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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; M.Umer Tariq [3]

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Table of Contents

Post arrest care and prevention

==Ethical issues

Cardiac Arrest: Prognosis

The out-of-hospital cardiac arrest (OHCA) has a worse survival rate (2-8% at discharge and 8-22% on admission), than an in-hospital cardiac arrest (15% at discharge). The principal determining factor is the initially documented rhythm. Patients with VF/VT have 10-15 times more chance of surviving than those suffering from Pulseless electrical activity or Asystole (as they are sensitive to defibrillation, whereas asystole and PEA are not).

Since mortality in case of OHCA is high, programs were developed to improve survival rate. A study by Bunch et al showed that, although mortality in case of ventricular fibrillation is high, rapid intervention with a defibrillator increases survival rate to that of patients that did not have a cardiac arrest.Eisenberg MS, Mengert TJ (2001). "Cardiac resuscitation". N. Engl. J. Med. 344 (17): 1304–13. PMID 11320390. </ref>

Survival is mostly related to the cause of the arrest (see above). In particular, patients who have suffered hypothermia have an increased survival rate, possibly because the cold protects the vital organs from the effects of tissue hypoxia. Survival rates following an arrest induced by toxins is very much dependent on identifying the toxin and administering an appropriate antidote. A patient who has suffered a myocardial infarction due to a blood clot in the Left coronary artery has a lower chance of survival as it cuts of the blood supply to most of the left ventricle (the chamber which must pump blood to the whole of the systemic circulation).

Cobbe et al (1996) conducted a study into survival rates from out of hospital cardiac arrest. 14.6% of those who had received resuscitation by ambulance staff survived as far as admission to an acute hospital ward. Of these, 59.3% died during that admission, half of these within the first 24 hours. 46.1% survived to hospital discharge (this is 6.75% of those who had been resuscitated by ambulance staff), however 97.5% suffered a mild to moderate neurological disability, and 2% suffered a major neurological disability. Of those who were successfully discharged from hospital, 70% were still alive 4 years after their discharge.

Ballew (1997) performed a review of 68 earlier studies into prognosis following in-hospital cardiac arrest. They found a survival to discharge rate of 14% (this roughly double the rate for out of hospital arrest found by Cobbe et al (see above)), although there was a wide range (0-28%).

Several high profile organisations (such as St John Ambulance and the British Heart Foundation) have promoted the "Chain of Survival", which is made up of 4 links, as a way to maximise prognosis following arrest:

• Early Access - Identifying patients at risk of cardiac arrest early is the best way of improving prognosis, as it is often possible to prevent the arrest. Similarly, if the arrest is witnessed there is a much greater chance of survival, as treatment can begin straight away before tissue hypoxia sets in.
• Early CPR - CPR is unlikely to revive the patient, but it does buy some time by keeping a (limited) circulation going until it is possible to reverse the arrest, thereby increasing the chances of this reversal being successful, and minimising the risk of cerebral hypoxia (which can lead to neurological impairment following return of circulation).
• Early defibrillation - Patients who present with VF/VT can be defibrillated, and the earlier this happens the better, as VF/VT often degenerate into asystole (which is unshockable).
• Early hospital care - Many patients suffer further arrests within the first 24 hours of admission, so it is better that they are in hospital where their chances of survival are a little higher.

Prevention

With positive outcomes following cardiac arrest so unlikely, a great deal of effort has been spent in finding effective strategies to prevent cardiac arrest.

As noted above, one of the prime causes of cardiac arrest outside of hospital is ischemic heart disease. Vast resources have been put into trying to reduce cardiovascular risks across much of the developed world. In particular schemes have been put in place to promote a healthy diet and exercise. For people considered to be particularly at risk of heart disease, measures such as blood pressure control, prescription of cholesterol lowering medications, and other medico-therapeutic interventions, have been widely used. A magnesium deficiency, or lower levels of magnesium, can contribute to heart disease and a healthy diet that contains adequte magnesium may help prevent heart disease. Magnesium can be used to enhance long term treatment, so it may be effective in long term prevention.

Patients in hospital are far less likely to have a cardiac arrest caused of primary cardiac origin, and hence present in Asystole or PEA, and have bleak outcomes. Extensive research has shown that patients in general wards often deteriorate for several hours or even days before a cardiac arrest occurs . This has been attributed to a lack of knowledge and skill amongst ward based staff, in particular a failure to carry out measurement of the Respiratory rate, which is often the major predictor of a deterioration and can often change up to 48 hours prior to a cardiac arrest. In response to this, many hospitals now have increased training for ward based staff. A number of "early warning" systems also exist which aim to quantify the risk which patients are at of deterioration based on their vital signs and thus provide a guide to staff. In addition, specialist staff are being utilised more effectively in order to augment the work already being done at ward level. These include:

• Crash teams (also known as Code teams) - These are designated staff members who have particular expertise in resuscitation, who are called to the scene of all arrests within the hospital.
• Medical Emergency Teams - These teams respond to all emergencies, with the aim of treating the patient in the acute phase of their illness in order to prevent a cardiac arrest.
• Critical care outreach - As well as providing the services of the other two types of team, these teams are also responsible for educating non-specialist staff. In addition, they help to facilitate transfers between intensive care/high dependency units and the general hospital wards. This is particularly important, as many studies have shown that a significant percentage of patients discharged from critical care environments quickly deteriorate and are re-admitted - the outreach team offers support to ward staff to prevent this from happening.

Implantable cardioverter defibrillators

A technically based intervention to prevent further cardiac arrest episodes is the use of an implantable cardioverter-defibrillator (ICD). This device is implanted in to the patient and can offer a 'pacemaker' effect to the heart as well as acting as an instant defibrillator in the event of arrhythmia. A recent study by Birnie et al at the University of Ottawa Heart Institute has demonstrated that ICDs are underused in both the United States and Canada. An accompanying editorial by Simpson explores some of the economic, geographic, social and political reasons for this.

Prevention of Sudden Cardiac Death

ACC / AHA Guidelines- Recommendations for Implantable Cardioverter Defibrillators (DO NOT EDIT)

“

Class I 1. ICD therapy is indicated in patients who are survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes. (Level of Evidence: A) 2. ICD therapy is indicated in patients with structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable. (Level of Evidence: B) 3. ICD therapy is indicated in patients with syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study. (Level of Evidence: B) 4. ICD therapy is indicated in patients with LVEF less than 35% due to prior MI who are at least 40 days post-MI and are in NYHA functional Class II or III. (Level of Evidence: A) 5. ICD therapy is indicated in patients with nonischemic DCM who have an LVEF less than or equal to 35% and who are in NYHA functional Class II or III. (Level of Evidence: B) 6. ICD therapy is indicated in patients with LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF less than 30%, and are in NYHA functional Class I. (Level of Evidence: A) 7. ICD therapy is indicated in patients with nonsustained VT due to prior MI, LVEF less than 40%, and inducible VF or sustained VT at electrophysiological study. (Level of Evidence: B) Class IIa 1. ICD implantation is reasonable for patients with unexplained syncope, significant LV dysfunction, and nonischemic DCM. (Level of Evidence: C) 2. ICD implantation is reasonable for patients with sustained VT and normal or near-normal ventricular function. (Level of Evidence: C) 3. ICD implantation is reasonable for patients with HCM who have 1 or more major{dagger} risk factors for SCD. (Level of Evidence: C) 4. ICD implantation is reasonable for the prevention of SCD in patients with ARVD/C who have 1 or more risk factors for SCD. (Level of Evidence: C) 5. ICD implantation is reasonable to reduce SCD in patients with long-QT syndrome who are experiencing syncope and/or VT while receiving beta blockers. (Level of Evidence: B) 6. ICD implantation is reasonable for non hospitalized patients awaiting transplantation. (Level of Evidence: C) 7. ICD implantation is reasonable for patients with Brugada syndrome who have had syncope. (Level of Evidence: C) 8. ICD implantation is reasonable for patients with Brugada syndrome who have documented VT that has not resulted in cardiac arrest. (Level of Evidence: C) 9. ICD implantation is reasonable for patients with catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while receiving beta blockers. (Level of Evidence: C) 10. ICD implantation is reasonable for patients with cardiac sarcoidosis, giant cell myocarditis, or Chagas disease. (Level of Evidence: C) Class IIb 1. ICD therapy may be considered in patients with nonischemic heart disease who have an LVEF of less than or equal to 35% and who are in NYHA functional Class I. (Level of Evidence: C) 2. ICD therapy may be considered for patients with long-QT syndrome and risk factors for SCD. (Level of Evidence: B) 3. ICD therapy may be considered in patients with syncope and advanced structural heart disease in whom thorough invasive and noninvasive investigations have failed to define a cause. (Level of Evidence: C) 4. ICD therapy may be considered in patients with a familial cardiomyopathy associated with sudden death. (Level of Evidence: C) 5. ICD therapy may be considered in patients with LV noncompaction. (Level of Evidence: C) Class III 1. ICD therapy is not indicated for patients who do not have a reasonable expectation of survival with an acceptable functional status for at least 1 year, even if they meet ICD implantation criteria specified in the Class I, IIa, and IIb recommendations above. (Level of Evidence: C) 2. ICD therapy is not indicated for patients with incessant VT or VF. (Level of Evidence: C) 3. ICD therapy is not indicated in patients with significant psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up. (Level of Evidence: C) 4. ICD therapy is not indicated for NYHA Class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or CRT-D. (Level of Evidence: C) 5. ICD therapy is not indicated for syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias and without structural heart disease. (Level of Evidence: C) 6. ICD therapy is not indicated when VF or VT is amenable to surgical or catheter ablation (e.g., atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, RV or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence of structural heart disease). (Level of Evidence: C) 7. ICD therapy is not indicated for patients with ventricular tachyarrhythmias due to a completely reversible disorder in the absence of structural heart disease (e.g., electrolyte imbalance, drugs, or trauma). (Level of Evidence: B)

”

ACC / AHA Guidelines- Recommendations for Implantable Cardioverter-Defibrillators in Pediatric Patients and Patients With Congenital Heart Disease (DO NOT EDIT)

“

Class I 1. ICD implantation is indicated in the survivor of cardiac arrest after evaluation to define the cause of the event and to exclude any reversible causes. (Level of Evidence: B) 2. ICD implantation is indicated for patients with symptomatic sustained VT in association with congenital heart disease who have undergone hemodynamic and electrophysiological evaluation. Catheter ablation or surgical repair may offer possible alternatives in carefully selected patients. (Level of Evidence: C) Class IIa 1. ICD implantation is reasonable for patients with congenital heart disease with recurrent syncope of undetermined origin in the presence of either ventricular dysfunction or inducible ventricular arrhythmias at electrophysiological study. (Level of Evidence: B) Class IIb 1. ICD implantation may be considered for patients with recurrent syncope associated with complex congenital heart disease and advanced systemic ventricular dysfunction when thorough invasive and noninvasive investigations have failed to define a cause. (Level of Evidence: C) Class III 1. All Class III recommendations found in Section 3, "Indications for Implantable Cardioverter-Defibrillator Therapy," apply to pediatric patients and patients with congenital heart disease, and ICD implantation is not indicated in these patient populations. (Level of Evidence: C)

”

Cardiac Arrest: Ethical Issues

Cardiopulmonary resuscitation and advanced cardiac life support are not always in a person's best interest. This is particularly true in the case of terminal illnesses when resuscitation will not alter the outcome of the disease. Properly performed CPR often fractures the rib cage, especially in older patients or those suffering from osteoporosis. Defibrillation, especially repeated several times as called for by ACLS protocols, may also cause electrical burns.

Some people with a terminal illness choose to avoid such measures and die peacefully. People with views on the treatment they wish to receive in the event of a cardiac arrest should discuss these views with both their doctor and with their family. A patient may ask their doctor to record a do not resuscitate (DNR) order in the medical record. Alternatively, in many jurisdictions, a person may formally state their wishes in an advance directive or advance health directive.

See also

• Asystole
• Clinical death
• Death
• Defibrillation
• Myocardial infarction
• Near-death experience
• Ventricular fibrillation

Additional resources

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