major nervous symptoms had developed in another two patients, which is not unusual (DOBSON et al. 1971). I n conclusion, it may be said that the mortality rate is high in patients discharged after cardiac arrest, especially during the first year, but after the third year of survival it approaches that of the normal population. However, the quality of life of many of the survivors is often unsatisfactory, but in order to clarify this, prospective serial examinations of all surviving patients are required.
ACKNOWLEDGEMENT M.’e wish to thank Dr. Ole Horwitz, the Danish
Institute of Clinical Epidemiology, for his help in computing the survival rates.
(1969) Management of ventricular fibrillation ontside hospital. Lancet i, 1169. BAUM,R. S., ALVAREZ,H. & COBS, I,. A. (1974) Survival after resuscitation from out-of-hospital ventricular fibrillation. Circulation 50, 1231. COBB,L. A., BAUM,R. S., ALVAREZ, H. & SCHAFFEK, W. A. (1975) Resuscitation from out-of-hospital ventricular fibrillatioc: 4 years follow-up. Circulation Suppl. 111, 223. A. E., ADLER,M. W. & DOBSON,M., TATTERSFIELD, MCNICOL,M. W. (1971) Attitudes and long-term adjustment of patients surviving cardiac arrest. Brit. med. 3.3, 207. DUPONT, B., FLENSTED-JENSEN, E. & SANDBE, E. (1969) T h e long-term prognosis for patients resuscitated after cardiac arrest. Amer. Heart 3. 78, 444. DYBDAHL, J. H., RUTLIN,E. & BERG-LARSEN, K. (1978) The prognosis of patients resuscitated during acute myocardial infarction. 3. Oslo C i O Hosp. 28,29. FABRICIUS-BJERRE, N., ASTVAD,K. & KJRRULFF,.J. (1974) Cardiac arrest following acute myocardial infarction. Acta med. scand. 195, 261. GEDDES, J. S., ADGEY,A. A. J. & PANTRIDGE, J. 1:. (1967) Prognosis after recovery from ventricular fibrillation complicating ischaemic heart disease. Lancet ii, 273. A. (1968) Cardiac arrest in GQTZSCHE,H. & LYSGARD, heart disease. Acta anaesth. scand. Suppl. 29, 2 17. HORWITZ, 0. (1978) Prognoseberegninger for et patientmateriale. Ugeskr. Leg. 140, 489. LAWRIE,D. M. (1969) Long-term survival aftrr ventricular fibrillation complicating acute myocardial infarction. Lancet ii, 1085. LEMIRE,J. G . & JOHNSON, A. L. (1972) Is cardiac resuscitation worthwhile? New En,$. 3. M e d . 286, 970. LIBERTHSON, R. R., NAGEL,E. L., HIKSHMAN, J. C. & NUSSENFELD, S. R. (1974) Prehospital ventricular defibrillation. N e w Engl. 3. M e d . 291, 317. LUND,I. & SKULBERG, A. (1971) Experiences with a doctor-manned ambulance service in Oslo. 3. Oslo City Hosp. 21, 150. NEWYORKHEARTASSOCIATION, INC.,CRITERIA COMMITTEE (1964) Diseases of heart and blood vessels. Nomenclature and Criteria for Diagnosis. 6th Ed. Iittlc, Brown & Co., Boston, p. 114. Address : Mogens Wernberg, M.D.
REFERENCES ADGLY, A. A. J., NELSON, 1’. G., SCOTT, M. E., GLDDhS, J. S., AILEN,J. D., ZAIDI,S. A. & PANTKIDGE, J. F.
Department of Anaesthesiology University Hospital DK-8000 Aarhus C Denmark
a
anaesth. scand. 1979, 23, 211-216
Long- and Short-Term Mortality Rates in Patients who Primarily Survive Cardiac Arrest Compared with a Normal Population M. WERNBERC and A. THOMASSEN Departments of Anaesthesiology and Clinical Neurophysiology, University Hospital, Aarhus, Denmark
This is a follow-up study of 180 survivors after cardiac arrest outside intensive care and coronary care units. The follow-up extended over 0.5 to 8.5 years (average 4.3 years) after the primary cardiac arrest. Of the patients, 72 (40%) were discharged from hospital, 13 with anoxic brain damage. Thirty-one per cent of the discharged patients died within the first year; death had occurred in 43% after 2 years, and in 50% after 3 years. After that time, the mortality was similar to that of a comparable normal population. At the end of the study, 34 patients were still alive, including eight with neurological sequelae. Their present cardiac function was satisfactory in the majority (59%) of the patients falling into group I or I1 of the American Heart Association classification. Their social situation, however, left much to be desired, as only 50% had fully or partly regained their previous level of activity. Received I1 August, accepted f o r publication 10 October 1978
Since the introduction of external thoracic mental state (DOBSONet al. 1971), and compression in 1960, the treatment of cardiac (4) their general social situation (DYBDAHL arrest has been systematized, resulting in the et al. 1978). survival of more patients following successful The present study is a follow-up of all resuscitation. The introduction of mobile primarily successful resuscitations outside emergency care systems, intensive care, and intensive care and coronary care units during coronary care units has further contributed an 8-year period. The prognosis is evaluated to the improved prognosis after cardiac by comparing the mortality of the patients arrest. with that of a normal population with the The long-term prognosis for survival has same sex and age distribution (HORWITZ been examined in several studies, which 1978). report that about 25% of resuscitated patients die within the first year of discharge MATERIAL AND METHODS & -JOHNSON 1972, RAUMet al. 1974, (LEMIRE The study comprised 180 patients who during the coBB et al. 1975, D~~~~~~ et al. 1978). 8-year period from April 1 1969 to March 31 1977 had addition to the Of the discharged been resuscitated from cardiac arrest and survived for patients, the following items have been a t least 24 h. studied: (1) their cardiac function (DUPONT Children under 16 years of age and patients with primary cerebral diseases, severe traumata or poisoning et al. 1969, LAWRIE1969, LEMIRE& JOHNSON 1972, FABRICIUS-BJERRE et al. 1974), (2) their were The follow-up was terminated on October 1 1977, working capacity (GEDDES et ADCEy which was from 0.5 to 8.5 years (average 4.3 years) et al. 1969, LAWRIE1969, FABRICIUS-BJERRE after cardiac arrest. et al. 1974, DYBDAHL et al. 1978), (3) their Diagnosis, hospital course, and state at discharge 0001-5172/79/030211-06$02.50/0
0 1979 The
Scandinavian Society of Anaesthesiologists
212
M . WERNBERG AND A . THOMASSEN
were ascertained from a review of the hospital records. RESULTS Follow-up data were obtained from hospital records of later admissions and from replies to questionnaires sent The 180 patients consisted of 120 men and to surviving patients. In cases of death after discharge, 60 women, whose ages ranged from 20 to 92 death certificates were obtained, and if an autopsy had years (average 64 years). been performed, the autopsy records were also studied. Resuscitation had occurred outside hospital The survival rates were computed and compared (107 cases), in general wards (57 cases), and with those of a comparable normal population by during ambulance transport to the emergency means of special programmes which have been developed at the Danish Institution of Clinical Epidemi- room (1 6 cases). ology (HORWITZ 1978). Using this method, the progThe diagnosis was arteriosclerotic heart nosis was assessed in three different ways: disease in 148 cases, including 103 with acute (1) The niortality rates (%) during the specific follow-up myocardial infarction. Acute asphyxia was periods, i.e. days, weeks, months or years after the found in 16, while other diagnoses were made cardiac arrest; (2) The number ofdeaths that had occurred among 100 in 16. new cases at the end of a specific follow-up period; Of the patients, 108 died in hospital, while (3) The death area, indicating the fractinn of the lifespan 72 were discharged alive; 38 patients died lost because of death during the follow-up period. after discharge during the follow-up period. The mortality of the patients was related to their age Table 1 shows the duration of follow-up at the time of cardiac arrest and to the original cause and of survival for each patient, as well as the of cardiac arrest. The quality of life of surviving patients was assessed mortality rates and deaths in 100 new from their day-to-day activities, which might be limited patients at the end of a specific follow-up mainly by anoxic mental impairment or cardiac period, and the same parameters in a comdisability. Their cardiac function was classified according to the principles of the NEWYORKHEARTASSOCI- parable normal population with the same sex and age distribution. ATION (1964).
Table 1 Mortality rates and survival table for patients with cardiac arrest compared with corresponding data from a normal popuiation with the same sex and age distribution. Number of patients
Mortality rate
(5:)
Deaths:
-
Time after cardiac arrest
Alive*
Dead?
Observation ceased?
1 day 2 days 3 days 7 days 14 clays 1 month 2 months 3 months 6 months 1 year 2 years 3 years 4 years 5 years
180 175 160 130 103 80 70 64 55 39 25 13 8 6
0 5 15 30 27 23 10 6 9 6 8 6
0
0 1
0 0 0 0 0 0 0 0 10 6 6 5 1
Paticntst
2.78 8.75 18.75 20.77 22.33 12.50 8.57 14.06 12.04 2 1.86 28.60
14.18
* Refers to the time in question. ? Refers to the immediately preceding period.
3 Percentage of deaths in
100 new cases in a specific period.
(x)
Normal?
Patients*
Normal
0.01 0.01 0.01 0.04 0.07 0.15 0.25 0.26 0.77 1.43 2.62 2.31 2.32 2.96
2.78 11.11 27.78 42.78 55.56 61.11 64.44 69.44 73.12 79.00 85.01 85.01 87.13
0.01 0.02 0.03 0.07 0.13 0.28 0.57 0.85 1.70 3.45 6.97 10.57 14.26 17.99
MORTALIlY RATES A F l E R CARDIAC ARREST
It appears that 55 patients were followed for more than 6 months, 39 for more than 1 year, 25 for more than 2 years, and 13 for more than 3 years. It should be noted that the mortality rate after cardiac arrest was greatest during the first few weeks, as nearly 25:l0 of the patients died within 1 week, approximately 43% within 2 weeks, and about 55% within the first month after cardiac arrest. After this time a definite decrease in mortality was seen, but the mortality rate was still many times greater than that of the normal population: it was 10 times as great 1, 2 and 3 years after cardiac arrest. After 3 years, only a limited mortality was seen, and none of the six patients who were followed for more than 5 years died during the follow-up period. Figure 1 illustrates the death area of the patients, which corresponds to the percentage of the total possible lifespan during the follow-up period which is lost due to death. For comparison, the death area of a comparable normal population is superimposed upon that of the patients. After 5 years of observation, the total death area of the patients made up 78.96% of the possible total, while it was only 8.850,/, for the normal population.
0area
Furthermore, the figure illustrates the area corresponding to the duration of the primary hospital stay, which lasted from 3 to 365 days, averaging 28 days and totalling 51 13 days. Owing to the special graduation of the abscissa, the hospitalization area is not as large as it appears in Figure 1 (it is actually 1.54% of the total area). The total time of survival after discharge corresponds to the white area, which represents 19.500,:. After discharge, 38 patients died 1-48 months (average 11.2 months) after cardiac arrest. Table 2 shows the relation between the original diagnosis and mortality. Note that the mortality after discharge was evenly distributed between patients with the two main diagnoses, i.e. occlusive and nonocclusive arteriosclerotic heart disease. However, the risk of sudden cardiac death was greatest in arteriosclerotic heart disease without acute infarction. Among the patients who died after discharge, five had sequelae of anoxic brain damage, severe in one, but only of moderate degree in four. The importance of age in the prognosis is
af t h e l i v i n g d i s c h a r g e d p a t i e n t s
t h e d e a t h area of normal personii t h e d e a t h a r e a o f p a t i e n t s a f t e r c a r d i a c arrest a r e a of t h e primary h o s p i t a l i z a t i o n after c,ii-diac a r r P 5 t
days
'
montt1s
'
time since c a r d i a c a r r e s t
213
yCL3rS
Fig. 1. Areas oldeatli, hospitalization and survival after discharge.
214
M . WERNDERG AN11 A . THOMASSEN
Table 2 Outcome related to the original cause of cardiac arrest.
Total number
Discharged alive
Still alive
Died after discharge
Cardiac death
Sudden cardiac death*
Acute myocardial infarction Arteriosclerotic heart disease without infarction Acute asphyxia Other diagnoses
103
37
17
20
17
8
45 16 16
21
9
12
7 7
5 3
2
9 1
4
2
0 1
Total
180
72
34
38
29
15
Cause of cardiac arrest
G
* Includes deaths only after discharge from hospital. illustrated in Figure 2. The younger patients seem to have better chances of survival, but the differences are not statistically significant. At the termination of the follow-up, 34 patients were still alive after observation periods varying from 7 months to 8.2 years (average 2.7 years) after cardiac arrest. The present conditions of these patients are shown in Table 3. I n most of the patients, cardiac function was classified as group 1 or 2. No drugs were given to 11 patients, while heart medicine was administered in 15 and diuretics in 16. The patients who, in spite of good cardiac
I -19
I /
, 1 1 1 1
1
1
function, were still convalescent or far frorn having regained previous activity were mainly disabled by sequelae of anoxic brain damage. A total of eight patients had mental impairment, one to such a n extent that he was permanently institutionalized. The others could manage at home, although four of them were a considerable burden to their families. Furthermore, troublesome nervous symptoms developed in two after their cardiac arrest. Many of the patients had later been repeatedly admitted to hospital because of their heart disease, one as often as 40 times.
>
and survival arrest.
after
cardiac
MORTALITY RATES AFTER CARDIAC ARREST
215
Table 3 Conditions of 34 patients still alive.
1
Bedridden or convalescent Far from having regained the same activity level as before cardiac arrest Having partly regained the same activity level as before Having fully regained the same activity level as before Total
* According to the New York
Heart function group* 2 3
4
Total
1
1
1
3
7
2
0
8
0
10
1
6
1
0
8
G
3
0
0
9
10
10
11
3
34
Heart Association.
up to 3 years after cardiac arrest, most pronounced in the first year. After 3 years the The majority of patients who primarily mortality rate of the patients approached survive cardiac arrest die in hospital. The that of the normal population. A similar figure in our series was SO%, which agrees decrease was found by LEMIRE& JOHNSON with other reports (LUND& SKULBERC 1971, (1972), but as in our study they had only a LIRERTHSON et al. 1974, DYBDAHL et al. limited number of patients with a sufficiently long time of observation. 1978). About half of the patients (15 out of 29) Studies on the mortality of patients discharged after cardiac arrest show that whose death was due to cardiac causes after 24-30% die within the first year, while death discharge died suddenly outside hospital, had occurred in 38-430/, after 2 years and in which is in accordance with earlier reports et al. 1969, BAUMet al. 1974, CORB 49% after 3 years (LEMIRE &JOHNSON 1972, (DUPONT et al. 1978). The risk BAUMet al. 1974, COBBet al. 1975, DYBDAHL et al. 1975, DYBDAHL et al. 1978). T h e corresponding figures in our oflater sudden cardiac death was most prostudy were 31%, 43%, and 50%, respectively. nounced if the primary arrest had been However, we reckoned the duration of sur- caused by arteriosclerotic heart disease withvival from the time of cardiac arrest and not out infarction. This difference between occlufrom the day of discharge. The long-term sive and non-occlusive arteriosclerotic heart prognosis after cardiac arrest in relation to a disease has previously been observed by mild coronary attack has been found to be GDTZSGHE & LYSCAARD (1968), BAUMet al. approximately the sameas that fo!lowing acute (1974) and COBBet al. (1975), but not by et al. (1969). A possible explanation myocardial infarction without cardiac arrest DUPONT (GEDDES et al. 1967). of this is that while the risk of cardiac arrest However, it does not seem reasonable to due to acute coronary occlusion is of relatively assess the severity of a disease by comparing short duration, non-occlusive arteriosclerotic it with another serious illness. We found it heart disease is a chronic progressing disease more illustrative to relate the mortality of in which myocardial fibrosis is probably the patients after cardiac arrest with that exciting cause of cardiac arrest. Like DYBDAHL et al. (1978), we found a occurring in a comparable normal population. By so doing, we found that the patients tendency to a lower mortality rate in younger had a significantly increased mortality rate patients. DISCUSSION
216
hl. CVERNEERG AND A. TIIOMASSEN
The Datients who were still alive at the end of the following study mainly had satisfactory cardiac function; 59% were in group I or 11. These findings are in accordance with those of DUPONTet al. (1969), LAWRIE(1969), LEMIRE& JOHNSON (1972), and FABRICIUS-RJERRE et al. (1974). However, the day-to-day activities and the social situation of many of the patients left a good deal to be desired, as only 9 (27%) had fully and 8 (24%) partly regained their previous level of activity. I n addition to a poor cardiac state, this was caused by neurological sequelae, especially mental impairment, which was found in 13 (180/,) of the discharged patients. Eight of these were still alive at the end of the study. Tlius, the mortality rate does not seem to be increased by anoxic brain damage iri discharged patients. Consequent to cardiac arrest, major nervous symptoms had developed in another two patients, which is not unusual (DOBSON et al. 1971). I n conclusion, it may be said that the mortality rate is high in patients discharged after cardiac arrest, especially during the first year, but after the third year of survival it approaches that of the normal population. However, the quality of life of many of the survivors is often unsatisfactory, but in order to clarify this, prospective serial examinations of all surviving patients are required.
ACKNOWLEDGEMENT M.’e wish to thank Dr. Ole Horwitz, the Danish
Institute of Clinical Epidemiology, for his help in computing the survival rates.
(1969) Management of ventricular fibrillation ontside hospital. Lancet i, 1169. BAUM,R. S., ALVAREZ,H. & COBS, I,. A. (1974) Survival after resuscitation from out-of-hospital ventricular fibrillation. Circulation 50, 1231. COBB,L. A., BAUM,R. S., ALVAREZ, H. & SCHAFFEK, W. A. (1975) Resuscitation from out-of-hospital ventricular fibrillatioc: 4 years follow-up. Circulation Suppl. 111, 223. A. E., ADLER,M. W. & DOBSON,M., TATTERSFIELD, MCNICOL,M. W. (1971) Attitudes and long-term adjustment of patients surviving cardiac arrest. Brit. med. 3.3, 207. DUPONT, B., FLENSTED-JENSEN, E. & SANDBE, E. (1969) T h e long-term prognosis for patients resuscitated after cardiac arrest. Amer. Heart 3. 78, 444. DYBDAHL, J. H., RUTLIN,E. & BERG-LARSEN, K. (1978) The prognosis of patients resuscitated during acute myocardial infarction. 3. Oslo C i O Hosp. 28,29. FABRICIUS-BJERRE, N., ASTVAD,K. & KJRRULFF,.J. (1974) Cardiac arrest following acute myocardial infarction. Acta med. scand. 195, 261. GEDDES, J. S., ADGEY,A. A. J. & PANTRIDGE, J. 1:. (1967) Prognosis after recovery from ventricular fibrillation complicating ischaemic heart disease. Lancet ii, 273. A. (1968) Cardiac arrest in GQTZSCHE,H. & LYSGARD, heart disease. Acta anaesth. scand. Suppl. 29, 2 17. HORWITZ, 0. (1978) Prognoseberegninger for et patientmateriale. Ugeskr. Leg. 140, 489. LAWRIE,D. M. (1969) Long-term survival aftrr ventricular fibrillation complicating acute myocardial infarction. Lancet ii, 1085. LEMIRE,J. G . & JOHNSON, A. L. (1972) Is cardiac resuscitation worthwhile? New En,$. 3. M e d . 286, 970. LIBERTHSON, R. R., NAGEL,E. L., HIKSHMAN, J. C. & NUSSENFELD, S. R. (1974) Prehospital ventricular defibrillation. N e w Engl. 3. M e d . 291, 317. LUND,I. & SKULBERG, A. (1971) Experiences with a doctor-manned ambulance service in Oslo. 3. Oslo City Hosp. 21, 150. NEWYORKHEARTASSOCIATION, INC.,CRITERIA COMMITTEE (1964) Diseases of heart and blood vessels. Nomenclature and Criteria for Diagnosis. 6th Ed. Iittlc, Brown & Co., Boston, p. 114. Address : Mogens Wernberg, M.D.
REFERENCES ADGLY, A. A. J., NELSON, 1’. G., SCOTT, M. E., GLDDhS, J. S., AILEN,J. D., ZAIDI,S. A. & PANTKIDGE, J. F.
Department of Anaesthesiology University Hospital DK-8000 Aarhus C Denmark
