Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association

Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association

Abstract

Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.

The number of people surviving sudden cardiac arrest (SCA) is increasing. This includes both adults and children, and it results from successful cardiac arrest systems of care. However, survival often results in lingering effects across a spectrum of physical, neurological, cognitive, emotional, and social issues. Some of these effects may not be apparent until after discharge from the hospital.

A lack of uniform patient-centered assessment and reliable provision of resources for SCA survivors after initial medical stabilization perpetuates a fragmented approach to hospital discharge planning. Resources for physical, cognitive, emotional, and social needs are not standardized. The absence of a coordinated plan during hospitalization to assess (short-term) and reassess (long-term) survivorship before and after discharge hampers improvements in systems to optimize patient-centered care. Without expectation or direction, families and caregivers are poorly equipped to support recovery, to assist in providing rehabilitation care, or to anticipate the patient’s psychosocial needs when transitioning from acute care to home or another care facility. Family members, caregivers, and healthcare providers may also need psychosocial support alongside that of the patient.

SCA survivors represent a heterogeneous group of patients, often with unique and complex needs that are inadequately addressed by current treatment recommendations. The few recommendations that do exist for follow-up after SCA are generally borrowed from other specialties for secondary prevention of cardiac events (eg, placement of an implantable cardioverter defibrillator [ICD], need for percutaneous coronary intervention or coronary artery bypass grafting) but do not address other domains affected by SCA (eg, cognitive, psychological, emotional, social). In the absence of structured care plans or support groups, informal communities of survivors have coalesced to discuss shared experiences and to assist with navigating survivorship.

The current situation for SCA survivorship stands in stark contrast to other disease states (eg, myocardial infarction, stroke)1 that have comprehensive recommendations for risk factor modification, surveillance, and rehabilitation. Cancer2 and solid organ transplantation3 survivorship guidelines are also excellent models that integrate the patient and support systems into the short- and long-term care plans. Finally, there is a growing movement in the critical care community to address the gaps in patient-centered care after critical illness, including providing specialty follow-up clinics.4 However, SCA survivors represent a small subset of all critically ill patients with unique needs.

Although the primary focus for this statement is adult cardiac arrest survivorship, much of the content may be applicable to pediatric SCA survivors and their families. Some guidance may be borrowed from the congenital heart disease literature.5 Unique issues for the pediatric population may include developmental delays as a result of critical illness, falling behind or feeling socially isolated as a result of missing school, and concerns about body image because of procedural scars or implanted devices. Long-term outcome assessment, rehabilitation consideration, and quality of life after critical illness are covered briefly elsewhere.5a

The purpose of this statement is to summarize the available science that describes the experience of patients and their families and caregivers after cardiac arrest and to organize a template survivorship plan that may be used to communicate across hospital systems and specialties. After reviewing the current post–cardiac arrest literature, the authors concluded that a need existed to expand the cardiac arrest system of care to include and focus on the individual patient (Figure 1). Thus, in this statement, we systematically approach the current gaps in care for cardiac arrest survivors by examining the healthcare system holistically. This statement draws attention to the far-reaching effects that a single cardiac arrest event has on individuals, their care providers, and their community. In addition, the Layperson Summary of Cardiac Arrest Survivorship section seeks to empower patients and caregivers to address their current and future needs with providers across the healthcare system.

Scope

Survivorship after critical illness focuses on the health and well-being of an individual after treatment until the end of his or her life. This includes fostering survivors’ will to return home and to their families. It also includes, when possible, fostering survivors’ ability to return to hobbies and previous work. Survivorship acknowledges the complex emotional, physical, social, and economic challenges associated with life during and after critical illness. It recognizes the importance of caregivers and support networks, who may also need guidance throughout the long recovery period.

Survivorship has been described as the defining challenge of critical care in the 21st century.6 Research into the function, disability, and health of survivors has increased, revealing significant opportunities for improving long-term quality of life, even during the first days in an intensive care unit (ICU).7 Although critical care often takes place within closed hospital units, many clinicians, researchers, and patient-partners have called for it to be a priority, necessitating coordination of multidisciplinary teams to assist with ICU therapies, discharge planning, and outpatient follow-up. Interventions and treatments for critical illness have led to increased survival. However, the critical care community recognizes that after surviving invasive and painful procedures, delirium, and loss of independence and function, patients and their loved ones need coordinated guidance beyond the ICU and hospital walls.

Epidemiology of SCA and Its Survivors

Over the past decade, survival after resuscitation from cardiac arrest has increased.1,8 The estimated annual incidence in the United States for out-of-hospital cardiac arrest (OHCA) treated by emergency medical services (EMS) is 184 383 encounters, and the incidence of OHCA has increased over time.9 Survival to hospital discharge after EMS-treated OHCA is estimated at 10.8% (≈19 913 individuals per year)10 to 11.4% (≈21 019 individuals per year).9 The annual incidence of in-hospital cardiac arrest (IHCA) is estimated at 209 000 individuals. Survival to hospital discharge after IHCA is 25.8% (≈53 922 individuals per year). These survival rates have increased over time, partly from standardized post–cardiac arrest care and avoidance of early withdrawal of life-sustaining therapies.11,12 Thus, >70 000 individuals are potentially discharged from the hospital after cardiac arrest in the United States each year without any formal rehabilitation plan, and this number is expected to increase.

Estimates of the functional status of patients who are discharged from the hospital after cardiac arrest vary widely. In large registries, 18% of survivors of OHCA and 40% of adult survivors of IHCA have moderate to severe functional impairments at hospital discharge, preventing return to work and normal daily activities. These registries define good outcomes broadly, using subjective scales that distinguish completely dependent patients from partially or fully independent patients (eg, Cerebral Performance Category [CPC] or modified Rankin Scale). However, the majority of patients report some impairment that alters their function or quality of life compared with their premorbid state on more objective scales or more granular instruments.13

Current Variation in Postarrest Care and Survivorship

Comprehensively understanding the survivorship needs of cardiac arrest survivors requires acknowledging the heterogeneity in clinical post–cardiac arrest care and its association with outcome. One potential reason for this heterogeneity is that different institutions often have unique entry criteria for postresuscitation care protocols. Some facilities have stringent requirements, whereby only patients with witnessed arrest and a shockable rhythm are treated with the protocol. Other facilities have broad inclusion criteria, applying their protocols to a diverse group of patients.14 Furthermore, once the protocol is engaged, multiple specialists care for these patients with variable coordination between service lines, which contributes to the patients’ fragmented postarrest care. Communication across healthcare facilities and care transitions may be hindered by space, time, and medical record incompatibility. This variation in “who” and “how” has implications not only for individual patients but also for measuring outcomes across systems.

Current recommendations for postarrest care include targeted temperature management, aggressive coronary revascularization, normalization of Pao2 and Paco2, and a multimodal workup to determine neurological prognosis.15 High-volume facilities with a standardized postarrest care bundle or a plan for patients resuscitated from cardiac arrest have demonstrated superior outcomes.12 This has led to a recommendation for designated cardiac arrest centers.11,16,17 The survival effect from treatment at high-volume centers continues for several years and is evident within regions of care.12

Components of postarrest care such as targeted temperature management have been studied in isolation, but little attention has been paid to the need for or timing of rehabilitation interventions in SCA survivors. Prior work has demonstrated that a significant proportion of patients are discharged with functional deficits (eg, difficulty walking, writing, or paying bills) but often do not receive rehabilitation after hospital discharge. Individual patients may be identified as needing rehabilitation in one domain or another, but the authors are not aware of existing protocols for systematically assessing SCA survivor rehabilitation needs. A survey study in Sweden revealed that although local guidelines for follow-up exist at some hospitals, they are not uniformly applied or explicit.18 To date, there has been 1 randomized trial focused on a home intervention in this population, as well as small feasibility trials of interventions delivered by phone.19 Thus, significant opportunities exist to optimize the physical, emotional, and cognitive aspects of survivorship to further improve outcomes.

Centering on the Survivor: Vulnerability of the Patient

The system of care for a disease refers to the healthcare delivery framework that supports the relevant stakeholders and their associated needs.20 The purpose of examining a disease and healthcare delivery through this model is to optimize delivery of healthcare resources to the patient. Thus far, the system-of-care approach has been beneficial for cardiac arrest in that it has helped stakeholders grow beyond functioning as independent silos within the house of medicine. It has encouraged the development of multidisciplinary teams that drive optimal care for patients after cardiac arrest. The systems-of-care approach to cardiac arrest has optimized EMS systems and promoted examination of IHCA and OHCA outcomes. However, the current system of care falls short by failing to organize discharge planning and long-term rehabilitation care resources, which, for many patients and their families, may be paramount to improving quality of life after cardiac arrest.

Outcomes and Quality of Life

Clinician-reported outcomes (return of spontaneous circulation [ROSC], survival at discharge, CPC score, modified Rankin Scale score) have been the standard for cardiac arrest studies and for defining good or acceptable outcomes. However, these results are insufficient because they originate from the (healthcare) provider perspective. Moreover, the concept of acceptable is not survivor defined, and assessment is frequently conducted at hospital discharge, thus failing to consider challenges encountered when survivors return home.

Quality of life is a broad term describing a person’s overall well-being, determined by satisfaction or dissatisfaction with various aspects of life. It is difficult to define beyond an individual level; therefore, it is difficult to measure. Health-related quality of life (HRQOL) is an individual’s perception of the impact of illness (and the treatment of illness) on discrete domains of daily life and functioning. It is temporal, should be assessed over time, and is defined only at the individual level. Patient-reported health status encompasses HRQOL and the symptoms resulting from a disease, such that disease-specific instruments assessing multiple domains are ideal if available. Although cardiovascular disease–specific health status surveys exist, they are inconsistently used in practice.21

Generic measures such as the 36-Item Short-Form Survey or the 12-Item Health Survey22,23 have captured reports of lower levels of physical or mental health in survivors of cardiac arrest compared with age- and sex-matched population values at 12 months,24,25 3 years,26,27 and 5 years.28 However, these findings are very much influenced by the choice of generic measures, with some studies reporting no difference in generic quality of life between survivors and the general population.29,30 Although they support health comparisons across population groups, generic measures lack specificity and may fail to account for variation in patient or system factors such as protocol inclusion criteria, provider biases, or cultural/religious differences. When used in isolation, generic measures provide a suboptimal assessment of outcome from the survivor’s perspective.29,31

For many survivors, their HRQOL may continue to change,24 and a longer-term assessment of HRQOL is recommended.29,32 Patient-reported outcome measures seek to assess either specific aspects of or the overarching concept of patient-reported health status.13,33,34 Alternatively, the lived experience may be explored with patients and their families by following more qualitative approaches such as interviews or focus groups.29,35,36 Although numerous domain-specific measures are available and have been widely used in this population (eg, assessing cognitive impairment27 or emotional well-being),37 a patient-reported outcome measure that is specific to the experience of cardiac arrest survivors is not currently available.29

Quality of life and patient-reported outcome measures are now included as supplementary outcomes in the updated international Utstein statement and reporting framework.38 Existing research has highlighted the lack of assessment guidance after cardiac arrest and the resulting heterogeneity in outcome reporting across many essential elements of survivorship, including HRQOL,29,39–41 cognitive function,42 and emotional well-being.37 This heterogeneity in reporting adds to the methodological variation reported in studies, thus limiting evidence synthesis of the impact of cardiac arrest and associated health care.

A recent statement from the International Liaison Committee on Resuscitation identified a core outcome set for cardiac arrest effectiveness studies that should include survival, neurological function, and HRQOL.43 As cardiac arrest–specific scales and core outcome sets are developed, both researchers and clinicians will have better tools to measure, assess, and reassess outcomes after cardiac arrest. These tools will also allow treatments and rehabilitation interventions to be in line with patients’ values and goals of care.

Addressing Arrest Causes and Preventing Recurrence

The causes of cardiac arrest vary substantially by individual characteristics and age.44–50 Data are lacking that systematically compare the different risks of recurrent arrest across causes among survivors.51 Given the differing natural histories of each cardiac arrest cause, long-term risks are expected to vary substantially.

The initial workup of patients with a cardiac arrest is focused on identifying reversible or treatable precipitants.4 Such precipitants include myocardial ischemia or infarction, cardiac arrhythmias, electrolyte abnormalities, or drug toxicity, among others. Beyond the early stages of the cardiac arrest, identifying the underlying cause of the arrest may have implications for the intermediate- and long-term management of patients. In CASPER (Cardiac Arrest Survivors With Preserved Ejection Fraction Registry), among patients with a cardiac arrest of unknown cause without overt heart disease, a cause was identified in ≈56% by use of a systematic workup approach comprising electrocardiography and cardiac rhythm assessment, cardiac imaging, provocative exercise and drug challenges, and selective electrophysiology testing.52

Because the ability to predict and prevent recurrent arrests in survivors is imperfect, prevention of recurrent cardiac arrest is focused on both minimizing the conditions that contribute to the arrest and maximizing the probability of survival should a recurrent arrest occur. On the basis of randomized trials,53–55 with few exceptions, guideline recommendations highlight the value of ICDs for secondary prevention after a cardiac arrest.56,57 Typically, ICDs are not indicated if the cause of the arrest is felt to be reversible and adequately treated.56,57

Beyond ICDs, management that minimizes the probability of recurrent arrest is generally condition specific, for example, optimizing neurohormonal blockade in patients with nonischemic cardiomyopathy, performing revascularization for patients with coronary artery disease, administering β-blockers, avoiding QT-prolonging medications in patients with long-QT syndrome, and abstaining from participation in competitive athletics in patients with arrhythmogenic right ventricular cardiomyopathy. Previous consensus statements can be helpful for the management of patients and prevention of recurrent cardiac arrest, particularly when the cause of the cardiac arrest has been identified.58–61

Efforts to maximize the probability of survival should an arrest occur include educating family and caregivers about what a cardiac arrest may look like and when to call for help. Some hospitals offer cardiopulmonary resuscitation (CPR) training to heart patients and their families before discharge so that if an arrest occurs in the home, family members may feel prepared to provide CPR until EMS providers or other first responders arrive. Few studies have examined the feasibility and outcomes related to such programs.62

Patients with inherited arrhythmia syndromes, which span both channelopathies and cardiomyopathies, may benefit from formal genetic counseling, testing, and familial evaluations.63–65 In such patients, the yield of genetic evaluation varies substantially by condition66,67 but can facilitate screening and direct carrier testing of relatives at risk for the condition. Genomic analysis with commercial genetic testing has increased dramatically as sequencing technology has become highly efficient, making test selection and variant interpretation more complex. Moreover, discussion of legal, economic, and ethical implications of testing is warranted when counseling patients. Testing in conjunction with an experienced genetic counselor is highly encouraged. Guidelines relating to the indications for genetic testing in such conditions have been outlined in contemporary consensus statements.63,64

The management of athletes who have experienced a cardiac arrest can be challenging, particularly when the underlying condition represents an absolute contraindication to long-term participation in competitive athletics. For example, because of risks of disease progression and arrhythmia, patients with arrhythmogenic cardiomyopathy should be counseled against participation in competitive athletics.59,68 Specific recommendations about participation in athletic activity are summarized elsewhere.5,68–75

Post–Critical Illness Syndrome Susceptibility

Survivors of cardiac arrest are at risk for post–critical illness syndrome, the potential psychological, cognitive, and physical impairments that result from surviving and being treated for critical illness. Whereas no previous guidelines addressing cardiac arrest survivorship exist, standards to discuss the effects of the disease process and treatment, to provide ideals for coordination of care, to address psychosocial care and fatigue, and to provide guidance for screening have been developed for other complex and potentially debilitating disease states (including cancer, stroke, and myocardial infarction).76–85 Specifically, guidelines for stroke rehabilitation aim to decrease the morbidity of immobility, depression, loss of autonomy, and loss of functional independence, complications that cardiac arrest survivors also face.85

Unanticipated critical illness and its treatments may have long-term consequences. This view has been increasingly recognized among patients requiring extracorporeal membrane oxygenation or ICU admission for sepsis or acute respiratory distress syndrome. The post–intensive care syndrome (PICS) is a collection of psychological, cognitive, and physical impairments that are common among survivors of critical illness.86 Few studies to date test interventions for improving PICS, and many studies focus only on the psychological aspects of recovery.87 Individual patients also report symptoms for years that are related to specific sequelae of intensive care such as tracheal stenosis, heterotopic ossification in joints, reduced joint mobility, and cosmetic concerns from procedural scars.88 Early interventions are increasingly being studied to reduce delirium and to enhance mobility in the ICU setting.89,90

A series of conferences attended by critical care stakeholders from rehabilitation, palliative care, occupational therapy, intensive care, and the National Heart, Lung, and Blood Institute has sought to inform the long-term consequences of critical illness. This group described PICS as a term that could be applied to a patient, a family member, or both.86 Furthermore, the group identified several research areas in which further evidence to understand PICS was required: risk factors (genetic, family characteristics, comorbidities, severity of illness, length of exposure), prevention (speech and swallowing, physical and occupational therapy, nutrition, sleep, psychiatric evaluations, sedation, oxygenation, glucose control), and transitions of care (medication reconciliation, transfer to other healthcare facilities, and end-of-life discussions).91

Although it is unclear whether the impairments and pathological processes of survivorship after post–cardiac arrest syndrome (PCAS) represent a phenotype distinct from the larger PICS,92 PCAS is known to result in a unique cascade of inflammatory processes in the immediate postresuscitation period.93 Unlike the families of other critically ill patients, the families of cardiac arrest survivors may have witnessed the arrest or performed CPR on their loved ones, creating unique psychosocial needs after survival. With PICS as a framework, additional attention is needed for the subset of post–cardiac arrest survivors and their loved ones.

Centering on the Survivors: At-Risk Body Systems and Their Impairments

The following body and psychosocial systems are presented methodically; however, there is significant overlap among domains. For example, vision impairment may impede a patient’s ability to read (physical function) or recognize objects (cognitive function) because of neurological injury, but it is presented in both the physical and cognitive impairment sections. Furthermore, some assessment tools are listed as examples but may not represent the comprehensive measures available to rehabilitation specialists and may not have been validated for use in cardiac arrest survivors. What follows represents just one scheme to discuss issues of survivorship, to provide guidance for measuring impairments, and to highlight the gaps for further investigation.

Musculoskeletal Considerations

Musculoskeletal impairment after critical illness includes muscle weakness, likely through a combination of a stress-induced catabolic state, inflammation, and immobilization. For example, the cross-sectional area of the quadriceps decreases 12.5% by day 7 and 17.7% by day 10 of ICU admission.94 Other studies report similar muscle wasting in the ICU.95 Survivors of acute respiratory distress syndrome have perceived weakness and limited ability to perform vigorous exercise for up to 5 years after their critical illness.88 Longitudinal studies find improvement in muscle wasting and weakness over 2 years after intensive care.96 Furthermore, objective post-ICU muscle weakness and wasting are associated with impairment of function and reduction in quality-of-life measures.

Post–cardiac arrest patients frequently complain of fatigue that limits activity and participation after hospitalization.97,98 Symptomatic fatigue is reported by more than half of survivors. To what extent postarrest fatigue is related to post–intensive care muscle weakness is not known. Cognitive and problem-solving strategies can improve participation in post–cardiac arrest patients with fatigue.19,99

CPR can also cause specific physical injuries to the chest. Case series report a prevalence of rib fractures of 9% to 85%. Larger series have identified a prevalence clustering at ≈60% by using more sensitive techniques such as computed tomography scan.100–114 Case series report sternal fractures in 4% to 66% of cases, with an overall prevalence of about one-half that of rib fractures (≈30% of cases).100,101,103–108,110,113,114 Abdominal visceral injuries occurred in 8% of 39 survivors in a case series.103 Chest injuries are reported more often in OHCA than in IHCA,112 more often after mechanical CPR than after manual CPR,109,113 and more often in women than in men.110

The duration and severity of pain from CPR-related chest injuries have not been studied. Although it is reasonable to speculate that interventions to treat CPR-related pain and to improve pulmonary hygiene may be beneficial, we identified no studies on this topic.

In addition to chest injuries, many post–cardiac arrest patients report impairment of vision and ambulation.97,115 It is unclear how specific these symptoms are to cardiac arrest. There have not been formal investigations of these specific symptoms.

Few specific therapies are established to improve physical functioning in critically ill patients. In a cohort, physical mobility was severely impaired in the hospital and for 3 months after a critical illness, but patients continued to recover for 12 months.116 More intensive physical therapy and occupational therapy interventions in the hospital focusing on improving mobility and strength did not alter objective mobility measures at 3 months, but this therapy did improve patient satisfaction with recovery. This observation suggests that educating patients about expected limitations and expected recovery can improve their adaptation to physical impairments. Table 1 summarizes physical impairments after critical illness and cardiac arrest.

A Cochrane review of post-ICU exercise-based therapy identified no regimen that resulted in a consistent improvement in patients’ exercise tolerance.95 One exception was a small trial in which 8 weeks of supervised aerobic training after hospitalization (cycle ergometer) increased the anaerobic threshold in 13 subjects compared with 17 subjects with usual care.117 No studies have explored exercise therapy specifically for cardiac arrest.

Neurological Impairment

Neurological injury that occurs while blood flow to the brain is interrupted (no-flow time) or is inadequate (low-flow time during CPR) accounts for much of the morbidity experienced by patients resuscitated from cardiac arrest. The resulting injury cascade (including excitotoxicity, disrupted calcium homeostasis, free radical formation, and pathological protease pathways) ultimately results in cell death. The larger pattern of brain injury is driven by neuron subpopulations selectively vulnerable to hypoxic-ischemic injury and has been well documented in both preclinical and clinical trials. The distribution includes selective neuronal death and cell necrosis in the hippocampus, as well as in the neocortex, the central nuclei, and the brainstem.118,119 Common clinical manifestations of this characteristic brain injury after cardiac arrest are summarized in Table 2 and are discussed in the next sections.

Seizures and Status Epilepticus

The susceptibility of the cerebral cortex to hypoperfusion during and immediately after cardiac arrest results in a high incidence of seizures in the early phase of recovery. The reported incidence of seizures after CPR ranges from 24% to 44%.120,121 The presence of seizures and status epilepticus has been suggested to herald an unfavorable outcome. However, seizure and status epilepticus may respond to aggressive antiseizure therapy in the acute period.122 Survivors who develop chronic epilepsy should be treated with a maintenance antiepileptic regimen.

Post–Cardiac Arrest Myoclonus

Myoclonus after cardiac arrest can occur acutely or may persist chronically, although both forms may coexist. Although early-phase myoclonus was initially deemed to portend a poor outcome,123 favorable phenotypes have been described that are responsive to treatment.124 The chronic type of post-hypoxic myoclonus, or Lance-Adams syndrome, includes positive myoclonic jerks from rapid, active muscle contractions triggered by action or attempts to move, particularly movements requiring coordination or dexterity.125 As a chronic condition, these symptoms can be mitigated and quality of life optimized. Some of the agents with favorable effects include clonazepam, valproic acid, and levetiracetam.126 For cardiac arrest survivors, diagnosis and management of seizures are important for improving outcome.127,128

Stroke and Stroke Syndromes

As the cerebral perfusion drops to ischemic levels, susceptible vascular territories may be infarcted. These injuries typically occur at watershed areas of the major cerebral blood vessels such as the distal areas of the middle cerebral artery and the anterior cerebral artery. This injury results in “man-in-the-barrel syndrome,” a clinical picture of brachial diplegia with intact lower extremity function.

Cardiac risk factors (eg, arrhythmia, heart failure, diabetes mellitus, dyslipidemia) leading to the arrest may also be risk factors for acute ischemic stroke. Stroke that occurs with or around cardiac arrest is approached similarly to a typical stroke, with neuroimaging to confirm diagnosis and options for either intravenous thrombolysis or thrombectomy, as the case may necessitate.

Movement Disorders and Motor Impairment

The areas that control the motor system are similarly vulnerable in cardiac arrest. These areas include portions of the basal ganglia, thalamus, cerebellum, and motor cortex. The clinical manifestation may be confused with seizures, especially during the early period. The electroencephalogram is key to differentiate these conditions from seizures. The nonepileptic movements may include parkinsonism, dystonia, chorea, tics, tremor, athetosis, and myoclonic syndromes.129 Patients may also have difficulty with balance and gait in the form of ataxia and dysmetria. The short- and long-term management of these movement disorders is largely supportive, and long-term care by a neurologist is essential for optimal outcome.129

Disorders of Consciousness

The cerebral cortex and other areas responsible for consciousness are among the most sensitive to global ischemia from cardiac arrest. Disorders of consciousness (DOCs) represent a spectrum of disease, distinct from delirium, ranging from the comatose state (extensive injury to areas responsible for arousal and awareness) to the minimally conscious state (inconsistent but clear evidence of consciousness) to the vegetative state (unresponsiveness with preserved arousal and sleep-wake cycles but with persistent lack of awareness of self and environment).93,130 DOCs are a major limiting factor in recovery and limit the chances of improvement with rehabilitation.

During the initial phase of recovery, the clinical approach to DOCs includes managing conditions that impair cortical and subcortical areas. Structural brain–related processes (eg, brain edema, seizures) should be treated along with systemic factors (eg, hypoxia, hypoperfusion, metabolic derangements). Some investigators have examined the role of neurostimulants to enhance recovery from DOCs during the immediate phase (5–13 days). Although case series on drugs such as amantadine,131 methylphenidate,131 and zolpidem132,133 suggest areas for further study, caution is advised because the sympathetic effects of these drugs may have unintended adverse effects, specifically related to cardiac function.

During the subacute phase (14–30 days), clinical decisions should be made about interventions that facilitate long-term care. Some of these include tracheostomy, resources for mechanical ventilator support, gastrostomy for enteric feeding, long-term vascular access, and strategies for the prevention of deep vein thrombosis and skin breakdown. Depending on the degree of the DOC, patients may be candidates for short-term rehabilitation with coma stimulation programs. However, for those who remain unable to participate in their own care (coma, persistent vegetative state, or severe cognitive impairment), long-term full-time nursing facilities may be required.

Withdrawal of Life-Sustaining Therapies and Brain Death

Up to two-thirds of patients with PCAS who are successfully resuscitated die during the hospitalization. The primary cause of death after cardiac arrest is believed to be neurological in nature, regardless of the primary cardiac arrest arrhythmia.134 However, some studies show that the most common cause of death in those who initially survive SCA is influenced by withdrawal of life-sustaining therapies. Withdrawal of life-sustaining therapies ranges from 59% to 82% in the literature.135–137

Brain death is relatively uncommon because patients who remain comatose usually retain some signs of neurological function. The diagnosis of brain death needs to satisfy specific clinical parameters such as irreversible absence of cerebral cortex and brainstem functions.123 Although the majority of cardiac arrest literature implicates neurological injury as the cause of death in most patients with PCAS, some studies suggest that a minority (≤10%) satisfy the brain death criteria.138,139

Cardiopulmonary Considerations

Cardiopulmonary dysfunction after cardiac arrest may be transient or long term. Ischemia and PCAS may result in cardiac muscle weakening, reduced ejection fraction, and valvular dysfunction that manifest as ongoing or intermittent symptoms of chest pain, shortness of breath, peripheral edema, or reduced exercise tolerance.93,140 Patients may be started on new medications, such as for blood pressure or heart rate control, which may carry side effects such as fatigue or depression.

Patients may need assistance with medication adherence because of cognitive impairment after cardiac arrest. Medication dose changes or weaning may be necessary because of side effects after discharge. Cardiac rehabilitation may serve not only to improve cardiopulmonary function but also as an opportunity to screen for and improve affective and cognitive impairments.141,142 Rehabilitation programs may also be an opportunity for patients to find a community and to connect with others who have had similar experiences.

Cognitive Dysfunction

Cognitive impairment is one of the most common residual problems among cardiac arrest survivors. Cognitive impairments include difficulty with memory, attention, and executive functioning (eg, planning, organization). Both language and communication may be affected, primarily (eg, as a result of difficulty with comprehension or word retrieval) or as a consequence of cognitive impairment (eg, resulting from difficulty attending to conversation amidst distraction). Patients are exposed to few cognitive demands in the initial hospital setting, making recognition of impairment difficult without specific assessment. Patients and family members may lack awareness of cognitive deficits until the patient is discharged home, after which caregivers may be the first to recognize new cognitive challenges. Table 3 summarizes the cognitive impairments common after global brain injury such as after cardiac arrest.

Most studies evaluating outcomes after cardiac arrest rely on a functional scale (typically the CPC) as the main end point, and these functional scales are insensitive to detect cognitive impairment.143 Although the number of studies specifically assessing cognitive outcomes after cardiac arrest has grown in recent years, the quality of evidence in this field remains suboptimal.42,144

Rates of cognitive impairment after cardiac arrest vary across studies. Factors explaining the discrepant findings include differences in the cohorts examined, sensitivity of the cognitive assessment tool, length of and loss to follow-up, and overall methodological quality. Prospective studies have found cognitive impairment in between one-quarter and one-half of cardiac arrest survivors assessed 3 to 6 months after resuscitation with a battery of neuropsychological tests. Contemporary study results show lower rates of cognitive dysfunction than older ones.145,146 However, the apparent longitudinal improvement in cognitive outcome after cardiac resuscitation has not been sufficiently studied.

There are limited data on predictors of cognitive outcome after cardiac resuscitation. Time to ROSC has not been consistently associated with cognitive results.143,147 Similarly, duration of coma was related to worse cognitive outcomes in some studies but not in others.92,148 Age does not appear to be a major determinant of cognitive outcomes143,149; older survivors can recover good cognition, and children and adolescents can remain cognitively impaired.150,151 Targeted temperature management may have a beneficial influence,152,153 and benefit has been observed with temperature targets of 33°C and 36°C.154

Among patients with residual cognitive dysfunction, the degree of cognitive impairment is usually mild; dementia caused by global anoxic-ischemia resulting from cardiac arrest is uncommon.155 Memory (especially short-term memory), attention, executive function, and psychomotor function are generally most affected. These cognitive deficits are dynamic and can improve over time; however, most of the improvement happens over the first 3 months after the arrest,24,98 and the dysfunction is persistent after that time.156,157

Survivors with cognitive dysfunction generally have worse quality of life, worse social functioning, and more psychological symptoms such as depression, anxiety, and posttraumatic stress syndrome, along with decreased exercise tolerance. While subjective cognitive complaints and objective cognitive dysfunction may not correlate,158 both are associated with worse quality of life.159 Cognitive recovery also influences the likelihood of returning to work.24

Available evidence solidly demonstrates that cognitive impairment is a common complication, even among patients with otherwise good functional recovery (eg, CPC 1). Therefore, studies investigating outcomes after cardiac arrest should include cognitive function evaluated by a validated tool as one of the end points. Currently, no specific tool is preferred. More research is also necessary to clarify the determinants of cognitive outcome and to identify interventions that may both prevent cognitive impairment and facilitate cognitive recovery after the arrest.

Chronic Critical Illness

Advancements in technology and postarrest care have created a new type of patient who challenges models of care, prognosis, and healthcare use. Patients who initially survive cardiac arrest may need prolonged intensive care and may become dependent on critical care therapies such as mechanical ventilation, mechanical circulatory devices, or hemodialysis. Some of these patients may have never been sick before, whereas some incur added chronic illness. These patients, described as chronically critically ill, require prolonged organ support and develop nosocomial infections and neuroendocrine, metabolic, neuromuscular, and immunological disturbances.160 Although definitions of chronic critical illness vary, prolonged ventilator dependence (eg, tracheostomy) and increased ICU length of stay characterize this syndrome.

The reported outcomes for this unique patient population are understandably poor. One-year mortality for the chronically critically ill ranges from 48% to 68%.161–165 Survivors to discharge experience significant cognitive and physical impairments that require subsequent institutionalization (ie, long-term acute care facilities, rehabilitation) and use a disproportionate proportion of healthcare resources.160,166,167

As cardiac arrest care evolves, support via mechanical circulatory devices (ventricular assist devices, total artificial heart, and extracorporeal membrane oxygenation configurations) is becoming more common as a bridge to recovery, destination therapy, and transplantation. For those patients who survive to discharge, the sequelae of chronic critical illness may persist. Complications from long-term mechanical support such as chronic thrombosis, infection, stroke, gastrointestinal bleeding, and mechanical failure are not uncommon.168–183 Device management includes long-term anticoagulation, management of hypertension, and treatment of right ventricular failure.183 The return to (new) normalcy for survivors with mechanical circulatory support includes management of fatigue, decreased strength, reduced energy levels, and increased stress and anxiety from adapting to the challenges of a new lifestyle.184–186

Affective Well-Being

The prevalence of affective sequelae after SCA has been an important area of investigation. High levels of anxiety and depression have been identified in SCA survivors after hospitalization.37,187 Studies have reported clinically significant depression in 8% to 45%, anxiety in 13% to 42%, and posttraumatic stress disorder (PTSD) in 19% to 27% of survivors.188–190 However, several different instruments have been used clinically with no definitive cutoffs for determining a diagnosis, which makes it difficult to know the true depth of anxiety and depression.

Anoxic brain injury after cardiac arrest increases the risk for depression, anxiety, and PTSD but for an uncertain duration of time.191 Over the first year after resuscitation, anxiety, depression, anger, and stress tend to be elevated in SCA survivors who receive an ICD shock compared with those who did not.192 Spouses of SCA survivors also tend to have higher anxiety and depression if their partner had experienced an ICD shock. In the longest follow-up reported in SCA survivors (up to 8 years),193 PTSD was noted in 27% of the survivors, with these individuals also reporting lower quality of life, more limited self-care, and more pain and depressed mood. In a comparison of SCA survivors who received therapeutic hypothermia with those with ST-segment–elevation myocardial infarction after 6 months,190 SCA survivors had more frequent anxiety (24% versus 13%) and more depression (19% versus 8%). High anxiety and depression levels were more common in women and those who were younger. Although there may be overlap among domains of impairment after cardiac arrest, patients experiencing significant affective sequelae may have otherwise good neurocognitive function.194

Table 4 summarizes common tools for assessing affective and psychosocial well-being. No large studies have evaluated the roles for pharmacotherapy, cognitive behavioral therapy, support groups, or exercise in cardiac arrest survivors specifically. Few practitioners discuss the risk of emotional lability with patients.

Existential Well-Being

An array of emotions ranging from fear, vulnerability, and loneliness have been described in cardiac arrest survivors. These are often contrasted in the same individuals with feelings of joy, elation, and gratitude for being alive.196 Feelings of anxiety, irritability, and disappointment have been linked to the challenges of adapting to life after cardiac arrest: difficulty in undertaking activities and roles that were previously taken for granted, a fear of the unknown, and fear of a recurrent arrest.197 Increased dependency on others may bring new challenges, both physical and emotional, with many (often men) finding it difficult to ask for help. Feelings of loneliness and abandonment may increase after hospital discharge, specifically when a change in care leads to feelings of neglect and unimportance.198,199

Survivors have described being fearful of their new reality, experiencing an existential vulnerability in which the finiteness of life and their own mortality has been exposed.36,200 The loss of memory surrounding their event may heighten the struggle to make sense of what happened. This causes many to redefine their attitudes toward life: to find healthier lifestyles, to not take things or people for granted, and to refine priorities with an increased focus on their personal relationships. At the same time, survivors may experience ongoing difficulties in accepting how their body had failed them and how their life has changed. This may result in an increased dependency on others and feelings of vulnerability, insecurity, and anxiety. Survivors may require long-term support from health professionals, spiritual counselors, and loved ones to accept and adapt to functional and existential changes.

Participation and Social Support

Reintegration and Return to Work

Survivors of SCA may experience a maladaptive pattern of intrusive thoughts, avoidance behaviors, and excessive cardiac symptom monitoring known to exacerbate cardiovascular-related distress and to worsen medical outcomes.193,201 Fear avoidance, such as fear of repeat arrest during activity or fear of defibrillator firing, after cardiac arrest may be a more important obstacle to community reintegration than physical impairment.26,202,203 Fear of another event may lead to somatic complaints, lack of confidence, and narrowing of social activities,204 as well as poor adherence to medications or follow up and increased mortality.205 However, patients rarely receive information on options for support for themselves and their relatives.206

Cardiac arrest significantly changes the lives of survivors, even among those with favorable adaptation.204 A central goal for patients surviving cardiac arrest is community reintegration, defined as the opportunity for individuals to live in their community with the already present condition (after a state of ill health such as a cardiac arrest) and to be valued for their uniqueness and abilities. We have a limited understanding of how specific barriers to community reintegration unfold for patients and their families after experiencing a cardiac arrest. Thus, we do not know whether certain resources might remove these barriers. Long-term reassessment is vital for societal reintegration of the SCA survivor after discharge from the hospital and rehabilitation.207

Work instability is defined as a state in which a mismatch between an individual’s functional or cognitive abilities and the demands of his or her job can threaten employment208 and is an important concern for SCA survivors and their caregivers. The large variation in return-to-work rates (13% and 76%) can be attributed to the variability across studies in severity of cognitive impairment, cognitive fatigue, and psychological distress after cardiac arrest.26,159,202,209,210 A recent study reported that 47% of cardiac arrest survivors had not returned to their full-time work or activities 6 months after their arrest.211 The effects of cognitive and physical impairment during long-term follow-up159 may be most significant among younger patients (<65 years of age). Younger survivors are more likely to return to their previous occupation where subclinical memory deficits are more easily uncovered and viewed as more serious compared with survivors who have retired. A greater focus on return to work as part of cardiac arrest rehabilitation may be of value for patients of working age.

Other potential contributing barriers to re-employment can be extrapolated from the literature in other cardiac and neurological pathogeneses. Among patients after ICD placement (many of whom are cardiac arrest survivors), level of education and marital status are important predictors of reemployment status.212 In patients with traumatic brain injuries, work-related difficulties are associated with multiple factors, including functional independence, cognitive disturbances, length of stay in rehabilitation settings, and educational level.213

Using energy-conservation strategies such as planning ahead, slowing the pace, delegating to others, and simplifying the task may allow survivors to return to daily activities.19 However, it is unclear whether these strategies have a positive effect on work reintegration. Most studies measure return to work as one of many other measures of societal participation but provide little insight into how post-SCA functional abilities affect work performance. Productivity measures developed to measure work instability in patients with musculoskeletal and neurological disorders may help quantify the benefits of rehabilitative interventions on SCA survivors. No specific post–cardiac arrest measures have been reported.

Social Support and Relationships

Survivors cite a need to seek a new normal in their relationships. They may have concerns about role changes in relationships and family, difficulty in being alone, and worries about resuming intimacy and sex.214 For survivors of cardiac arrest, supportive social relationships affect health outcomes and are important for adjustment to illness.215

The literature on social support networks for patients, families, and caregivers of cardiac arrest is deficient. The ideal structure, process, and timing for support groups for survivors of critical illness are not known.216 Groups led by a healthcare professional may offer an environment that supports sharing stories and helps participants gain a positive outlook.217 Family-centered follow-up programs may provide a dual role in recovery by allowing survivors to gain independence and reduce caregiver burden.218 Support groups for family or spouses can provide a resource for camaraderie with others who have shared similar experiences and may be beneficial early in the recovery process.197,219

Support networks such as support groups also have limitations that should be considered. Peer support groups may not appeal to everyone, and clinicians must take several factors into account, including illness presentation, age, sex, personality traits, and previous experiences, when recommending such groups.220 Virtual support forums have been created spontaneously by cardiac arrest survivors with a need to connect to others. These may best suit the needs of patients or family members who have limited mobility or restricted availability or who prefer anonymity. Virtual support networks may allow increased access to a support group when local or physical meetings are not available.221,222 Conversely, many virtual peer groups are not monitored by an administrative team with clinical expertise and could disseminate inaccurate medical information among members. Caution is advised that virtual forums do not replace communication with and support from close family members and friends during and after the inital recovery period.

There is a paucity of data addressing how sex, race, and other socioeconomic indicators affect societal reintegration for cardiac arrest survivors. Female sex may be associated with impaired physical functioning compared with male sex.147 Although male patients have been reported to have higher quality of life and cognitive functioning, female patients have higher levels of participation in society and instrumental daily activities, all of which are key elements of societal reintegration.26

Studies on the effect of social class after prolonged illness suggest that patients from manual labor classes have a higher risk of unemployment and adverse social consequences.223,224 Much like socioeconomic class, other contributors to chronic burden (eg, ongoing financial strain, multiple comorbidities) may affect self-rated health after cardiac arrest among minority groups.225 Future research studies on cardiac arrest survivors should include purposeful sampling for enrollment to measure the effects of social determinants of health on the reintegration of cardiac arrest survivors.

Effect of Treating the Patient: Needs of the Care Team

The care team refers to the healthcare providers, caregivers, and family members who implement the delivered care for the postarrest patient. The team serves as a clinical microsystem, the purpose of which is to “standardize care where possible, based on best current evidence; to stratify patients based on medical need, and provide the best evidence-based care within each stratum; and to customize care to meet individual needs for patients with complex health problems.”226

Lay Rescuers and EMS Providers

Much of the chain of survival for OHCA is delivered before arrival to the hospital by prehospital providers and, ideally, the lay public. Witnesses to an unresponsive person should summon EMS and then be instructed by telecommunicators to initiate telephone-assisted CPR and to retrieve portable automated external defibrillators when available. The arrival of professional rescuers allows the chain to advance to advanced cardiovascular life support and rapid transport to a receiving center.

It is increasingly recognized that lay rescuers who respond to an unconscious patient and provide early interventions may have unique emotional or psychological needs to be addressed.227 Lay rescuers may experience anxiety or PTSD about providing or not providing basic life support. Similar to EMS providers, they often have no feedback about their performance or the outcome of the patient. Some systems attempt to connect rescuers with follow-up and support, but many initial rescuers remain anonymous. These lay rescuers may represent an untapped resource for improving community engagement and survivorship.

With a focus on the chain of survival in the early 2000s, EMS agencies were among the first to witness improvements in outcomes (eg, more patients delivered to the hospital with ROSC) and took ownership of effecting change for the cardiac arrest care team. Those therapies started by EMS created momentum and were often continued throughout the hospital stay (eg, targeted temperature management). In large municipalities (eg, New York), standardization of EMS care provided momentum to encourage hospitals to adopt in-hospital care pathways or risk diversion of patients with OHCA. The recognition of destination decisions based on in-hospital services gave rise to the concept of regional cardiac arrest centers, discussed later, and solidified the importance of EMS providers as critical to a successful OHCA care team.

Hospital Providers Who Treat Patients With Cardiac Arrest

The current international recommendations on post–cardiac arrest care highlight the complexity of treating PCAS and suggest a multifaceted approach to mitigating the resulting sequelae.15,228 Despite research examining the effectiveness of multidisciplinary teams to improve delivery of care to the postarrest patient, no work has evaluated the value of multidisciplinary teams for improving rehabilitative care or improving long-term outcomes or quality of life.

Hospital-based care providers may also experience emotional or psychological effects of caring for a patient with cardiac arrest.229 Team debriefings may be beneficial after resuscitation efforts have been handed off to new providers. Debriefings allow a review of team performance (education, quality improvement), as well as recognition of the natural stressors associated with caring for a patient near death, especially when the patient is young and the cardiac arrest is unexpected.230

Caregivers and Family of Survivors

Survival after cardiac arrest is a dynamic experience that extends far beyond the individual patient. It is vital to acknowledge that survivors’ and family members’/caregivers’ points of reference about the cardiac arrest and subsequent recovery vary on the basis of memory limitations that exist from an undefined period of time before arrest.231 In addition, previous experience with acute illness, whether the arrest was witnessed by family or caregivers, whether family provided initial CPR, and in-hospital treatments (eg, targeted temperature management) influence an individual’s ability to cope with recovery from critical illness such as cardiac arrest.232

Survivors are focused primarily on returning to their prearrest life, whereas family members and caregivers are left processing the fear, pain, and anxiety of the actual arrest and subsequent hospitalization.233–235 A high percentage of relatives experience posttraumatic stress syndrome during the early phase of their loved one’s illness, which increases their risk of experiencing PTSD later. The CPR experience has been reported by family in retrospective analyses as frightening, difficult, chaotic, and producing feelings of guilt about whether CPR was performed correctly; support should be focused on removing that guilt.232,236

The demands on friends, family, and caregivers at hospital discharge for survivors of cardiac arrest are substantial and extend beyond physical care.234,235,237 In-depth interviews of partners of patients who survived cardiac arrest without serious brain injury identified social network support as both a support and a burden.232 Immediately after the arrest, partners reported calls and visits by family and friends as supportive. However, as the hospitalization continued, these same supportive measures were perceived as detracting attention from the patient’s needs.232 When participants were able to delegate responsibilities such as providing updates and information to family and friends, the social network burden was reduced.232 Results from these interviews support the need for patients’ relatives to have private time and space to process their feelings.238

Hospital discharge and homecoming have been identified as stressors in the recovery from cardiac arrest for family and caregivers.232 Relatives reported a lack of support from healthcare members after transfer from the ICU and again at discharge, creating an increased level of anxiety during recovery.238,239 One framework for hospital discharge planning and ongoing follow-up education for patients who have received an ICD after arrest includes (1) education on ICD function, (2) expected progression of emotional and physical recovery, (3) education on safety and maintenance of ICD, (4) discussion of activities of daily living after ICD, (5) strategies to assist with survivors’ care, and (6) strategies to assist with partner self-care. Program content should include psychological and physiological aspects of recovery, as well as education on neurocognitive deficits and family coping.240,241 CPR training for families may also reduce fear and anxiety.242 Medical professionals have an important role in providing adequate information about support groups for patients and families during hospitalization and at discharge.220

Published literature indicates that inpatient hospitalization is not the best time to provide comprehensive education or support programs because patients and their families and caregivers are experiencing high levels of anxiety, depression, anger, stress, confusion, and memory deficit. Therefore, community or outpatient settings should be considered for comprehensive education.240,241 Survivors and caregivers are at the highest risk of emotional changes in the first year after cardiac arrest, with the greatest improvement in the first 3 months.243 Ongoing strategies must be developed, including comprehensive intervention programs, and should be extended to the community or outpatient setting for up to 1 year after cardiac arrest.

Family of Nonsurvivors

Regardless of whether the patient survives, the family is considered an integral part of the system of care. The American Heart Association reports that almost 90% of the 326 000 people with OHCA die annually. That is ≈293 000 families of nonsurvivors from SCA each year who are faced with a devastating event. The disruptive change brought about by SCA is unwanted and unplanned, and as a result, recovery and adjustment take days, months, or years.

Family members are at increased risk of prolonged, complicated grief and bereavement. In a survey analysis of family members of young patients with SCA in Australia, prolonged grief was reported by 20.6%, and posttraumatic stress symptoms were reported by 44% of first-degree family members.244 Participants also reported higher levels of depression, anxiety, and stress compared with the general population.244 Currently, there is no framework to provide support for surviving family members or a systematic approach to engage them in meaningful advocacy. In contrast, breast cancer support networks provide support for families of survivors and nonsurvivors, and they collectively work on advocacy.

Interaction with healthcare providers and surviving family members will affect the grieving process and is a window of opportunity to provide support and lessen the negative psychological impact. However, previous studies have reported that many healthcare professionals are not equipped with the skills to support family members at the time of death.245,246 Therefore, healthcare professionals and multidisciplinary team providers need knowledge of the grieving stages and bereavement process and how to provide time-sensitive, ongoing support to the family unit. Lessons can be learned from the American Trauma Society, which has developed a program called the 2nd Trauma Program. This program provides lectures and workshops to help staff engage in empathic death disclosure and consulting services to help emergency caregivers cope with the acute and chronic stresses of trauma. Such an interdisciplinary quality improvement program should be considered and replicated to help hospital professionals and teams provide support to the healthcare providers and families of cardiac arrest nonsurvivors.

The narrative analysis by Mayer and colleagues247 of families who experienced an SCA suggests that unanswered questions about the cause of death were especially difficult for surviving family members. Providers must recognize that information may need to be repeated and communicated in lay terms. A common recurring priority for the participants in the Mayer et al study was the importance of sharing the story of their loved one’s SCA. Participants were thankful for the opportunity to share their stories. Even people who have endured the worst suffering want to talk about it. Many bereaved survivors also expressed a strong desire to help others.

Family members who are grieving after the loss of a loved one from SCA may suffer from significant psychological morbidity. This may impact their own physical health; hence, additional psychological support should be provided.248 Rehabilitation, which has recently been touted as the missing link in the chain of survival, should include families of nonsurvivors. The best support comes from those who have suffered similar losses; thus, survivor networks are an option for engaging bereaved family members as a means for psychological support and an opportunity for reintegration back into society. General bereavement resources may also be useful.

Features of the Organization to Improve Survivorship

The first and second levels of the healthcare delivery system for cardiac arrest are the patient and the care team, respectively. The third level of the healthcare delivery system of care is the organization, which “supports the development and work of care teams by providing infrastructure and complementary resources.”20 Large strides have been made at this level to effect change.249

Acute Care Hospital Features

Integral to a cardiac arrest center is the post–cardiac arrest service team,250 which can serve to sustain and standardize care between the multiple service lines.251 Three studies demonstrate the overall positive effect of treatment at a cardiac arrest center on outcomes from OHCA.12,17,252 Sulzgruber et al252 examined the outcomes at a single high-volume cardiac arrest center over the past 2 decades. Over time, improvements in each link of the chain of survival were observed. Statistically significant improvements in ROSC and 6-month survival were also observed. Schober et al17 examined a prospective multicenter registry and found that treatment at a high-volume cardiac arrest center was associated with statistically significant improvement in survival. Finally, Elmer et al12 determined that treatment at an institution classified as a high-volume cardiac arrest center was associated with improved survival. Despite this reassuring research, no study has investigated the effect of a rehabilitation-focused or discharge care protocol or process on improving long-term outcomes or quality of life after cardiac arrest.

Rehabilitation Resources and Outpatient Care

The most recent European Resuscitation Council guidelines incorporate recommendations for a multidisciplinary approach to rehabilitation for post–cardiac arrest patients.228 They recommend the systematic organization of follow-up care, including screening for cognitive and emotional impairments.

One published article delineates the common elements of the multidisciplinary outpatient treatment services provided at a collection of cardiac arrest centers.253 Four themes central to postdischarge planning included cardiac rehabilitation, neurological rehabilitation, psychological support, and family member reintegration. Additional rehabilitation services were not standardized in these high-volume centers.

One early intervention service for patients discharged from the hospital after SCA has been described in the literature.254 The early intervention service targeted survivors and their caregivers. The team was composed of specialized nurses with experience in cardiology, neurology, and rehabilitation medicine. The protocol included between 1 and 6 outpatient consultations, initiated immediately after discharge from the hospital. At these visits, survivors were screened for cognitive challenges, emotional changes, principles of self-management, posttraumatic stress, and caregiver strain. Specific tools for measurement are evidence based and provided in this statement.254

Only 1 study has examined the effect of an intervention on post–cardiac arrest patients.255 The intervention comprised 11 individual psychosocial therapy sessions given optimally twice a week after hospital discharge. The primary outcome was mortality. There was a statistically significant difference in mortality between the control and intervention groups (7 versus 1; P=0.03).

Outside this literature, little is known about the effect of or the degree of coordination of rehabilitation resources for postarrest patients. Disparities in access to care are unknown, although family support and socioeconomic status may play a role in how often one can access resources and how likely one is to access resources. Geography may determine how far one might need to travel to obtain resources.

Organizational Feedback: Ongoing Quality Improvement

Local quality improvement data collection is often useful across an individual system to measure outcomes, to assess performance, and to improve quality of care. Several national databases invite data contribution for regional and national reporting, both out-of-hospital and in-hospital arrests, but typically capture survival as an outcome measure at hospital discharge. Attempts to link separate EMS and in-hospital databases have had variable results because of challenges in linking patient records between databases. In contrast to international resources, there is no single national database for cardiac arrest data in the United States. Improving survivorship and quality of life for cardiac arrest survivors necessitates assessing, measuring, and including complex, long-term outcome measures in both quality improvement and research databases.

Organization Feedback: Partners in Celebration

Celebrations of successful resuscitation are complex events with both positive and challenging components. Surviving cardiac arrest makes a sudden, profound alteration in the life of the patient, the caregivers, and the treating teams. Many individuals are affected, including lay rescuers, EMS personnel, dispatchers, hospital staff, patients, friends, family, and caregivers. Stories of survival are impactful and deserve to be shared. “They [survivors] wear their survival stories like badges of honor and relay them to others with revelations of what could have been.”256

Survival celebrations are frequently organized as positive feedback for EMS and all those involved in resuscitation. For years, EMS and hospital personnel have provided care with the knowledge that few patients with cardiac arrest will survive. Frequently, survivors and families are seeking an opportunity to give back, to thank those involved. Healthcare personnel are given an opportunity to see that their work includes more than evidence-based, task-driven protocols and in fact has a human factor. Researchers note, “Meeting a patient…is invigorating, motivating, and gratifying….Sometimes, meeting survivors also inspires EMS providers to update local protocols to match the latest evidence, teach bystanders how to perform CPR, or institute new training programs.”256

Survivors and their families may find meaning by sharing with rescuers or commemorating a date. Some want to offer thanks; some celebrate their “rebirthday”; and some need to fill in the missing pieces in their events. Survivors and community stakeholders can leverage survival celebrations to educate their localities on the importance of CPR education, automated external defibrillator use, and prompt activation of emergency response systems. Although the timing and magnitude of a survival celebration should be dictated by the survivor and his or her family, healthcare personnel and support networks can provide structure and connection in bringing such an event together.

Features of the Environment for Improved Survivorship

The environmental level of a system of care refers to “the conditions under which organizations, care teams, individual patients, and individual care providers operate.”20 It includes the financial, social, economic, and political aspects of care. The environmental layer of a system of care includes identifying issues such as disparities and coverage. For cardiac arrest, the most relevant issues are as follows.

Economic Costs to the System of Caring for Patients With Cardiac Arrest

Understanding the cost and utility of post–cardiac arrest care can help develop the potential case for increased reimbursement and appropriate resource allocation for these patients. Multidisciplinary postarrest services are often not reimbursed in parity with other critical care specialties. Optimal postarrest care should consider the potential for overuse of surveillance and seek to prevent the underuse of beneficial coordination of care.257

Many survivors of cardiac arrest require significant provocative and diagnostic testing to evaluate for arrest cause. Survivors may require an ICD for secondary prevention of arrhythmia or a cardiac stent for treating coronary occlusion. These downstream interventions help offset the initial investment by the healthcare system in resuscitation care (eg, provision for targeted temperature management) that clearly improves outcomes but is often poorly reimbursed.

Although the economic burden of caring for survivors of cardiac arrest is significant, 1 study found that the costs per life-year and per quality-adjusted life-year were comparable to those of survivors of other critical illnesses.28 Several studies demonstrate that cardiac arrest care per quality-adjusted life-year and per disability-adjusted life-year is an acceptable cost, in line with other healthcare interventions.28,258–260 The economic burden of survival includes the cost to society (loss of productivity and contribution to the work force42,207,261,262) and the cost to the survivor (resource-intensive critical care, readmission, long-term nursing care, rehabilitation, and management of complications28,258,263–265). The cost for index hospitalization after cardiac arrest frequently exceeds twice the US median household income.266

Economic Costs to the Patient of Surviving Cardiac Arrest

The economic impact of survivorship after cardiac arrest is substantial, but interpreting the cost of postarrest care is challenging because survival data may not be adjusted for local hospital policies, do-not-attempt-resuscitation orders, and patient risk. One study estimated a cost of approximately $100 000 (conventional and rehabilitation care) per patient with OHCA with ROSC.258 Another study reported a cost of approximately $19 000 for the first year of readmissions and care for patients with IHCA who survived to discharge.263

Readmission and intensive care costs for both IHCA and OHCA survivors are significant. Costs are influenced by patient-specific factors such as age, race, ventilator liberation, and neurological disability and other factors such as discharge destination (eg, rehabilitation center, skilled nursing facility), interventions (eg, therapeutic hypothermia, time to defibrillation), and geography.258,264,267–269 The financial burden of healthcare costs for atherosclerotic cardiovascular disease has recently been identified to have a negative impact on HRQOL, psychological distress, and depression risk but has not yet been explored among patients with SCA.270

Despite the breadth of individual survivorship needs after cardiac arrest, standardized rehabilitation protocols and partnerships for identifying those needs do not exist. Early evaluation for rehabilitation needs is necessary for optimal timing and organization of rehabilitation services.271 To qualify for inpatient rehabilitation, patients must typically require services in at least 2 domains such as physical and occupational. Patients must also be able to participate in a minimum of several (>3) hours of therapy per day. Alone, cognitive impairment is typically not enough to qualify for inpatient rehabilitation, although it is very common and often interferes with independent living.

Insurance providers often cover a certain number of inpatient rehabilitation days per plan-year. If days are exhausted, patients or families may pay out of pocket for services, or the patient may be transferred to a skilled nursing facility for additional long-term care. If patients become unable to participate in rehabilitation activities and rehabilitation days still exist, they may need to be moved to a skilled nursing facility temporarily until they may resume full participation in therapy.

As an alternative, intensive outpatient rehabilitation programs have their own prerequisites for treatment of multiple therapy needs. Patients who have enough support to go home and do not qualify for inpatient rehabilitation may travel to these programs several times a week. Finally, there are separate outpatient rehabilitation specialty services such as physical therapy, occupational therapy, speech-language pathologists, and cardiac rehabilitation for which insurance providers typically cover a certain number of visits per plan year. Access to, coverage for, and ability to navigate the complex requirements of rehabilitation services may play a large role in patients returning to work and participating in activities of daily life.2 Thus, efficiently optimizing these resources and coordinating their delivery to SCA survivors may have a large impact on society.

Joint Society Recommendations: Guidelines

This statement has summarized the complex and multifaceted areas for assessment and potential treatment for the SCA survivor. Several specialists may be involved in the post–cardiac arrest survivorship plan and need to coordinate care to improve rehabilitation consistency for each patient. Therefore, it stands to reason that joint guidelines are needed to improve treatment consistency across all providers and settings. Partnerships exist among healthcare providers for patients with critical illness, stroke, and transplantation, for example, and may expedite knowledge translation and clinical implementation.

Urgent Research Goals

Table 5 summarizes the top research goals and gaps in knowledge for cardiac arrest survivorship, organized according to presentation in this document. Numerous other knowledge gaps are listed throughout this statement. Future research should focus on elucidating common domains, patterns, and severity of dysfunction in patients discharged from the hospital after resuscitation from cardiac arrest. Initially, this will require multiple measures. It is important to remember that recovery and transition to survivorship occur on an individual’s own timeline; hence, engagement with the survivor throughout recovery is critical.

Developing a tailored measure that represents the breadth of postarrest dysfunction should be a goal for the resuscitation community. One potential measure is the CPC-Extended tool, which is more granular than the CPC score and tests 10 domains of function.97 Because the domains change (improve/worsen) over time, serial evaluations are recommended.272 At a minimum, all patients should have some assessment of cognition, mobility, and ability to perform activities of daily living before discharge. This can be completed by a physiatrist (physical medicine and rehabilitation specialist) or a combination of physical, occupational, and speech-language therapy specialists before discharge from the hospital. Reassessment at 3 and 6 months and 1 year after the arrest should be considered.

Rehabilitation interventions in other disease states with patients who have medically complex conditions have been studied. These may include aerobic exercise, resistance training, cognitive training, or strategy training. Behavioral modification to prevent return to sedentary behavior may also be used. Combining several modalities may be required to optimize recovery for the individual patient after arrest. Research should focus not only on using rehabilitation interventions to improve outcomes for the postarrest population as a whole but also on tailoring components of the intervention to specific deficits found on testing. For example, aerobic exercise may improve mood and decrease fatigue, whereas individualized strategies may improve the ability to complete the complex activities of daily living. Determining an optimal rehabilitation strategy, including its timing, for each domain of dysfunction should be a goal for the resuscitation community.

Finally, many family members experience significant stress when caring for their loved one. Future studies should evaluate coping mechanisms for family members. Empowering both patient and family will help ensure a strong environment for recovery. Engagement with families of nonsurvivors of cardiac arrest is also an area devoid of research. These bereaved family members may provide insight into prevention, promote community CPR trainings, and be fierce advocates for future cardiac arrest policy legislation. More attention, immediate care during bereavement, and research are needed for surviving family members of those with SCA.

Ethical Considerations

The ethics surrounding initiating resuscitation and deciding to withdraw life-sustaining therapy are outside the scope of this document. Ethical considerations within post–cardiac arrest survivorship are not adequately studied. For example, do we know and inform patients and families of the possible harms pertaining to cognitive testing? Who receives test results, and how do results affect a person’s future insurability, return to work, or motivation for social reintegration? Should patients and families provide consent for testing, and what if they decline or decline retesting later? What motivates patients and families to adapt to a “new normal,” and how do we empower them to do so?

The accuracy of assessment is crucial to understanding the impact on survival; when assessment is inappropriate or lacks granularity, the impact of survival is underestimated. We may underestimate the need for rehabilitation, such that services may not be provided. Poor access to and poor insurance coverage for rehabilitation may make it difficult to identify improvements or declines over time. Experienced providers are aware that fatigue may be a barrier to completing a test rather than poor concentration or attention. Assessment timing often takes place at easy administrative intervals (eg, hospital discharge), not necessarily at times when testing may best reflect the patient’s abilities or participation.

Additional ethical concerns that have not been explored include how patients perceive various testing and whether we are evaluating things that matter to them. Future work may take examples from the field of vascular dementia or Alzheimer disease and should include patients and loved ones as partners. It behooves the resuscitation community to ensure that an adequate and representative picture of the experience and the unmet needs of survivors is presented over both the short and long terms.

Advocacy Considerations

Support groups and counseling for survivors of multiple other conditions such as cancer, diabetes mellitus, stroke, and transplantation are well established and provide a space for both sharing with others who may have had similar experiences and increasing societal awareness of the disease. Because survival rates for cardiac arrest are low in any one system or region, survivors, friends, and family members who are looking for support may not have local groups to connect with and need to be referred to national support organizations.

Many national nonprofit organizations, readily accessible through the internet, provide treatment, support programs for patients and their families, and advocacy for improved cardiac arrest response. Online communities offer people affected personally by cardiac arrest (whether as a survivor, friend, or family member) a space to share experiences and coping strategies. Many of these programs were founded by either a survivor or a family member of a survivor. Advocacy initiatives for most of these organizations revolve around advancing cardiac arrest prevention programs such as heart screening programs for youth and increasing lay rescuer CPR and automated external defibrillator awareness and training through legislation to increase public-access defibrillators and CPR training in schools and at work. However, there is a paucity of information on these websites about advocacy directed at improving long-term outcomes. United advocacy efforts could be powerful in effecting change in many areas of survivorship.

Patient Engagement in Health Care and Research

Survivors of cardiac arrest and their family members have a unique knowledge derived from their personal experience of the event that renders them both legitimate and powerful experience-based experts. The active engagement of survivors and their family members in both health care and research underscores the unique power of this evidence and the contribution to shared learning, constructive dialogue, and the codevelopment of research programs that have greater relevance to the community of survivors. There is growing evidence that the active engagement of key stakeholders, including patients and members of the public, in defining research priorities shifts the focus of research toward socially grounded endeavors. Although the integration of the values and insights from across the range of legitimate stakeholders may increase the complexity of recommendations, such active engagement may bring us closer to recognizing what is best for survivors and their families. It therefore behooves the resuscitation community to consider how it can engage with and incorporate the values and views of all legitimate stakeholders in moving the challenge of postarrest survival and survivorship forward.

Conclusions

The number of people touched by cardiac arrest is impossible to measure when considering the layers of the cardiac arrest system of care. Promoting attention to quality of life and survivorship acknowledges the complex emotional, physical, social, and economic challenges associated with life during and after cardiac arrest. It also recognizes the importance of caregivers and support networks, who may also need guidance throughout the long recovery period.

This statement outlines the domains central to systematic hospital discharge planning and rehabilitation after cardiac arrest. We have developed a template discharge checklist for use among multidisciplinary providers involved in caring for patients after cardiac arrest (Figure 2). A 1-year road map to recovery (Figure 3) will also help with transitions of care across the healthcare system. We hope these tools will require updates soon.

Layperson Summary of Cardiac Arrest Survivorship

SCA stops the flow of blood through the heart to the brain and other vital organs of the body. It can happen at any age for several reasons. There might be an electric problem, also known as an arrhythmia. There might be a blocked artery of the heart (eg, a heart attack). A drug overdose may also cause cardiac arrest.

Over the past decade, survival from cardiac arrest has improved. Like surviving stroke or cancer, it often requires medications and treatments after discharge. It may also create new challenges with physical function, memory, speech, or depression. Recovery can take months to years after the event.

This section is a summary of what may happen to the patient or their loved ones after surviving SCA. What is known about the short- and long-term effects of cardiac arrest are described. This information will assist patients or their loved ones to communicate better with the team at the hospital, as well as with healthcare providers after discharge.

Survival Rates Are Low but Improving

SCA is deadly. If it occurs outside of a hospital, only 11% of patients survive to hospital discharge.

The chance of survival improves when someone contacts 9-1-1 right away. Then, anyone may and should start immediate CPR (chest compressions) and use an automated external defibrillator if available.

After transport to the hospital, more tests and interventions may be necessary.

If cardiac arrest occurs during a hospitalization, 26% of people survive to discharge.

With more uniform postarrest care, survival rates have improved. Each year, 70 000 people in the United States leave the hospital after cardiac arrest. We expect this number to increase.

Survivors May Need New Medications or Rehabilitation for Their Heart

Patients may have a weak heart after cardiac arrest. They may need to take new medications every day and follow a new diet.

Patients may need a small device called an ICD inserted in their chest before discharge or shortly after. This device may shock the heart if an abnormal heart rhythm occurs, which can happen without warning and is a life-threatening emergency.

Cardiac arrest survivors may need to attend a special exercise program to help the heart get stronger (cardiac rehabilitation). This may also allow patients to meet others who have similar heart problems.

Survivors Are Vulnerable to Neurological Injuries

Patients with cardiac arrest may receive temporary life support in the ICU. Patients may remain in a coma for an uncertain period. This means waiting and watching for changes in brain waves or physical examination.

In the hospital, patients may develop seizures, muscle contractions, or tremors. They may be unable to control body movements. These disorders may continue after discharge and are often treated with medications.

Patients may also have a stroke after cardiac arrest. This may lead to further difficulty with physical or cognitive functions such as memory and the ability to think or focus.

Survivors Are at Risk for Physical Injuries

Hospitalization causes physical effects from decreased movement or inactivity. This is especially true for patients in the ICU. They may lose muscle tone or become stiff.

Physical injuries may make it hard for patients to feed themselves, write, walk, stand, or even sit. Fatigue, or tiredness, may also limit how long patients can do an activity. Physical and occupational therapists will assess and treat various physical impairments.

Patients who received CPR may have chest pain from bruised or broken ribs. Procedures done in the hospital may leave scars.

Being on a ventilator for a long time can cause voice changes or problems speaking or swallowing. Communication may be difficult and frustrating. Speech-language pathology specialists will assess these impairments. They can help create temporary tools to help patients communicate in the hospital or at home.

Survivors May Have Trouble With Memory and Thinking Abilities

Patients may have difficulty paying attention. Patients may not be able to have a conversation or complete a task because of an inability to focus. Paying attention is important in many daily activities such as managing medications, cooking, and driving.

Patients may also have difficulty with both short-term and long-term memory. Patients may ask questions over and over. They may not remember a conversation from a few minutes earlier. It is very common for patients not to remember the events of the entire day or days before their cardiac arrest. Difficulty with memory may make remembering people or names of objects difficult. It may also impair the ability to do simple math or spelling.

Patients may struggle with organizing or planning, self-regulation, and task management. Together, these are called executive functions. For example, patients may be more impulsive than before the cardiac arrest. They may lack the ability to control certain emotions such as anger. They may be tearful often. Patients may be unable to complete a task that has many steps. They may not be able to solve new problems. For these reasons, some patients may not be able to live alone. They may need significant help with shopping or paying bills. They may not be able to drive for months after discharge.

Cognitive fatigue means that someone can think or focus for only short periods of time. This may play a large role in returning to work. Patients may be unable to perform mental tasks at the same level as before. Ways to reduce stress include having a routine and breaking tasks into small pieces.

Specialists such as speech-language pathologists may offer additional therapy and strategies for overcoming some of these impairments.

Survivors May Experience Anxiety or Depression

Cardiac arrest survivors often experience anxiety, depression, and posttraumatic stress. Loved ones or caregivers are also at risk. Loved ones who performed CPR or witnessed CPR may experience posttraumatic stress. Feelings or expectations may strain relationships with friends or family.

Anxiety about the cardiac arrest event itself or whether another event will occur is common. Depression may result from a new medical diagnosis or the new need for daily treatments. Depression may also result from the inability to return to normal.

Financial issues are very common after a prolonged hospitalization. Time away from work for both patients and their family members may also cause a financial burden. Short-term disability and Family and Medical Leave Act paperwork should be filed as soon as possible.

Surviving Cardiac Arrest May Interrupt Daily Life

Surviving cardiac arrest may interrupt daily life for a short or long time. Some patients return to work or hobbies; others struggle. Patients may want to be independent again, although caregivers worry about them being on their own. Cultural, religious, or personal beliefs may play a role in recovery and healing.

Patients may search for meaning about what happened. Counseling and therapy may be beneficial for patients, their loved ones, and caregivers. Therapy also may be useful for those who have lost a loved one to cardiac arrest. In some cases, support groups may provide a safe place to discuss feelings with others. Advocacy groups can help survivors find community and raise awareness about survivorship.

Conclusions

Surviving cardiac arrest may result in many challenges and is not easy. Both patients and their loved ones may need therapy or counseling for months or years after. With the information presented in this scientific statement, patients and their loved ones will have a better understanding of cardiac arrest and how to be an advocate for their care.

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on September 25, 2019, and the American Heart Association Executive Committee on October 22, 2019. A copy of the document is available at https://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@wolterskluwer.com.

The American Heart Association requests that this document be cited as follows: Sawyer KN, Camp-Rogers TR, Kotini-Shah P, Del Rios M, Gossip MR, Moitra VK, Haywood KL, Dougherty CM, Lubitz SA, Rabinstein AA, Rittenberger JC, Callaway CW, Abella BS, Geocadin RG, Kurz MC; on behalf of the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research; and Stroke Council. Sudden cardiac arrest survivorship: a scientific statement from the American Heart Association. Circulation. 2020;141:e654–e685. doi: 10.1161/CIR.0000000000000747

References

• 1. Daya MR, Schmicker RH, Zive DM, Rea TD, Nichol G, Buick JE, Brooks S, Christenson J, MacPhee R, Craig A, et al.; Resuscitation Outcomes Consortium Investigators. Out-of-hospital cardiac arrest survival improving over time: results from the Resuscitation Outcomes Consortium (ROC).Resuscitation. 2015; 91:108–115. doi: 10.1016/j.resuscitation.2015.02.003CrossrefMedlineGoogle Scholar
• 2. Alfano CM, Ganz PA, Rowland JH, Hahn EE. Cancer survivorship and cancer rehabilitation: revitalizing the link.J Clin Oncol. 2012; 30:904–906. doi: 10.1200/jco.2011.37.1674CrossrefMedlineGoogle Scholar
• 3. Mathur S, Janaudis-Ferreira T, Wickerson L, Singer LG, Patcai J, Rozenberg D, Blydt-Hansen T, Hartmann EL, Haykowsky M, Helm D, et al.. Meeting report: consensus recommendations for a research agenda in exercise in solid organ transplantation.Am J Transplant. 2014; 14:2235–2245. doi: 10.1111/ajt.12874CrossrefMedlineGoogle Scholar
• 4. Al-Khatib SM, Yancy CW, Solis P, Becker L, Benjamin EJ, Carrillo RG, Ezekowitz JA, Fonarow GC, Kantharia BK, Kleinman M, et al.. 2016 AHA/ACC clinical performance and quality measures for prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.Circ Cardiovasc Qual Outcomes. 2017; 10:e000022. doi: 10.1161/HCQ.0000000000000022LinkGoogle Scholar
• 5. Black HR, Sica D, Ferdinand K, White WB; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 6: hypertension: a scientific statement from the American Heart Association and the American College of Cardiology.Circulation. 2015; 132:e298–e302. doi: 10.1161/cir.0000000000000242LinkGoogle Scholar
• 5a. Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian A-M, Haskell SE, et al.; on behalf of the American Heart Association Emergency Cardiovascular Care Science Subcommittee; American Heart Association Emergency Cardiovascular Care Pediatric Emphasis Group; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Genomic and Precision Medicine; and Stroke Council. Pediatric post–cardiac arrest care: a scientific statement from the American Heart Association.Circulation. 2019; 140:e194–e233. doi: 10.1161/CIR.0000000000000697LinkGoogle Scholar
• 6. Iwashyna TJ. Survivorship will be the defining challenge of critical care in the 21st century.Ann Intern Med. 2010; 153:204–205. doi: 10.7326/0003-4819-153-3-201008030-00013CrossrefMedlineGoogle Scholar
• 7. Iwashyna TJ. Trajectories of recovery and dysfunction after acute illness, with implications for clinical trial design.Am J Respir Crit Care Med. 2012; 186:302–304. doi: 10.1164/rccm.201206-1138EDCrossrefMedlineGoogle Scholar
• 8. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després J-P, Fullerton HJ, et al.; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2016 update: a report from the American Heart Association [published correction appears in Circulation. 2016;133:e599].Circulation. 2016; 133:e38–e360. doi: 10.1161/cir.0000000000000350LinkGoogle Scholar
• 9. Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, et al.; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2017 update: a report from the American Heart Association [published corrections appear in Circulation. 2017;135:e196 and Circulation. 2017;136:e646].Circulation. 2017; 135:e146–e603. doi: 10.1161/CIR.0000000000000485AbstractGoogle Scholar
• 10.CARES Cardiac Arrest Registry to Enhance Survival.https://mycares.net/. Accessed May 8, 2018.Google Scholar
• 11. Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen LP, Smedsrud C, Draegni T, Steen PA. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest.Resuscitation. 2007; 73:29–39. doi: 10.1016/j.resuscitation.2006.08.016CrossrefMedlineGoogle Scholar
• 12. Elmer J, Rittenberger JC, Coppler PJ, Guyette FX, Doshi AA, Callaway CW; Pittsburgh Post-Cardiac Arrest Service. Long-term survival benefit from treatment at a specialty center after cardiac arrest.Resuscitation. 2016; 108:48–53. doi: 10.1016/j.resuscitation.2016.09.008CrossrefMedlineGoogle Scholar
• 13. Andrew E, Nehme Z, Bernard S, Smith K. Comparison of health-related quality of life and functional recovery measurement tools in out-of-hospital cardiac arrest survivors.Resuscitation. 2016; 107:57–64. doi: 10.1016/j.resuscitation.2016.07.242CrossrefMedlineGoogle Scholar
• 14. Camp-Rogers TR, Sawyer KN, McNicol DR, Kurz MC. An observational study of patient selection criteria for post-cardiac arrest therapeutic hypothermia.Resuscitation. 2013; 84:1536–1539. doi: 10.1016/j.resuscitation.2013.07.013CrossrefMedlineGoogle Scholar
• 15. Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, et al.. Part 8: post–cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care [published correction appears in Circulation. 2017;136:e197].Circulation. 2015; 132(suppl 2):S465–S482. doi: 10.1161/cir.0000000000000262LinkGoogle Scholar
• 16. Rittenberger JC, Guyette FX, Tisherman SA, DeVita MA, Alvarez RJ, Callaway CW. Outcomes of a hospital-wide plan to improve care of comatose survivors of cardiac arrest.Resuscitation. 2008; 79:198–204. doi: 10.1016/j.resuscitation.2008.08.014CrossrefMedlineGoogle Scholar
• 17. Schober A, Sterz F, Laggner AN, Poppe M, Sulzgruber P, Lobmeyr E, Datler P, Keferböck M, Zeiner S, Nuernberger A, et al.. Admission of out-of-hospital cardiac arrest victims to a high volume cardiac arrest center is linked to improved outcome.Resuscitation. 2016; 106:42–48. doi: 10.1016/j.resuscitation.2016.06.021CrossrefMedlineGoogle Scholar
• 18. Israelsson J, Lilja G, Bremer A, Stevenson-Ågren J, Årestedt K. Post cardiac arrest care and follow-up in Sweden: a national web-survey.BMC Nurs. 2016; 15:1. doi: 10.1186/s12912-016-0123-0CrossrefMedlineGoogle Scholar
• 19. Kim YJ, Rogers JC, Raina KD, Callaway CW, Rittenberger JC, Leibold ML, Holm MB. Solving fatigue-related problems with cardiac arrest survivors living in the community.Resuscitation. 2017; 118:70–74. doi: 10.1016/j.resuscitation.2017.07.005CrossrefMedlineGoogle Scholar
• 20.National Academy of Engineering and Institute of Medicine. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington, DC: National Academies Press; 2005.Google Scholar
• 21. Rumsfeld JS, Alexander KP, Goff DC, Graham MM, Ho PM, Masoudi FA, Moser DK, Roger VL, Slaughter MS, Smolderen KG, et al.; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Stroke Council. Cardiovascular health: the importance of measuring patient-reported health status: a scientific statement from the American Heart Association.Circulation. 2013; 127:2233–2249. doi: 10.1161/CIR.0b013e3182949a2eLinkGoogle Scholar
• 22. Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection.Med Care. 1992; 30:473–483.CrossrefMedlineGoogle Scholar
• 23. Ware J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.Med Care. 1996; 34:220–233. doi: 10.1097/00005650-199603000-00003CrossrefMedlineGoogle Scholar
• 24. Ørbo M, Aslaksen PM, Larsby K, Schäfer C, Tande PM, Anke A. Alterations in cognitive outcome between 3 and 12 months in survivors of out-of-hospital cardiac arrest.Resuscitation. 2016; 105:92–99. doi: 10.1016/j.resuscitation.2016.05.017CrossrefMedlineGoogle Scholar
• 25. Deasy C, Bray J, Smith K, Harriss L, Bernard S, Cameron P; VACAR Steering Committee. Functional outcomes and quality of life of young adults who survive out-of-hospital cardiac arrest.Emerg Med J. 2013; 30:532–537. doi: 10.1136/emermed-2012–201267CrossrefMedlineGoogle Scholar
• 26. Wachelder EM, Moulaert VR, van Heugten C, Verbunt JA, Bekkers SC, Wade DT. Life after survival: long-term daily functioning and quality of life after an out-of-hospital cardiac arrest.Resuscitation. 2009; 80:517–522. doi: 10.1016/j.resuscitation.2009.01.020CrossrefMedlineGoogle Scholar
• 27. Moulaert VR, Wachelder EM, Verbunt JA, Wade DT, van Heugten CM. Determinants of quality of life in survivors of cardiac arrest.J Rehabil Med. 2010; 42:553–558. doi: 10.2340/16501977-0547CrossrefMedlineGoogle Scholar
• 28. Graf J, Mühlhoff C, Doig GS, Reinartz S, Bode K, Dujardin R, Koch KC, Roeb E, Janssens U. Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest.Crit Care. 2008; 12:R92. doi: 10.1186/cc6963CrossrefMedlineGoogle Scholar
• 29. Haywood KL, Pearson N, Morrison LJ, Castrén M, Lilja G, Perkins GD. Assessing health-related quality of life (HRQoL) in survivors of out-of-hospital cardiac arrest: a systematic review of patient-reported outcome measures.Resuscitation. 2018; 123:22–37. doi: 10.1016/j.resuscitation.2017.11.065CrossrefMedlineGoogle Scholar
• 30. Smith K, Andrew E, Lijovic M, Nehme Z, Bernard S. Quality of life and functional outcomes 12 months after out-of-hospital cardiac arrest.Circulation. 2015; 131:174–181. doi: 10.1161/CIRCULATIONAHA.114.011200LinkGoogle Scholar
• 31. Kuspinar A, Mayo NE. A review of the psychometric properties of generic utility measures in multiple sclerosis.Pharmacoeconomics. 2014; 32:759–773. doi: 10.1007/s40273-014-0167-5CrossrefMedlineGoogle Scholar
• 32. Moulaert VR, van Heugten CM, Winkens B, Bakx WG, de Krom MC, Gorgels TP, Wade DT, Verbunt JA. Early neurologically-focused follow-up after cardiac arrest improves quality of life at one year: a randomised controlled trial.Int J Cardiol. 2015; 193:8–16. doi: 10.1016/j.ijcard.2015.04.229CrossrefMedlineGoogle Scholar
• 33. Haywood KL, Mars TS, Potter R, Patel S, Matharu M, Underwood M. Assessing the impact of headaches and the outcomes of treatment: a systematic review of patient-reported outcome measures (PROMs).Cephalalgia. 2017:333102417731348. doi: 10.1177/0333102417731348Google Scholar
• 34. Smith TG, Castro KM, Troeschel AN, Arora NK, Lipscomb J, Jones SM, Treiman KA, Hobbs C, McCabe RM, Clauser SB. The rationale for patient-reported outcomes surveillance in cancer and a reproducible method for achieving it.Cancer. 2016; 122:344–351. doi: 10.1002/cncr.29767CrossrefMedlineGoogle Scholar
• 35. Bremer A, Dahlberg K, Sandman L. Experiencing out-of-hospital cardiac arrest: significant others’ lifeworld perspective.Qual Health Res. 2009; 19:1407–1420. doi: 10.1177/1049732309348369CrossrefMedlineGoogle Scholar
• 36. Haydon G, van der Riet P, Inder K. A systematic review and meta-synthesis of the qualitative literature exploring the experiences and quality of life of survivors of a cardiac arrest.Eur J Cardiovasc Nurs. 2017; 16:475–483. doi: 10.1177/1474515117705486CrossrefMedlineGoogle Scholar
• 37. Wilder Schaaf KP, Artman LK, Peberdy MA, Walker WC, Ornato JP, Gossip MR, Kreutzer JS; Virginia Commonwealth University ARCTIC Investigators. Anxiety, depression, and PTSD following cardiac arrest: a systematic review of the literature.Resuscitation. 2013; 84:873–877. doi: 10.1016/j.resuscitation.2012.11.021CrossrefMedlineGoogle Scholar
• 38. Perkins GD, Jacobs IG, Nadkarni VM, Berg RA, Bhanji F, Biarent D, Bossaert LL, Brett SJ, Chamberlain D, de Caen AR, et al.; Utstein Collaborators. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: a statement for healthcare professionals from a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.Resuscitation. 2015; 96:328–340. doi: 10.1016/j.resuscitation.2014.11.002MedlineGoogle Scholar
• 39. Elliott VJ, Rodgers DL, Brett SJ. Systematic review of quality of life and other patient-centred outcomes after cardiac arrest survival.Resuscitation. 2011; 82:247–256. doi: 10.1016/j.resuscitation.2010.10.030CrossrefMedlineGoogle Scholar
• 40. Haydon G, van der Riet P, Maguire J. Survivors’ quality of life after cardiopulmonary resuscitation: an integrative review of the literature.Scand J Caring Sci. 2017; 31:6–26. doi: 10.1111/scs.12323CrossrefMedlineGoogle Scholar
• 41. Whitehead L, Perkins GD, Clarey A, Haywood KL. A systematic review of the outcomes reported in cardiac arrest clinical trials: the need for a core outcome set.Resuscitation. 2015; 88:150–157. doi: 10.1016/j.resuscitation.2014.11.013CrossrefMedlineGoogle Scholar
• 42. Moulaert VR, Verbunt JA, van Heugten CM, Wade DT. Cognitive impairments in survivors of out-of-hospital cardiac arrest: a systematic review.Resuscitation. 2009; 80:297–305. doi: 10.1016/j.resuscitation.2008.10.034CrossrefMedlineGoogle Scholar
• 43. Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Böttiger BW, Brooks A, Castrén M, Ong ME, Hazinski MF, et al.; on behalf of the COSCA Collaborators. COSCA (Core Outcome Set for Cardiac Arrest) in adults: an advisory statement from the International Liaison Committee on Resuscitation.Circulation. 2018; 137:e783–e801. doi: 10.1161/CIR.0000000000000562LinkGoogle Scholar
• 44. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes.Circulation. 2011; 123:1594–1600. doi: 10.1161/CIRCULATIONAHA.110.004622LinkGoogle Scholar
• 45. Meyer L, Stubbs B, Fahrenbruch C, Maeda C, Harmon K, Eisenberg M, Drezner J. Incidence, causes, and survival trends from cardiovascular-related sudden cardiac arrest in children and young adults 0 to 35 years of age: a 30-year review.Circulation. 2012; 126:1363–1372. doi: 10.1161/CIRCULATIONAHA.111.076810LinkGoogle Scholar
• 46. Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, et al.. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association Athletes: a decade in review.Circulation. 2015; 132:10–19. doi: 10.1161/CIRCULATIONAHA.115.015431LinkGoogle Scholar
• 47. Risgaard B, Winkel BG, Jabbari R, Behr ER, Ingemann-Hansen O, Thomsen JL, Ottesen GL, Gislason GH, Bundgaard H, Haunsø S, et al.. Burden of sudden cardiac death in persons aged 1 to 49 years: nationwide study in Denmark.Circ Arrhythm Electrophysiol. 2014; 7:205–211. doi: 10.1161/CIRCEP.113.001421LinkGoogle Scholar
• 48. Harmon KG, Drezner JA, Maleszewski JJ, Lopez-Anderson M, Owens D, Prutkin JM, Asif IM, Klossner D, Ackerman MJ. Pathogeneses of sudden cardiac death in National Collegiate Athletic Association athletes.Circ Arrhythm Electrophysiol. 2014; 7:198–204. doi: 10.1161/CIRCEP.113.001376LinkGoogle Scholar
• 49. Chugh SS, Jui J, Gunson K, Stecker EC, John BT, Thompson B, Ilias N, Vickers C, Dogra V, Daya M, et al.. Current burden of sudden cardiac death: multiple source surveillance versus retrospective death certificate-based review in a large U.S. community.J Am Coll Cardiol. 2004; 44:1268–1275. doi: 10.1016/j.jacc.2004.06.029CrossrefMedlineGoogle Scholar
• 50. Finocchiaro G, Papadakis M, Robertus JL, Dhutia H, Steriotis AK, Tome M, Mellor G, Merghani A, Malhotra A, Behr E, et al.. Etiology of sudden death in sports: insights from a United Kingdom Regional Registry.J Am Coll Cardiol. 2016; 67:2108–2115. doi: 10.1016/j.jacc.2016.02.062CrossrefMedlineGoogle Scholar
• 51. Nehme Z, Andrew E, Nair R, Bernard S, Smith K. Recurrent out-of-hospital cardiac arrest.Resuscitation. 2017; 121:158–165. doi: 10.1016/j.resuscitation.2017.08.011CrossrefMedlineGoogle Scholar
• 52. Krahn AD, Healey JS, Chauhan V, Birnie DH, Simpson CS, Champagne J, Gardner M, Sanatani S, Exner DV, Klein GJ, et al.. Systematic assessment of patients with unexplained cardiac arrest: Cardiac Arrest Survivors With Preserved Ejection Fraction Registry (CASPER).Circulation. 2009; 120:278–285. doi: 10.1161/CIRCULATIONAHA.109.853143LinkGoogle Scholar
• 53.Antiarrhythmics Versus Implantable Defibrillators Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias.N Engl J Med. 1997; 337:1576–1583. doi: 10.1056/nejm199711273372202CrossrefMedlineGoogle Scholar
• 54. Kuck KH, Cappato R, Siebels J, Rüppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest: the Cardiac Arrest Study Hamburg (CASH).Circulation. 2000; 102:748–754. doi: 10.1161/01.cir.102.7.748CrossrefMedlineGoogle Scholar
• 55. Connolly SJ, Gent M, Roberts RS, Dorian P, Roy D, Sheldon RS, Mitchell LB, Green MS, Klein GJ, O’Brien B. Canadian Implantable Defibrillator Study (CIDS): a randomized trial of the implantable cardioverter defibrillator against amiodarone.Circulation. 2000; 101:1297–1302. doi: 10.1161/01.cir.101.11.1297CrossrefMedlineGoogle Scholar
• 56. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, et al.. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.Circulation. 2013; 127:e283–e352. doi:LinkGoogle Scholar
• 57. Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, Elliott PM, Fitzsimons D, Hatala R, Hindricks G, et al.. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).Eur Heart J. 2015; 36:2793–2867. doi: 10.1093/eurheartj/ehv316CrossrefMedlineGoogle Scholar
• 58. Priori SG, Wilde AA, Horie M, Cho Y, Behr ER, Berul C, Blom N, Brugada J, Chiang CE, Huikuri H, et al.. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013.Heart Rhythm. 2013; 10:1932–1963. doi: 10.1016/j.hrthm.2013.05.014CrossrefMedlineGoogle Scholar
• 59. Corrado D, Wichter T, Link MS, Hauer RN, Marchlinski FE, Anastasakis A, Bauce B, Basso C, Brunckhorst C, Tsatsopoulou A, et al.. Treatment of arrhythmogenic right ventricular cardiomyopathy/dysplasia: an International Task Force consensus statement.Circulation. 2015; 132:441–453. doi: 10.1161/CIRCULATIONAHA.115.017944LinkGoogle Scholar
• 60. Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, et al.. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2011; 124:2761–2796. doi: 10.1161/CIR.0b013e318223e230LinkGoogle Scholar
• 61. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, et al.. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death).Circulation. 2006; 114:e385–e484. doi: 10.1161/CIRCULATIONAHA.106.178233LinkGoogle Scholar
• 62. Blewer AL, Leary M, Decker CS, Andersen JC, Fredericks AC, Bobrow BJ, Abella BS. Cardiopulmonary resuscitation training of family members before hospital discharge using video self-instruction: a feasibility trial.J Hosp Med. 2011; 6:428–432. doi: 10.1002/jhm.847CrossrefMedlineGoogle Scholar
• 63. Ackerman MJ, Priori SG, Willems S, Berul C, Brugada R, Calkins H, Camm AJ, Ellinor PT, Gollob M, Hamilton R, et al.; Heart Rhythm Society (HRS); European Heart Rhythm Association (EHRA). HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and cardiomyopathies: this document was developed as a partnership between the Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA).Europace. 2011; 13:1077–1109. doi: 10.1093/europace/eur245CrossrefMedlineGoogle Scholar
• 64. Hershberger RE, Lindenfeld J, Mestroni L, Seidman CE, Taylor MR, Towbin JA; Heart Failure Society of America. Genetic evaluation of cardiomyopathy: a Heart Failure Society of America practice guideline.J Card Fail. 2009; 15:83–97. doi: 10.1016/j.cardfail.2009.01.006CrossrefMedlineGoogle Scholar
• 65. Steinberg C, Padfield GJ, Champagne J, Sanatani S, Angaran P, Andrade JG, Roberts JD, Healey JS, Chauhan VS, Birnie DH, et al.. Cardiac abnormalities in first-degree relatives of unexplained cardiac arrest victims: a report from the Cardiac Arrest Survivors With Preserved Ejection Fraction Registry.Circ Arrhythm Electrophysiol. 2016; 9:e004274. doi: 10.1161/circep.115.004274LinkGoogle Scholar
• 66. Sturm AC, Hershberger RE. Genetic testing in cardiovascular medicine: current landscape and future horizons.Curr Opin Cardiol. 2013; 28:317–325. doi: 10.1097/HCO.0b013e32835fb728MedlineGoogle Scholar
• 67. Hofman N, Tan HL, Alders M, Kolder I, de Haij S, Mannens MM, Lombardi MP, Dit Deprez RH, van Langen I, Wilde AA. Yield of molecular and clinical testing for arrhythmia syndromes: report of 15 years’ experience.Circulation. 2013; 128:1513–1521. doi: 10.1161/CIRCULATIONAHA.112.000091LinkGoogle Scholar
• 68. Maron BJ, Udelson JE, Bonow RO, Nishimura RA, Ackerman MJ, Estes NAM, Cooper LT, Link MS, Maron MS; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e273–e280. doi: 10.1161/cir.0000000000000239LinkGoogle Scholar
• 69. Van Hare GF, Ackerman MJ, Evangelista JK, Kovacs RJ, Myerburg RJ, Shafer KM, Warnes CA, Washington RL; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 4: congenital heart disease: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e281–e291. doi: 10.1161/cir.0000000000000240LinkGoogle Scholar
• 70. Bonow RO, Nishimura RA, Thompson PD, Udelson JE; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 5: valvular heart disease: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e292–e297. doi: 10.1161/cir.0000000000000241LinkGoogle Scholar
• 71. Braverman AC, Harris KM, Kovacs RJ, Maron BJ; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 7: aortic diseases, including Marfan syndrome: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e303–e309. doi: 10.1161/cir.0000000000000243LinkGoogle Scholar
• 72. Thompson PD, Myerburg RJ, Levine BD, Udelson JE, Kovacs RJ; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 8: coronary artery disease: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e310–e314. doi: 10.1161/CIR.0000000000000244LinkGoogle Scholar
• 73. Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes NAM; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 9: arrhythmias and conduction defects: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e315–e325. doi: 10.1161/CIR.0000000000000245LinkGoogle Scholar
• 74. Ackerman MJ, Zipes DP, Kovacs RJ, Maron BJ; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 10: the cardiac channelopathies: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e326–e329. doi: 10.1161/cir.0000000000000246LinkGoogle Scholar
• 75. Link MS, Estes NAM, Maron BJ; on behalf of the American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and the American College of Cardiology. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 13: commotio cordis: a scientific statement from the American Heart Association and American College of Cardiology.Circulation. 2015; 132:e339–e342. doi: 10.1161/cir.0000000000000249LinkGoogle Scholar
• 76. Andersen BL, DeRubeis RJ, Berman BS, Gruman J, Champion VL, Massie MJ, Holland JC, Partridge AH, Bak K, Somerfield MR, et al.; American Society of Clinical Oncology. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation.J Clin Oncol. 2014; 32:1605–1619. doi: 10.1200/JCO.2013.52.4611CrossrefMedlineGoogle Scholar
• 77. Bower JE, Bak K, Berger A, Breitbart W, Escalante CP, Ganz PA, Schnipper HH, Lacchetti C, Ligibel JA, Lyman GH, et al.; American Society of Clinical Oncology. Screening, assessment, and management of fatigue in adult survivors of cancer: an American Society of Clinical oncology clinical practice guideline adaptation.J Clin Oncol. 2014; 32:1840–1850. doi: 10.1200/JCO.2013.53.4495CrossrefMedlineGoogle Scholar
• 78. Cohen EE, LaMonte SJ, Erb NL, Beckman KL, Sadeghi N, Hutcheson KA, Stubblefield MD, Abbott DM, Fisher PS, Stein KD, et al.. American Cancer Society head and neck cancer survivorship care guideline.CA Cancer J Clin. 2016; 66:203–239. doi: 10.3322/caac.21343CrossrefMedlineGoogle Scholar
• 79. El-Shami K, Oeffinger KC, Erb NL, Willis A, Bretsch JK, Pratt-Chapman ML, Cannady RS, Wong SL, Rose J, Barbour AL, et al.. American Cancer Society colorectal cancer survivorship care guidelines.CA Cancer J Clin. 2015; 65:428–455. doi: 10.3322/caac.21286CrossrefMedlineGoogle Scholar
• 80. Guy GP, Ekwueme DU, Yabroff KR, Dowling EC, Li C, Rodriguez JL, de Moor JS, Virgo KS. Economic burden of cancer survivorship among adults in the United States.J Clin Oncol. 2013; 31:3749–3757. doi: 10.1200/JCO.2013.49.1241CrossrefMedlineGoogle Scholar
• 81. McCabe MS, Bhatia S, Oeffinger KC, Reaman GH, Tyne C, Wollins DS, Hudson MM. American Society of Clinical Oncology statement: achieving high-quality cancer survivorship care.J Clin Oncol. 2013; 31:631–640. doi: 10.1200/JCO.2012.46.6854CrossrefMedlineGoogle Scholar
• 82. Nekhlyudov L, Lacchetti C, Davis NB, Garvey TQ, Goldstein DP, Nunnink JC, Ninfea JIR, Salner AL, Salz T, Siu LL. Head and neck cancer survivorship care guideline: American Society of Clinical Oncology clinical practice guideline endorsement of the American Cancer Society guideline.J Clin Oncol. 2017; 35:1606–1621. doi: 10.1200/jco.2016.71.8478CrossrefMedlineGoogle Scholar
• 83. Resnick MJ, Lacchetti C, Bergman J, Hauke RJ, Hoffman KE, Kungel TM, Morgans AK, Penson DF. Prostate cancer survivorship care guideline: American Society of Clinical Oncology clinical practice guideline endorsement.J Clin Oncol. 2015; 33:1078–1085. doi: 10.1200/JCO.2014.60.2557CrossrefMedlineGoogle Scholar
• 84. Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, Cannady RS, Pratt-Chapman ML, Edge SB, Jacobs LA, et al.. American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline.CA Cancer J Clin. 2016; 66:43–73. doi: 10.3322/caac.21319CrossrefMedlineGoogle Scholar
• 85. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, et al.; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published corrections appear in Stroke. 2017;48:e78 and Stroke. 2017;48:e369].Stroke. 2016; 47:e98–e169. doi: 10.1161/STR.0000000000000098LinkGoogle Scholar
• 86. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, Zawistowski C, Bemis-Dougherty A, Berney SC, Bienvenu OJ, et al.. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference.Crit Care Med. 2012; 40:502–509. doi: 10.1097/CCM.0b013e318232da75CrossrefMedlineGoogle Scholar
• 87. Mehlhorn J, Freytag A, Schmidt K, Brunkhorst FM, Graf J, Troitzsch U, Schlattmann P, Wensing M, Gensichen J. Rehabilitation interventions for postintensive care syndrome: a systematic review.Crit Care Med. 2014; 42:1263–1271. doi: 10.1097/CCM.0000000000000148CrossrefMedlineGoogle Scholar
• 88. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, et al.; Canadian Critical Care Trials Group. Functional disability 5 years after acute respiratory distress syndrome.N Engl J Med. 2011; 364:1293–1304. doi: 10.1056/NEJMoa1011802CrossrefMedlineGoogle Scholar
• 89. Barr J, Pandharipande PP. The pain, agitation, and delirium care bundle: synergistic benefits of implementing the 2013 pain, agitation, and delirium guidelines in an integrated and interdisciplinary fashion.Crit Care Med. 2013; 41(suppl 1):S99–S115. doi: 10.1097/CCM.0b013e3182a16ff0CrossrefMedlineGoogle Scholar
• 90. Ibrahim K, McCarthy CP, McCarthy KJ, Brown CH, Needham DM, Januzzi JL, McEvoy JW. Delirium in the cardiac intensive care unit.J Am Heart Assoc. 2018; 7doi: 10.1161/jaha.118.008568LinkGoogle Scholar
• 91. Elliott D, Davidson JE, Harvey MA, Bemis-Dougherty A, Hopkins RO, Iwashyna TJ, Wagner J, Weinert C, Wunsch H, Bienvenu OJ, et al.. Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.Crit Care Med. 2014; 42:2518–2526. doi: 10.1097/CCM.0000000000000525CrossrefMedlineGoogle Scholar
• 92. Sabedra AR, Kristan J, Raina K, Holm MB, Callaway CW, Guyette FX, Dezfulian C, Doshi AA, Rittenberger JC; Post Cardiac Arrest Service. Neurocognitive outcomes following successful resuscitation from cardiac arrest.Resuscitation. 2015; 90:67–72. doi: 10.1016/j.resuscitation.2015.02.023CrossrefMedlineGoogle Scholar
• 93. Neumar RW, Nolan JP, Adrie C, Aibiki M, Berg RA, Böttiger BW, Callaway C, Clark RS, Geocadin RG, Jauch EC, et al.. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council.Circulation. 2008; 118:2452–2483. doi: 10.1161/CIRCULATIONAHA.108.190652LinkGoogle Scholar
• 94. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Phadke R, Padhke R, Dew T, et al.. Acute skeletal muscle wasting in critical illness.JAMA. 2013; 310:1591–1600. doi: 10.1001/jama.2013.278481CrossrefMedlineGoogle Scholar
• 95. Connolly B, MacBean V, Crowley C, Lunt A, Moxham J, Rafferty GF, Hart N. Ultrasound for the assessment of peripheral skeletal muscle architecture in critical illness: a systematic review.Crit Care Med. 2015; 43:897–905. doi: 10.1097/CCM.0000000000000821CrossrefMedlineGoogle Scholar
• 96. Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS, et al.. Physical complications in acute lung injury survivors: a two-year longitudinal prospective study.Crit Care Med. 2014; 42:849–859. doi: 10.1097/ccm.0000000000000040CrossrefMedlineGoogle Scholar
• 97. Balouris SA, Raina KD, Rittenberger JC, Callaway CW, Rogers JC, Holm MB. Development and validation of the Cerebral Performance Categories-Extended (CPC-E).Resuscitation. 2015; 94:98–105. doi: 10.1016/j.resuscitation.2015.05.013CrossrefMedlineGoogle Scholar
• 98. Moulaert VRM, van Heugten CM, Gorgels TPM, Wade DT, Verbunt JA. Long-term outcome after survival of a cardiac arrest: a prospective longitudinal cohort study.Neurorehabil Neural Repair. 2017; 31:530–539. doi: 10.1177/1545968317697032CrossrefMedlineGoogle Scholar
• 99. Kim YJ, Rogers JC, Raina KD, Callaway CW, Rittenberger JC, Leibold ML, Holm MB. An intervention for cardiac arrest survivors with chronic fatigue: a feasibility study with preliminary outcomes.Resuscitation. 2016; 105:109–115. doi: 10.1016/j.resuscitation.2016.05.020CrossrefMedlineGoogle Scholar
• 100. Beom JH, You JS, Kim MJ, Seung MK, Park YS, Chung HS, Chung SP, Park I. Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study.Scand J Trauma Resusc Emerg Med. 2017; 25:8. doi: 10.1186/s13049-017-0352-6CrossrefMedlineGoogle Scholar
• 101. Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardiopulmonary resuscitation.Resuscitation. 2004; 63:339–343. doi: 10.1016/j.resuscitation.2004.07.005CrossrefMedlineGoogle Scholar
• 102. Boland LL, Satterlee PA, Hokanson JS, Strauss CE, Yost D. Chest compression injuries detected via routine post-arrest care in patients who survive to admission after out-of-hospital cardiac arrest.Prehosp Emerg Care. 2015; 19:23–30. doi: 10.3109/10903127.2014.936636CrossrefMedlineGoogle Scholar
• 103. Dunham GM, Perez-Girbes A, Bolster F, Sheehan K, Linnau KF. Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest.Eur Radiol. 2018; 28:4122–4127. doi: 10.1007/s00330-017-5117-0CrossrefMedlineGoogle Scholar
• 104. Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Deeper chest compression: more complications for cardiac arrest patients?Resuscitation. 2013; 84:760–765. doi: 10.1016/j.resuscitation.2013.02.015CrossrefMedlineGoogle Scholar
• 105.Ihnát Rudinská L, Hejna P, Ihnát P, Tomášková H, Smatanová M, Dvořáček I. Intra-thoracic injuries associated with cardiopulmonary resuscitation: frequent and serious.Resuscitation. 2016; 103:66–70. doi: 10.1016/j.resuscitation.2016.04.002CrossrefMedlineGoogle Scholar
• 106.Kashiwagi Y, Sasakawa T, Tampo A, Kawata D, Nishiura T, Kokita N, Iwasaki H, Fujita S. Computed tomography findings of complications resulting from cardiopulmonary resuscitation.Resuscitation. 2015; 88:86–91. doi: 10.1016/j.resuscitation.2014.12.022CrossrefMedlineGoogle Scholar
• 107.Kim EY, Yang HJ, Sung YM, Cho SH, Kim JH, Kim HS, Choi HY. Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation.Resuscitation. 2011; 82:1285–1288. doi: 10.1016/j.resuscitation.2011.05.023CrossrefMedlineGoogle Scholar
• 108.Kim MJ, Park YS, Kim SW, Yoon YS, Lee KR, Lim TH, Lim H, Park HY, Park JM, Chung SP. Chest injury following cardiopulmonary resuscitation: a prospective computed tomography evaluation.Resuscitation. 2013; 84:361–364. doi: 10.1016/j.resuscitation.2012.07.011CrossrefMedlineGoogle Scholar
• 109.Koga Y, Fujita M, Yagi T, Nakahara T, Miyauchi T, Kaneda K, Kawamura Y, Oda Y, Tsuruta R. Effects of mechanical chest compression device with a load-distributing band on post-resuscitation injuries identified by post-mortem computed tomography.Resuscitation. 2015; 96:226–231. doi: 10.1016/j.resuscitation.2015.08.013CrossrefMedlineGoogle Scholar
• 110.Kralj E, Podbregar M, Kejžar N, Balažic J. Frequency and number of resuscitation related rib and sternum fractures are higher than generally considered.Resuscitation. 2015; 93:136–141. doi: 10.1016/j.resuscitation.2015.02.034CrossrefMedlineGoogle Scholar
• 111.Oya S, Shinjo T, Fujii Y, Kamo J, Teruya H, Kinoshita H. CPR related thoracic injury: a comparison of CPR guidelines between 2005 and 2010.Acute Med Surg. 2016; 3:351–355. doi: 10.1002/ams2.215CrossrefMedlineGoogle Scholar
• 112.Seung MK, You JS, Lee HS, Park YS, Chung SP, Park I. Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest.Resuscitation. 2016; 98:64–72. doi: 10.1016/j.resuscitation.2015.11.004CrossrefMedlineGoogle Scholar
• 113.Smekal D, Lindgren E, Sandler H, Johansson J, Rubertsson S. CPR-related injuries after manual or mechanical chest compressions with the LUCAS™ device: a multicentre study of victims after unsuccessful resuscitation.Resuscitation. 2014; 85:1708–1712. doi: 10.1016/j.resuscitation.2014.09.017CrossrefMedlineGoogle Scholar
• 114.Yamaguchi R, Makino Y, Chiba F, Torimitsu S, Yajima D, Inokuchi G, Motomura A, Hashimoto M, Hoshioka Y, Shinozaki T, et al.. Frequency and influencing factors of cardiopulmonary resuscitation-related injuries during implementation of the American Heart Association 2010 guidelines: a retrospective study based on autopsy and postmortem computed tomography.Int J Legal Med. 2017; 131:1655–1663. doi: 10.1007/s00414-017-1673-8CrossrefMedlineGoogle Scholar
• 115.Nichol G, Stiell IG, Hebert P, Wells GA, Vandemheen K, Laupacis A. What is the quality of life for survivors of cardiac arrest? A prospective study.Acad Emerg Med. 1999; 6:95–102. doi: 10.1111/j.1553-2712.1999.tb01044.xCrossrefMedlineGoogle Scholar
• 116.Walsh TS, Salisbury LG, Merriweather JL, Boyd JA, Griffith DM, Huby G, Kean S, Mackenzie SJ, Krishan A, Lewis SC, et al.; RECOVER Investigators. Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.JAMA Intern Med. 2015; 175:901–910. doi: 10.1001/jamainternmed.2015.0822CrossrefMedlineGoogle Scholar
• 117.Batterham AM, Bonner S, Wright J, Howell SJ, Hugill K, Danjoux G. Effect of supervised aerobic exercise rehabilitation on physical fitness and quality-of-life in survivors of critical illness: an exploratory minimized controlled trial (PIX study).Br J Anaesth. 2014; 113:130–137. doi: 10.1093/bja/aeu051CrossrefMedlineGoogle Scholar
• 118.Woodruff TM, Thundyil J, Tang SC, Sobey CG, Taylor SM, Arumugam TV. Pathophysiology, treatment, and animal and cellular models of human ischemic stroke.Mol Neurodegener. 2011; 6:11. doi: 10.1186/1750-1326-6-11CrossrefMedlineGoogle Scholar
• 119.George PM, Steinberg GK. Novel stroke therapeutics: unraveling stroke pathophysiology and its impact on clinical treatments.Neuron. 2015; 87:297–309. doi: 10.1016/j.neuron.2015.05.041CrossrefMedlineGoogle Scholar
• 120.Nielsen N, Sunde K, Hovdenes J, Riker RR, Rubertsson S, Stammet P, Nilsson F, Friberg H; Hypothermia Network. Adverse events and their relation to mortality in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia.Crit Care Med. 2011; 39:57–64. doi: 10.1097/CCM.0b013e3181fa4301CrossrefMedlineGoogle Scholar
• 121.Krumholz A, Stern BJ, Weiss HD. Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus.Neurology. 1988; 38:401–405. doi: 10.1212/wnl.38.3.401CrossrefMedlineGoogle Scholar
• 122.Geocadin RG, Ritzl EK. Seizures and status epilepticus in post cardiac arrest syndrome: therapeutic opportunities to improve outcome or basis to withhold life sustaining therapies?Resuscitation. 2012; 83:791–792. doi: 10.1016/j.resuscitation.2012.04.003CrossrefMedlineGoogle Scholar
• 123.Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.Neurology. 2006; 67:203–210. doi: 10.1212/01.wnl.0000227183.21314.cdCrossrefMedlineGoogle Scholar
• 124.Seder DB, Sunde K, Rubertsson S, Mooney M, Stammet P, Riker RR, Kern KB, Unger B, Cronberg T, Dziodzio J, et al.. Neurologic outcomes and postresuscitation care of patients with myoclonus following cardiac arrest.Crit Care Med. 2015; 43:965–972. doi: 10.1097/ccm.0000000000000880CrossrefMedlineGoogle Scholar
• 125.Lance JW, Adams RD. The syndrome of intention or action myoclonus as a sequel to hypoxic encephalopathy.Brain. 1963; 86:111–136. doi: 10.1093/brain/86.1.111CrossrefMedlineGoogle Scholar
• 126.Khot S, Tirschwell DL. Long-term neurological complications after hypoxic-ischemic encephalopathy.Semin Neurol. 2006; 26:422–431. doi: 10.1055/s-2006-948323CrossrefMedlineGoogle Scholar
• 127.Varelas PN, ed. Seizures in Critical Care. 3rd ed. Basel, Switzerland: Springer International Publishing AG; 2017.CrossrefGoogle Scholar
• 128.Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, et al.; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus.Neurocrit Care. 2012; 17:3–23. doi: 10.1007/s12028-012-9695-zCrossrefMedlineGoogle Scholar
• 129.Venkatesan A, Frucht S. Movement disorders after resuscitation from cardiac arrest.Neurol Clin. 2006; 24:123–132. doi: 10.1016/j.ncl.2005.11.001CrossrefMedlineGoogle Scholar
• 130.Hoesch RE, Koenig MA, Geocadin RG. Coma after global ischemic brain injury: pathophysiology and emerging therapies.Crit Care Clin. 2008; 24:25–44, vii. doi: 10.1016/j.ccc.2007.11.003CrossrefMedlineGoogle Scholar
• 131.Reynolds JC, Rittenberger JC, Callaway CW. Methylphenidate and amantadine to stimulate reawakening in comatose patients resuscitated from cardiac arrest.Resuscitation. 2013; 84:818–824. doi: 10.1016/j.resuscitation.2012.11.014CrossrefMedlineGoogle Scholar
• 132.Brefel-Courbon C, Payoux P, Ory F, Sommet A, Slaoui T, Raboyeau G, Lemesle B, Puel M, Montastruc JL, Demonet JF, et al.. Clinical and imaging evidence of zolpidem effect in hypoxic encephalopathy.Ann Neurol. 2007; 62:102–105. doi: 10.1002/ana.21110CrossrefMedlineGoogle Scholar
• 133.Schiff ND, Posner JB. Another “awakenings.”Ann Neurol. 2007; 62:5–7. doi: 10.1002/ana.21158CrossrefMedlineGoogle Scholar
• 134.Laver S, Farrow C, Turner D, Nolan J. Mode of death after admission to an intensive care unit following cardiac arrest.Intensive Care Med. 2004; 30:2126–2128. doi: 10.1007/s00134-004-2425-zCrossrefMedlineGoogle Scholar
• 135.Rossetti AO, Oddo M, Logroscino G, Kaplan PW. Prognostication after cardiac arrest and hypothermia: a prospective study.Ann Neurol. 2010; 67:301–307. doi: 10.1002/ana.21984MedlineGoogle Scholar
• 136.Bouwes A, Robillard LB, Binnekade JM, de Pont AC, Wieske L, Hartog AW, Schultz MJ, Horn J. The influence of rewarming after therapeutic hypothermia on outcome after cardiac arrest.Resuscitation. 2012; 83:996–1000. doi: 10.1016/j.resuscitation.2012.04.006CrossrefMedlineGoogle Scholar
• 137.Fugate JE, Wijdicks EF, Mandrekar J, Claassen DO, Manno EM, White RD, Bell MR, Rabinstein AA. Predictors of neurologic outcome in hypothermia after cardiac arrest.Ann Neurol. 2010; 68:907–914. doi: 10.1002/ana.22133CrossrefMedlineGoogle Scholar
• 138.Mulder M, Gibbs HG, Smith SW, Dhaliwal R, Scott NL, Sprenkle MD, Geocadin RG. Awakening and withdrawal of life-sustaining treatment in cardiac arrest survivors treated with therapeutic hypothermia.Crit Care Med. 2014; 42:2493–2499. doi: 10.1097/CCM.0000000000000540CrossrefMedlineGoogle Scholar
• 139.Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T. The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest.Resuscitation. 2013; 84:337–342. doi: 10.1016/j.resuscitation.2012.09.015CrossrefMedlineGoogle Scholar
• 140.Negovsky VA, Gurvitch AM. Post-resuscitation disease: a new nosological entity. Its reality and significance.Resuscitation. 1995; 30:23–27. doi: 10.1016/0300-9572(95)00861-mCrossrefMedlineGoogle Scholar
• 141.Boyce LW, Goossens PH. Rehabilitation after cardiac arrest: integration of neurologic and cardiac rehabilitation.Semin Neurol. 2017; 37:94–102. doi: 10.1055/s-0036-1593860CrossrefMedlineGoogle Scholar
• 142.Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, Franklin B, Sanderson B, Southard D. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.Circulation. 2007; 115:2675–2682. doi: 10.1161/CIRCULATIONAHA.106.180945LinkGoogle Scholar
• 143.Fugate JE, Moore SA, Knopman DS, Claassen DO, Wijdicks EF, White RD, Rabinstein AA. Cognitive outcomes of patients undergoing therapeutic hypothermia after cardiac arrest.Neurology. 2013; 81:40–45. doi: 10.1212/WNL.0b013e318297ee7eCrossrefMedlineGoogle Scholar
• 144.Perez CA, Samudra N, Aiyagari V. Cognitive and functional consequence of cardiac arrest.Curr Neurol Neurosci Rep. 2016; 16:70. doi: 10.1007/s11910-016-0669-yCrossrefMedlineGoogle Scholar
• 145.van Alem AP, de Vos R, Schmand B, Koster RW. Cognitive impairment in survivors of out-of-hospital cardiac arrest.Am Heart J. 2004; 148:416–421. doi: 10.1016/j.ahj.2004.01.031CrossrefMedlineGoogle Scholar
• 146.Sauvé MJ, Doolittle N, Walker JA, Paul SM, Scheinman MM. Factors associated with cognitive recovery after cardiopulmonary resuscitation.Am J Crit Care. 1996; 5:127–139.CrossrefMedlineGoogle Scholar
• 147.van Alem AP, Waalewijn RA, Koster RW, de Vos R. Assessment of quality of life and cognitive function after out-of-hospital cardiac arrest with successful resuscitation.Am J Cardiol. 2004; 93:131–135. doi: 10.1016/j.amjcard.2003.09.027CrossrefMedlineGoogle Scholar
• 148.Nichol G, Guffey D, Stiell IG, Leroux B, Cheskes S, Idris A, Kudenchuk PJ, Macphee RS, Wittwer L, Rittenberger JC, et al.; Resuscitation Outcomes Consortium Investigators. Post-discharge outcomes after resuscitation from out-of-hospital cardiac arrest: a ROC PRIMED substudy.Resuscitation. 2015; 93:74–81. doi: 10.1016/j.resuscitation.2015.05.011CrossrefMedlineGoogle Scholar
• 149.Torgersen J, Strand K, Bjelland TW, Klepstad P, Kvåle R, Søreide E, Wentzel-Larsen T, Flaatten H. Cognitive dysfunction and health-related quality of life after a cardiac arrest and therapeutic hypothermia.Acta Anaesthesiol Scand. 2010; 54:721–728. doi: 10.1111/j.1399-6576.2010.02219.xCrossrefMedlineGoogle Scholar
• 150.Slomine BS, Silverstein FS, Christensen JR, Holubkov R, Page K, Dean JM, Moler FW; Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA) Trial Investigators. Neurobehavioral outcomes in children after out-of-hospital cardiac arrest.Pediatrics. 2016; 137doi: 10.1542/peds.2015–3412CrossrefMedlineGoogle Scholar
• 151.Maryniak A, Bielawska A, Walczak F, Szumowski Ł, Bieganowska K, Rekawek J, Paszke M, Szymaniak E, Knecht M. Long-term cognitive outcome in teenage survivors of arrhythmic cardiac arrest.Resuscitation. 2008; 77:46–50. doi: 10.1016/j.resuscitation.2007.10.024CrossrefMedlineGoogle Scholar
• 152.Ørbo M, Aslaksen PM, Larsby K, Norli L, Schäfer C, Tande PM, Vangberg TR, Anke A. Determinants of cognitive outcome in survivors of out-of-hospital cardiac arrest.Resuscitation. 2014; 85:1462–1468. doi: 10.1016/j.resuscitation.2014.08.010CrossrefMedlineGoogle Scholar
• 153.Tiainen M, Poutiainen E, Kovala T, Takkunen O, Häppölä O, Roine RO. Cognitive and neurophysiological outcome of cardiac arrest survivors treated with therapeutic hypothermia.Stroke. 2007; 38:2303–2308. doi: 10.1161/STROKEAHA.107.483867LinkGoogle Scholar
• 154.Lilja G, Nielsen N, Friberg H, Horn J, Kjaergaard J, Nilsson F, Pellis T, Wetterslev J, Wise MP, Bosch F, et al.. Cognitive function in survivors of out-of-hospital cardiac arrest after target temperature management at 33°C versus 36°C.Circulation. 2015; 131:1340–1349. doi: 10.1161/CIRCULATIONAHA.114.014414LinkGoogle Scholar
• 155.Tiainen M, Poutiainen E, Oksanen T, Kaukonen KM, Pettilä V, Skrifvars M, Varpula T, Castrén M. Functional outcome, cognition and quality of life after out-of-hospital cardiac arrest and therapeutic hypothermia: data from a randomized controlled trial.Scand J Trauma Resusc Emerg Med. 2015; 23:12. doi: 10.1186/s13049-014-0084-9CrossrefMedlineGoogle Scholar
• 156.Buanes EA, Gramstad A, Søvig KK, Hufthammer KO, Flaatten H, Husby T, Langørgen J, Heltne JK. Cognitive function and health-related quality of life four years after cardiac arrest.Resuscitation. 2015; 89:13–18. doi: 10.1016/j.resuscitation.2014.12.021CrossrefMedlineGoogle Scholar
• 157.Mateen FJ, Josephs KA, Trenerry MR, Felmlee-Devine MD, Weaver AL, Carone M, White RD. Long-term cognitive outcomes following out-of-hospital cardiac arrest: a population-based study.Neurology. 2011; 77:1438–1445. doi: 10.1212/WNL.0b013e318232ab33CrossrefMedlineGoogle Scholar
• 158.Steinbusch CVM, van Heugten CM, Rasquin SMC, Verbunt JA, Moulaert VRM. Cognitive impairments and subjective cognitive complaints after survival of cardiac arrest: a prospective longitudinal cohort study.Resuscitation. 2017; 120:132–137. doi: 10.1016/j.resuscitation.2017.08.007CrossrefMedlineGoogle Scholar
• 159.Bunch TJ, White RD, Smith GE, Hodge DO, Gersh BJ, Hammill SC, Shen WK, Packer DL. Long-term subjective memory function in ventricular fibrillation out-of-hospital cardiac arrest survivors resuscitated by early defibrillation.Resuscitation. 2004; 60:189–195. doi: 10.1016/j.resuscitation.2003.09.010CrossrefMedlineGoogle Scholar
• 160.Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness.Am J Respir Crit Care Med. 2010; 182:446–454. doi: 10.1164/rccm.201002-0210CICrossrefMedlineGoogle Scholar
• 161.Gracey DR, Naessens JM, Krishan I, Marsh HM. Hospital and posthospital survival in patients mechanically ventilated for more than 29 days.Chest. 1992; 101:211–214. doi: 10.1378/chest.101.1.211CrossrefMedlineGoogle Scholar
• 162.Engoren M, Arslanian-Engoren C, Fenn-Buderer N. Hospital and long-term outcome after tracheostomy for respiratory failure.Chest. 2004; 125:220–227. doi: 10.1378/chest.125.1.220CrossrefMedlineGoogle Scholar
• 163.Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri L; Quality of Life After Mechanical Ventilation in the Aged (QOL-MV) Investigators. Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study.Crit Care. 2007; 11:R9. doi: 10.1186/cc5667CrossrefMedlineGoogle Scholar
• 164.Carson SS, Garrett J, Hanson LC, Lanier J, Govert J, Brake MC, Landucci DL, Cox CE, Carey TS. A prognostic model for one-year mortality in patients requiring prolonged mechanical ventilation.Crit Care Med. 2008; 36:2061–2069. doi: 10.1097/CCM.0b013e31817b8925CrossrefMedlineGoogle Scholar
• 165.Stoller JK, Xu M, Mascha E, Rice R. Long-term outcomes for patients discharged from a long-term hospital-based weaning unit.Chest. 2003; 124:1892–1899. doi: 10.1378/chest.124.5.1892CrossrefMedlineGoogle Scholar
• 166.Cox CE, Carson SS. Medical and economic implications of prolonged mechanical ventilation and expedited post-acute care.Semin Respir Crit Care Med. 2012; 33:357–361. doi: 10.1055/s-0032-1321985CrossrefMedlineGoogle Scholar
• 167.Kahn JM, Le T, Angus DC, Cox CE, Hough CL, White DB, Yende S, Carson SS. The epidemiology of chronic critical illness in the United States.Crit Care Med. 2015; 43:282–287. doi: 10.1097/ccm.0000000000000710CrossrefMedlineGoogle Scholar
• 168.Mallidi HR, Anand J, Singh SK. Long-term mechanical circulatory support: a new disease state?J Thorac Cardiovasc Surg. 2015; 150:e13–e14. doi: 10.1016/j.jtcvs.2015.04.049CrossrefMedlineGoogle Scholar
• 169.Koster A, Loebe M, Sodian R, Potapov EV, Hansen R, Müller J, Mertzlufft F, Crystal GJ, Kuppe H, Hetzer R. Heparin antibodies and thromboembolism in heparin-coated and noncoated ventricular assist devices.J Thorac Cardiovasc Surg. 2001; 121:331–335. doi: 10.1067/mtc.2001.111655CrossrefMedlineGoogle Scholar
• 170.Matsubayashi H, Fastenau DR, McIntyre JA. Changes in platelet activation associated with left ventricular assist system placement.J Heart Lung Transplant. 2000; 19:462–468. doi: 10.1016/s1053-2498(00)00088-7CrossrefMedlineGoogle Scholar
• 171.Slaughter MS. Long-term continuous flow left ventricular assist device support and end-organ function: prospects for destination therapy.J Card Surg. 2010; 25:490–494. doi: 10.1111/j.1540-8191.2010.01075.xCrossrefMedlineGoogle Scholar
• 172.Wilson SR, Givertz MM, Stewart GC, Mudge GHVentricular assist devices the challenges of outpatient management.J Am Coll Cardiol. 2009; 54:1647–1659. doi: 10.1016/j.jacc.2009.06.035CrossrefMedlineGoogle Scholar
• 173.Mountis MM, Starling RC. Management of left ventricular assist devices after surgery: bridge, destination, and recovery.Curr Opin Cardiol. 2009; 24:252–256. doi: 10.1097/HCO.0b013e32832c7c09CrossrefMedlineGoogle Scholar
• 174.Letsou GV, Shah N, Gregoric ID, Myers TJ, Delgado R, Frazier OH. Gastrointestinal bleeding from arteriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device.J Heart Lung Transplant. 2005; 24:105–109. doi: 10.1016/j.healun.2003.10.018CrossrefMedlineGoogle Scholar
• 175.Crow S, John R, Boyle A, Shumway S, Liao K, Colvin-Adams M, Toninato C, Missov E, Pritzker M, Martin C, et al.. Gastrointestinal bleeding rates in recipients of nonpulsatile and pulsatile left ventricular assist devices.J Thorac Cardiovasc Surg. 2009; 137:208–215. doi: 10.1016/j.jtcvs.2008.07.032CrossrefMedlineGoogle Scholar
• 176.Steinlechner B, Dworschak M, Birkenberg B, Duris M, Zeidler P, Fischer H, Milosevic L, Wieselthaler G, Wolner E, Quehenberger P, et al.. Platelet dysfunction in outpatients with left ventricular assist devices.Ann Thorac Surg. 2009; 87:131–137. doi: 10.1016/j.athoracsur.2008.10.027CrossrefMedlineGoogle Scholar
• 177.Geisen U, Heilmann C, Beyersdorf F, Benk C, Berchtold-Herz M, Schlensak C, Budde U, Zieger B. Non-surgical bleeding in patients with ventricular assist devices could be explained by acquired von Willebrand disease.Eur J Cardiothorac Surg. 2008; 33:679–684. doi: 10.1016/j.ejcts.2007.12.047CrossrefMedlineGoogle Scholar
• 178.Mehra MR, Stewart GC, Uber PA. The vexing problem of thrombosis in long-term mechanical circulatory support.J Heart Lung Transplant. 2014; 33:1–11. doi: 10.1016/j.healun.2013.12.002CrossrefMedlineGoogle Scholar
• 179.Starling RC, Moazami N, Silvestry SC, Ewald G, Rogers JG, Milano CA, Rame JE, Acker MA, Blackstone EH, Ehrlinger J, et al.. Unexpected abrupt increase in left ventricular assist device thrombosis.N Engl J Med. 2014; 370:33–40. doi: 10.1056/NEJMoa1313385CrossrefMedlineGoogle Scholar
• 180.Najjar SS, Slaughter MS, Pagani FD, Starling RC, McGee EC, Eckman P, Tatooles AJ, Moazami N, Kormos RL, Hathaway DR, et al.; HVAD Bridge to Transplant ADVANCE Trial Investigators. An analysis of pump thrombus events in patients in the HeartWare ADVANCE bridge to transplant and continued access protocol trial.J Heart Lung Transplant. 2014; 33:23–34. doi: 10.1016/j.healun.2013.12.001CrossrefMedlineGoogle Scholar
• 181.Kirklin JK, Naftel DC, Kormos RL, Pagani FD, Myers SL, Stevenson LW, Acker MA, Goldstein DL, Silvestry SC, Milano CA, et al.. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of pump thrombosis in the HeartMate II left ventricular assist device.J Heart Lung Transplant. 2014; 33:12–22. doi: 10.1016/j.healun.2013.11.001CrossrefMedlineGoogle Scholar
• 182.Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume ED, Myers SL, Miller MA, Baldwin JT, Young JB. Seventh INTERMACS annual report: 15,000 patients and counting.J Heart Lung Transplant. 2015; 34:1495–1504. doi: 10.1016/j.healun.2015.10.003CrossrefMedlineGoogle Scholar
• 183.Cook JL, Colvin M, Francis GS, Grady KL, Hoffman TM, Jessup M, John R, Kiernan MS, Mitchell JE, Pagani FD, et al.; on behalf of the American Heart Association Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; and Council on Cardiovascular Surgery and Anesthesia. Recommendations for the use of mechanical circulatory support: ambulatory and community patient care: a scientific statement from the American Heart Association.Circulation. 2017; 135:e1145–e1158. doi: 10.1161/CIR.0000000000000507LinkGoogle Scholar
• 184.Grady KL, Magasi S, Hahn EA, Buono S, McGee EC, Yancy C. Health-related quality of life in mechanical circulatory support: development of a new conceptual model and items for self-administration.J Heart Lung Transplant. 2015; 34:1292–1304. doi: 10.1016/j.healun.2015.04.003CrossrefMedlineGoogle Scholar
• 185.Usher BM, Cammarata K. Heart failure and family caregiver burden: an update.Prog Cardiovasc Nurs. 2009; 24:113–114. doi: 10.1111/j.1751-7117.2009.00046.xCrossrefMedlineGoogle Scholar
• 186.Hooley PJ, Butler G, Howlett JG. The relationship of quality of life, depression, and caregiver burden in outpatients with congestive heart failure.Congest Heart Fail. 2005; 11:303–310. doi: 10.1111/j.1527-5299.2005.03620.xCrossrefMedlineGoogle Scholar
• 187.Bertini G, Giglioli C, Giovannini F, Bartoletti A, Cricelli F, Margheri M, Russo L, Taddei T, Taiti A. Neuropsychological outcome of survivors of out-of-hospital cardiac arrest.J Emerg Med. 1990; 8:407–412. doi: 10.1016/0736-4679(90)90166-sCrossrefMedlineGoogle Scholar
• 188.Presciutti A, Verma J, Pavol M, Anbarasan D, Falo C, Brodie D, Rabbani LE, Roh DJ, Park S, Claassen J, et al.. Posttraumatic stress and depressive symptoms characterize cardiac arrest survivors’ perceived recovery at hospital discharge.Gen Hosp Psychiatry. 2018; 53:108–113. doi: 10.1016/j.genhosppsych.2018.02.006CrossrefMedlineGoogle Scholar
• 189.Presciutti A, Sobczak E, Sumner JA, Roh DJ, Park S, Claassen J, Kronish I, Agarwal S. The impact of psychological distress on long-term recovery perceptions in survivors of cardiac arrest.J Crit Care. 2019; 50:227–233. doi: 10.1016/j.jcrc.2018.12.011CrossrefMedlineGoogle Scholar
• 190.Lilja G, Nilsson G, Nielsen N, Friberg H, Hassager C, Koopmans M, Kuiper M, Martini A, Mellinghoff J, Pelosi P, et al.. Anxiety and depression among out-of-hospital cardiac arrest survivors.Resuscitation. 2015; 97:68–75. doi: 10.1016/j.resuscitation.2015.09.389CrossrefMedlineGoogle Scholar
• 191.Wilson M, Staniforth A, Till R, das Nair R, Vesey P. The psychosocial outcomes of anoxic brain injury following cardiac arrest.Resuscitation. 2014; 85:795–800. doi: 10.1016/j.resuscitation.2014.02.008CrossrefMedlineGoogle Scholar
• 192.Dougherty CM. Psychological reactions and family adjustment in shock versus no shock groups after implantation of internal cardioverter defibrillator.Heart Lung. 1995; 24:281–291. doi: 10.1016/s0147-9563(05)80071-8CrossrefMedlineGoogle Scholar
• 193.Gamper G, Willeit M, Sterz F, Herkner H, Zoufaly A, Hornik K, Havel C, Laggner AN. Life after death: posttraumatic stress disorder in survivors of cardiac arrest–prevalence, associated factors, and the influence of sedation and analgesia.Crit Care Med. 2004; 32:378–383. doi: 10.1097/01.CCM.0000108880.97967.C0CrossrefMedlineGoogle Scholar
• 194.Davies SE, Rhys M, Voss S, Greenwood R, Thomas M, Benger JR. Psychological wellbeing in survivors of cardiac arrest, and its relationship to neurocognitive function.Resuscitation. 2017; 111:22–25. doi: 10.1016/j.resuscitation.2016.11.004CrossrefMedlineGoogle Scholar
• 195.Lau B, Kirkpatrick JN, Merchant RM, Perman SM, Abella BS, Gaieski DF, Becker LB, Chiames C, Reitsma AM. Experiences of sudden cardiac arrest survivors regarding prognostication and advance care planning.Resuscitation. 2010; 81:982–986. doi: 10.1016/j.resuscitation.2010.03.031CrossrefMedlineGoogle Scholar
• 196.Bremer A, Dahlberg K, Sandman L. To survive out-of-hospital cardiac arrest: a search for meaning and coherence.Qual Health Res. 2009; 19:323–338. doi: 10.1177/1049732309331866CrossrefMedlineGoogle Scholar
• 197.Sawyer KN, Brown F, Christensen R, Damino C, Newman MM, Kurz MC. Surviving sudden cardiac arrest: a pilot qualitative survey study of survivors.Ther Hypothermia Temp Manag. 2016; 6:76–84. doi: 10.1089/ther.2015.0031CrossrefMedlineGoogle Scholar
• 198.Ketilsdottir A, Albertsdottir HR, Akadottir SH, Gunnarsdottir TJ, Jonsdottir H. The experience of sudden cardiac arrest: becoming reawakened to life.Eur J Cardiovasc Nurs. 2014; 13:429–435. doi: 10.1177/1474515113504864CrossrefMedlineGoogle Scholar
• 199.Palacios-Ceña D, Losa-Iglesias ME, Salvadores-Fuentes P, Fernández-de-las-Peñas C. Sudden cardiac death: the perspectives of Spanish survivors.Nurs Health Sci. 2011; 13:149–155. doi: 10.1111/j.1442-2018.2011.00593.xCrossrefMedlineGoogle Scholar
• 200.Aristidou M, Vouzavali F, Karanikola MN, Lambrinou E, Papathanassoglou E. A Meta-ethnography of out-of-hospital cardiac arrest survivors’ meanings on life and death.J Cardiovasc Nurs. 2018; 33:E10–E20. doi: 10.1097/JCN.0000000000000467CrossrefMedlineGoogle Scholar
• 201.Rosman L, Whited A, Lampert R, Mosesso VN, Lawless C, Sears SF. Cardiac anxiety after sudden cardiac arrest: severity, predictors and clinical implications.Int J Cardiol. 2015; 181:73–76. doi: 10.1016/j.ijcard.2014.11.115CrossrefMedlineGoogle Scholar
• 202.Sunnerhagen KS, Johansson O, Herlitz J, Grimby G. Life after cardiac arrest; a retrospective study.Resuscitation. 1996; 31:135–140. doi: 10.1016/0300-9572(95)00903-5CrossrefMedlineGoogle Scholar
• 203.Geri G, Dumas F, Bonnetain F, Bougouin W, Champigneulle B, Arnaout M, Carli P, Marijon E, Varenne O, Mira JP, et al.. Predictors of long-term functional outcome and health-related quality of life after out-of-hospital cardiac arrest.Resuscitation. 2017; 113:77–82. doi: 10.1016/j.resuscitation.2017.01.028CrossrefMedlineGoogle Scholar
• 204.Ladwig KH, Schoefinius A, Dammann G, Danner R, Gürtler R, Herrmann R. Long-acting psychotraumatic properties of a cardiac arrest experience.Am J Psychiatry. 1999; 156:912–919. doi: 10.1176/ajp.156.6.912CrossrefMedlineGoogle Scholar
• 205.Vilchinsky N, Ginzburg K, Fait K, Foa EB. Cardiac-disease-induced PTSD (CDI-PTSD): a systematic review.Clin Psychol Rev. 2017; 55:92–106. doi: 10.1016/j.cpr.2017.04.009CrossrefMedlineGoogle Scholar
• 206.Pedersen SS, Knudsen C, Dilling K, Sandgaard NCF, Johansen JB. Living with an implantable cardioverter defibrillator: patients’ preferences and needs for information provision and care options.Europace. 2017; 19:983–990. doi: 10.1093/europace/euw109MedlineGoogle Scholar
• 207.Lundgren-Nilsson A, Rosén H, Hofgren C, Sunnerhagen KS. The first year after successful cardiac resuscitation: function, activity, participation and quality of life.Resuscitation. 2005; 66:285–289. doi: 10.1016/j.resuscitation.2005.04.001CrossrefMedlineGoogle Scholar
• 208.Gilworth G, Chamberlain MA, Harvey A, Woodhouse A, Smith J, Smyth MG, Tennant A. Development of a work instability scale for rheumatoid arthritis.Arthritis Rheum. 2003; 49:349–354. doi: 10.1002/art.11114CrossrefMedlineGoogle Scholar
• 209.Middelkamp W, Moulaert VR, Verbunt JA, van Heugten CM, Bakx WG, Wade DT. Life after survival: long-term daily life functioning and quality of life of patients with hypoxic brain injury as a result of a cardiac arrest.Clin Rehabil. 2007; 21:425–431. doi: 10.1177/0269215507075307CrossrefMedlineGoogle Scholar
• 210.Kragholm K, Wissenberg M, Mortensen RN, Fonager K, Jensen SE, Rajan S, Lippert FK, Christensen EF, Hansen PA, Lang-Jensen T, et al.. Return to work in out-of-hospital cardiac arrest survivors: a nationwide register-based follow-up study.Circulation. 2015; 131:1682–1690. doi: 10.1161/CIRCULATIONAHA.114.011366LinkGoogle Scholar
• 211.Lilja G, Nielsen N, Bro-Jeppesen J, Dunford H, Friberg H, Hofgren C, Horn J, Insorsi A, Kjaergaard J, Nilsson F, et al.. Return to work and participation in society after out-of-hospital cardiac arrest.Circ Cardiovasc Qual Outcomes. 2018; 11:e003566. doi: 10.1161/CIRCOUTCOMES.117.003566LinkGoogle Scholar
• 212.Kalbfleisch KR, Lehmann MH, Steinman RT, Jackson K, Axtell K, Schuger CD, Tchou PJ. Reemployment following implantation of the automatic cardioverter defibrillator.Am J Cardiol. 1989; 64:199–202. doi: 10.1016/0002-9149(89)90457-8CrossrefMedlineGoogle Scholar
• 213.Scaratti C, Leonardi M, Sattin D, Schiavolin S, Willems M, Raggi A. Work-related difficulties in patients with traumatic brain injury: a systematic review on predictors and associated factors.Disabil Rehabil. 2017; 39:847–855. doi: 10.3109/09638288.2016.1162854CrossrefMedlineGoogle Scholar
• 214.Dougherty CM, Benoliel JQ, Bellin C. Domains of nursing intervention after sudden cardiac arrest and automatic internal cardioverter defibrillator implantation.Heart Lung. 2000; 29:79–86.CrossrefMedlineGoogle Scholar
• 215.Forslund AS, Lundblad D, Jansson JH, Zingmark K, Söderberg S. Risk factors among people surviving out-of-hospital cardiac arrest and their thoughts about what lifestyle means to them: a mixed methods study.BMC Cardiovasc Disord. 2013; 13:62. doi: 10.1186/1471-2261-13-62CrossrefMedlineGoogle Scholar
• 216.Mikkelsen ME, Jackson JC, Hopkins RO, Thompson C, Andrews A, Netzer G, Bates DM, Bunnell AE, Christie LM, Greenberg SB, et al.. Peer support as a novel strategy to mitigate post-intensive care syndrome.AACN Adv Crit Care. 2016; 27:221–229. doi: 10.4037/aacnacc2016667CrossrefMedlineGoogle Scholar
• 217.Dickerson SS, Posluszny M, Kennedy MC. Help seeking in a support group for recipients of implantable cardioverter defibrillators and their support persons.Heart Lung. 2000; 29:87–96. doi: 10.1067/mhl.2000.104138CrossrefMedlineGoogle Scholar
• 218.Czerwonka AI, Herridge MS, Chan L, Chu LM, Matte A, Cameron JI. Changing support needs of survivors of complex critical illness and their family caregivers across the care continuum: a qualitative pilot study of Towards RECOVER.J Crit Care. 2015; 30:242–249. doi: 10.1016/j.jcrc.2014.10.017CrossrefMedlineGoogle Scholar
• 219.Dickerson SS. Cardiac spouses’ help-seeking experiences.Clin Nurs Res. 1998; 7:6–24. doi: 10.1177/105477389800700102CrossrefMedlineGoogle Scholar
• 220.Hildingh C, Fridlund B. Patient participation in peer support groups after a cardiac event.Br J Nurs. 2001; 10:1357–1363. doi: 10.12968/bjon.2001.10.20.9355CrossrefMedlineGoogle Scholar
• 221.Dickerson SS, Flaig DM, Kennedy MC. Therapeutic connection: help seeking on the internet for persons with implantable cardioverter defibrillators.Heart Lung. 2000; 29:248–255. doi: 10.1067/mhl.2000.108326CrossrefMedlineGoogle Scholar
• 222.Salzmann-Erikson M, Hiçdurmaz D. Use of social media among individuals who suffer from post-traumatic stress: a qualitative analysis of narratives.Qual Health Res. 2017; 27:285–294. doi: 10.1177/1049732315627364CrossrefMedlineGoogle Scholar
• 223.Lindholm C, Burström B, Diderichsen F. Class differences in the social consequences of illness?J Epidemiol Community Health. 2002; 56:188–192. doi: 10.1136/jech.56.3.188CrossrefMedlineGoogle Scholar
• 224.Hultin H, Lindholm C, Möller J. Is there an association between long-term sick leave and disability pension and unemployment beyond the effect of health status? A cohort study.PLoS One. 2012; 7:e35614. doi: 10.1371/journal.pone.0035614CrossrefMedlineGoogle Scholar
• 225.Nayak S, Hubbard A, Sidney S, Syme SL. Characteristics associated with self-rated health in the CARDIA study: contextualising health determinants by income group.Prev Med Rep. 2016; 4:199–208. doi: 10.1016/j.pmedr.2016.06.001CrossrefMedlineGoogle Scholar
• 226.Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change.Milbank Q. 2001; 79:281–315. doi: 10.1111/1468-0009.00206CrossrefMedlineGoogle Scholar
• 227.Møller TP, Hansen CM, Fjordholt M, Pedersen BD, Østergaard D, Lippert FK. Debriefing bystanders of out-of-hospital cardiac arrest is valuable.Resuscitation. 2014; 85:1504–1511. doi: 10.1016/j.resuscitation.2014.08.006CrossrefMedlineGoogle Scholar
• 228.Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.Intensive Care Med. 2015; 41:2039–2056. doi: 10.1007/s00134-015-4051-3CrossrefMedlineGoogle Scholar
• 229.Clark R, McLean C. The professional and personal debriefing needs of ward based nurses after involvement in a cardiac arrest: an explorative qualitative pilot study.Intensive Crit Care Nurs. 2018; 47:78–84. doi: 10.1016/j.iccn.2018.03.009CrossrefMedlineGoogle Scholar
• 230.Ireland S, Gilchrist J, Maconochie I. Debriefing after failed paediatric resuscitation: a survey of current UK practice.Emerg Med J. 2008; 25:328–330. doi: 10.1136/emj.2007.048942CrossrefMedlineGoogle Scholar
• 231.Dougherty CM, Shaver JF. Psychophysiological responses after sudden cardiac arrest during hospitalization.Appl Nurs Res. 1995; 8:160–168. doi: 10.1016/s0897-1897(95)80369-6CrossrefMedlineGoogle Scholar
• 232.Holm MS, Norekvål TM, Fålun N, Gjengedal E. Partners’ ambivalence towards cardiac arrest and hypothermia treatment: a qualitative study.Nurs Crit Care. 2012; 17:231–238. doi: 10.1111/j.1478-5153.2012.00490.xCrossrefMedlineGoogle Scholar
• 233.Doolittle ND, Sauvé MJ. Impact of aborted sudden cardiac death on survivors and their spouses: the phenomenon of different reference points.Am J Crit Care. 1995; 4:389–396.CrossrefMedlineGoogle Scholar
• 234.Pusswald G, Fertl E, Faltl M, Auff E. Neurological rehabilitation of severely disabled cardiac arrest survivors, part II. Life situation of patients and families after treatment.Resuscitation. 2000; 47:241–248. doi: 10.1016/s0300-9572(00)00240-9CrossrefMedlineGoogle Scholar
• 235.Löf S, Sandström A, Engström A. Patients treated with therapeutic hypothermia after cardiac arrest: relatives’ experiences.J Adv Nurs. 2010; 66:1760–1768. doi: 10.1111/j.1365-2648.2010.05352.xCrossrefMedlineGoogle Scholar
• 236.Weslien M, Nilstun T, Lundqvist A, Fridlund B. When the unreal becomes real: family members’ experiences of cardiac arrest.Nurs Crit Care. 2005; 10:15–22. doi: 10.1111/j.1362-1017.2005.00094.xCrossrefMedlineGoogle Scholar
• 237.Dougherty CM, Pyper GP, Benoliel JQ. Domains of concern of intimate partners of sudden cardiac arrest survivors after ICD implantation.J Cardiovasc Nurs. 2004; 19:21–31. doi: 10.1097/00005082-200401000-00006CrossrefMedlineGoogle Scholar
• 238.Wallin E, Larsson IM, Rubertsson S, Kristoferzon ML. Relatives’ experiences of everyday life six months after hypothermia treatment of a significant other’s cardiac arrest.J Clin Nurs. 2013; 22:1639–1646. doi: 10.1111/jocn.12112CrossrefMedlineGoogle Scholar
• 239.Larsson IM, Wallin E, Rubertsson S, Kristoferzon ML. Relatives’ experiences during the next of kin’s hospital stay after surviving cardiac arrest and therapeutic hypothermia.Eur J Cardiovasc Nurs. 2013; 12:353–359. doi: 10.1177/1474515112459618CrossrefMedlineGoogle Scholar
• 240.Dougherty CM. Longitudinal recovery following sudden cardiac arrest and internal cardioverter defibrillator implantation: survivors and their families.Am J Crit Care. 1994; 3:145–154.CrossrefMedlineGoogle Scholar
• 241.Dougherty CM. Family-focused interventions for survivors of sudden cardiac arrest.J Cardiovasc Nurs. 1997; 12:45–58. doi: 10.1097/00005082-199710000-00006CrossrefMedlineGoogle Scholar
• 242.Cartledge S, Bray JE, Leary M, Stub D, Finn J. A systematic review of basic life support training targeted to family members of high-risk cardiac patients.Resuscitation. 2016; 105:70–78. doi: 10.1016/j.resuscitation.2016.04.028CrossrefMedlineGoogle Scholar
• 243.van Wijnen HG, Rasquin SM, van Heugten CM, Verbunt JA, Moulaert VR. The impact of cardiac arrest on the long-term wellbeing and caregiver burden of family caregivers: a prospective cohort study.Clin Rehabil. 2017; 31:1267–1275. doi: 10.1177/0269215516686155CrossrefMedlineGoogle Scholar
• 244.Ingles J, Spinks C, Yeates L, McGeechan K, Kasparian N, Semsarian C. Posttraumatic stress and prolonged grief after the sudden cardiac death of a young relative.JAMA Intern Med. 2016; 176:402–405. doi: 10.1001/jamainternmed.2015.7808CrossrefMedlineGoogle Scholar
• 245.Purves Y, Edwards S. Initial needs of bereaved relatives following sudden and unexpected death.Emerg Nurse. 2005; 13:28–34. doi: 10.7748/en2005.11.13.7.28.c1199CrossrefMedlineGoogle Scholar
• 246.Scott T. Sudden traumatic death: caring for the bereaved.Trauma. 2007; 9:103–109. doi: 10.1177/1460408607084127CrossrefGoogle Scholar
• 247.Mayer DD, Rosenfeld AG, Gilbert K. Lives forever changed: family bereavement experiences after sudden cardiac death.Appl Nurs Res. 2013; 26:168–173. doi: 10.1016/j.apnr.2013.06.007CrossrefMedlineGoogle Scholar
• 248.Clements PT, DeRanieri JT, Vigil GJ, Benasutti KM. Life after death: grief therapy after the sudden traumatic death of a family member.Perspect Psychiatr Care. 2004; 40:149–154. doi: 10.1111/j.1744-6163.2004.tb00012.xCrossrefMedlineGoogle Scholar
• 249.McCarthy JJ, Carr B, Sasson C, Bobrow BJ, Callaway CW, Neumar RW, Ferrer JME, Garvey JL, Ornato JP, Gonzales L, et al.; on behalf of the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; and the Mission: Lifeline Resuscitation Subcommittee. Out-of-hospital cardiac arrest resuscitation systems of care: a scientific statement from the American Heart Association.Circulation. 2018; 137:e645–e660. doi: 10.1161/CIR.0000000000000557LinkGoogle Scholar
• 250.Williams D, Calder S, Cocchi MN, Donnino MW. From door to recovery: a collaborative approach to the development of a post-cardiac arrest center.Crit Care Nurse. 2013; 33:42–54. doi: 10.4037/ccn2013341CrossrefMedlineGoogle Scholar
• 251.Kurz MC, Donnelly JP, Wang HE. Variations in survival after cardiac arrest among academic medical center-affiliated hospitals.PLoS One. 2017; 12:e0178793. doi: 10.1371/journal.pone.0178793CrossrefMedlineGoogle Scholar
• 252.Sulzgruber P, Sterz F, Schober A, Uray T, Van Tulder R, Hubner P, Wallmüller C, El-Tattan D, Graf N, Ruzicka G, et al.. Editor’s choice-progress in the chain of survival and its impact on outcomes of patients admitted to a specialized high-volume cardiac arrest center during the past two decades.Eur Heart J Acute Cardiovasc Care. 2016; 5:3–12. doi: 10.1177/2048872615620904CrossrefMedlineGoogle Scholar
• 253.Donnino MW, Rittenberger JC, Gaieski D, Cocchi MN, Giberson B, Peberdy MA, Abella BS, Bobrow BJ, Callaway C. The development and implementation of cardiac arrest centers.Resuscitation. 2011; 82:974–978. doi: 10.1016/j.resuscitation.2011.03.021CrossrefMedlineGoogle Scholar
• 254.Moulaert VR, Verbunt JA, Bakx WG, Gorgels AP, de Krom MC, Heuts PH, Wade DT, van Heugten CM. “Stand still…, and move on,” a new early intervention service for cardiac arrest survivors and their caregivers: rationale and description of the intervention.Clin Rehabil. 2011; 25:867–879. doi: 10.1177/0269215511399937CrossrefMedlineGoogle Scholar
• 255.Cowan MJ, Pike KC, Budzynski HK. Psychosocial nursing therapy following sudden cardiac arrest: impact on two-year survival.Nurs Res. 2001; 50:68–76. doi: 10.1097/00006199-200103000-00002CrossrefMedlineGoogle Scholar
• 256.Harkins K, St. Amand C. Celebrating and supporting survivors of sudden cardiac arrest.J Emerg Med Serv. 2015. http://www.jems.com/articles/supplements/special-topics/five-years-10-000-saves-just-getting-started/celebrating-and-supporting-survivors-of-sudden-cardiac-arrest.html. Accessed May 8, 2018.Google Scholar
• 257.Kurz MC. For whom the bell tolls….Resuscitation. 2011; 82:1371–1372. doi: 10.1016/j.resuscitation.2011.08.006CrossrefMedlineGoogle Scholar
• 258.Merchant RM, Becker LB, Abella BS, Asch DA, Groeneveld PW. Cost-effectiveness of therapeutic hypothermia after cardiac arrest.Circ Cardiovasc Qual Outcomes. 2009; 2:421–428. doi: 10.1161/CIRCOUTCOMES.108.839605LinkGoogle Scholar
• 259.Paniagua D, Lopez-Jimenez F, Londoño JC, Mangione CM, Fleischmann K, Lamas GA. Outcome and cost-effectiveness of cardiopulmonary resuscitation after in-hospital cardiac arrest in octogenarians.Cardiology. 2002; 97:6–11. doi: 10.1159/000047412CrossrefMedlineGoogle Scholar
• 260.Ginsberg GM, Kark JD, Einav S. Cost-utility analysis of treating out of hospital cardiac arrests in Jerusalem.Resuscitation. 2015; 86:54–61. doi: 10.1016/j.resuscitation.2014.10.024CrossrefMedlineGoogle Scholar
• 261.Saner H, Borner Rodriguez E, Kummer-Bangerter A, Schüppel R, von Planta M. Quality of life in long-term survivors of out-of-hospital cardiac arrest.Resuscitation. 2002; 53:7–13. doi: 10.1016/s0300-9572(02)00002-3CrossrefMedlineGoogle Scholar
• 262.Cronberg T, Lilja G, Horn J, Kjaergaard J, Wise MP, Pellis T, Hovdenes J, Gasche Y, Åneman A, Stammet P, et al.; TTM Trial Investigators. Neurologic function and health-related quality of life in patients following targeted temperature management at 33°C vs 36°C after out-of-hospital cardiac arrest: a randomized clinical trial.JAMA Neurol. 2015; 72:634–641. doi: 10.1001/jamaneurol.2015.0169CrossrefMedlineGoogle Scholar
• 263.Chan PS, Nallamothu BK, Krumholz HM, Curtis LH, Li Y, Hammill BG, Spertus JA; for the American Heart Association’s Get With The Guidelines-Resuscitation Investigators. Readmission rates and long-term hospital costs among survivors of an in-hospital cardiac arrest.Circ Cardiovasc Qual Outcomes. 2014; 7:889–895. doi: 10.1161/CIRCOUTCOMES.114.000925LinkGoogle Scholar
• 264.Chan PS, Nallamothu BK, Krumholz HM, Spertus JA, Li Y, Hammill BG, Curtis LH. Long-term outcomes in elderly survivors of in-hospital cardiac arrest.N Engl J Med. 2013; 368:1019–1026. doi: 10.1056/NEJMoa1200657CrossrefMedlineGoogle Scholar
• 265.Naess AC, Steen PA. Long term survival and costs per life year gained after out-of-hospital cardiac arrest.Resuscitation. 2004; 60:57–64. doi: 10.1016/S0300-9572(03)00262-4CrossrefMedlineGoogle Scholar
• 266.Lundbye JB, ed. Therapeutic Hypothermia After Cardiac Arrest: Clinical Application and Management. London, UK: Springer-Verlag London; 2012.CrossrefGoogle Scholar
• 267.Chan PS, McNally B, Nallamothu BK, Tang F, Hammill BG, Spertus JA, Curtis LH. Long-term outcomes among elderly survivors of out-of-hospital cardiac arrest.J Am Heart Assoc. 2016; 5:e002924. doi: 10.1161/JAHA.115.002924LinkGoogle Scholar
• 268.Kolte D, Khera S, Aronow WS, Palaniswamy C, Mujib M, Ahn C, Iwai S, Jain D, Sule S, Ahmed A, et al.. Regional variation in the incidence and outcomes of in-hospital cardiac arrest in the United States.Circulation. 2015; 131:1415–1425. doi: 10.1161/CIRCULATIONAHA.114.014542LinkGoogle Scholar
• 269.van Alem AP, Dijkgraaf MG, Tijssen JG, Koster RW. Health system costs of out-of-hospital cardiac arrest in relation to time to shock.Circulation. 2004; 110:1967–1973. doi: 10.1161/01.CIR.0000143150.13727.19LinkGoogle Scholar
• 270.Annapureddy A, Valero-Elizondo J, Khera R, Grandhi GR, Spatz ES, Dreyer RP, Desai NR, Krumholz HM, Nasir K. Association between financial burden, quality of life, and mental health among those with atherosclerotic cardiovascular disease in the United States.Circ Cardiovasc Qual Outcomes. 2018; 11:e005180. doi: 10.1161/CIRCOUTCOMES.118.005180LinkGoogle Scholar
• 271.Cartier C. From home to hospital and back again: economic restructuring, end of life, and the gendered problems of place-switching health services.Soc Sci Med. 2003; 56:2289–2301. doi: 10.1016/s0277-9536(02)00228-9CrossrefMedlineGoogle Scholar
• 272.Becker LB, Aufderheide TP, Geocadin RG, Callaway CW, Lazar RM, Donnino MW, Nadkarni VM, Abella BS, Adrie C, Berg RA, et al.; on behalf of the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association.Circulation. 2011; 124:2158–2177. doi: 10.1161/CIR.0b013e3182340239LinkGoogle Scholar