Resuscitation 82 (2011) 247 256
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Review article
Systematic review of quality of life and other patient-centred outcomes after
cardiac arrest survival
Vanessa J. Elliotta,", David L. Rodgersb, Stephen J. Bretta
a
Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, United Kingdom
b
Center for Simulation, Advanced Education and Innovation, The Children s Hospital of Philadelphia, Philadelphia, PA, United States
a r t i c l e i n f o a b s t r a c t
Article history:
Objectives: In cardiac arrest patients (in hospital and pre hospital) does resuscitation produce a good
Received 13 August 2010
Quality of Life (QoL) for survivors after discharge from the hospital?
Received in revised form 21 October 2010
Methods: Embase, Medline, The Cochrane Database of Systematic Reviews, Academic Search Premier,
Accepted 27 October 2010
the Central Database of Controlled Trials and the American Heart Association (AHA) Resuscitation End-
note Library were searched using the terms ( Cardiac Arrest (Mesh) OR Cardiopulmonary Resuscitation
Keywords:
(Mesh) OR Heart Arrest (Mesh)) AND ( Outcomes OR Quality of Life OR Depression OR Post-traumatic
Cardiac arrest
Stress Disorder OR Anxiety OR Cognitive Function OR Participation OR Social Function OR Health
Resuscitation
Utilities Index OR SF-36 OR EQ-5D as text term.
Outcomes
Results: There were 9 inception (prospective) cohort studies (LOE P1), 3 follow up of untreated control
Quality of life
groups in randomised control trials (LOE P2), 11 retrospective cohort studies (LOE P3) and 47 case series
(LOE P4). 46 of the studies were supportive with respect to the search question, 17 neutral and 7 negative.
Discussion: The majority of studies concluded that QoL after cardiac arrest is good. This review demon-
strated a remarkable heterogeneity of methodology amongst studies assessing QoL in cardiac arrest
survivors. There is a requirement for consensus development with regard to quality of life and patient
centred outcome assessment in this population.
© 2010 Elsevier Ireland Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
2.2. Evidence appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
2.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
3.1. Study population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
5. Authors conclusions and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.10.030.
"
Corresponding author at: ICU, Imperial College, Du Cane Road, London, United Kingdom. Tel.: +44 07976 980933.
E-mail address: van elliott@hotmail.com (V.J. Elliott).
0300-9572/$ see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2010.10.030
248 V.J. Elliott et al. / Resuscitation 82 (2011) 247 256
Table 1
1. Introduction
ILCOR levels of evidence for prognostic studies.
The major part of the scientific literature underpinning resus- LOE P1 Inception (prospective) cohort studies (or meta-analyses of
inception cohort studies), or validation of Clinical Decision
citation after cardiac arrest has focussed on survival, and much of
Rule (CDR)
this short-term survival. Recent developments in post resuscitation
LOE P2 Follow up of untreated control groups in RCTs (or
care have demonstrated improvements in short term survival, but
meta-analyses of follow up studies), or derivation of CDR, or
with the potential for very substantial associated health and social
validated on split-sample only
care costs.1,2 Large sums of money have been invested in provid- LOE P3 Retrospective cohort studies
LOE P4 Case series
ing training, equipment and personnel to maximise the chances of
LOE P5 Studies not directly related to the specific patient/population
survival for patients experiencing a cardiac arrest.
(e.g. Different patient/population, animal models, mechanical
Concern has been expressed that in spite of this investment, sur-
models etc.)
vivors of cardiac arrests go on to experience a diminished existence,
associated with an unacceptable quality of life, and that this would
ence or absence of relevant quality items reported in the studies.4
thus not justify the efforts and costs involved.3
Quality was defined in the 2010 evidence review in terms of the
Thus, the aim of this systematic review was to determine
following questions5:
whether the quality of life for patients who have experienced a
cardiac arrest and survived is acceptable.
" Were comparison groups clearly defined?
The research question addressed was: in cardiac arrest patients
" Were outcomes measured in the same (preferably blinded),
(in hospital and prehospital) does resuscitation produce a good
objective way?
Quality of Life (QoL) for survivors after discharge from the hospital?
" Were known confounders identified and appropriately controlled
2. Methods for?
" Was follow-up of patients sufficiently long and complete?
This review was conducted in accordance with the International
Liaison Committee on Resuscitation (ILCOR) 2010 evidence evalua- Presence of all 4 factors led to a rating of good, 3 factors fair, 2
tion process. Expert review of the search strategy and findings were factors poor. A study with only one of these factors present would
conducted by the worksheet evaluation experts. be considered of insufficient quality to include. The studies were
then assigned supportive, neutral or opposing with regard to the
research question.
2.1. Search strategy
The electronic databases Medline and EmBASE, Academic 2.3. Data extraction
Search Premier (including CINAHL, PsychARTICLES, psychINFO &
Health Source: Nursing/Academic Edition), the Cochrane Database The following data were obtained from all articles: authors, date
of Systematic Reviews, the Central Database of Controlled Trials of publication, study design, inclusion/exclusion criteria, number of
and the American Heart Association (AHA) Resuscitation Endnote patients in study, age of participants, control group characteristics
Library were searched using the terms Cardiac Arrest (Mesh) OR (if used), length/time of follow up, outcome measures used and
Cardiopulmonary Resuscitation (Mesh) OR Heart Arrest (Mesh) comparisons with control groups. Both reviewers extracted these
AND Outcomes , Quality of Life , Depression , Post Traumatic data independently and concurrently and the results merged. The
Stress Disorder , Anxiety , Cognitive Function , Participation , third reviewer was again used as the deciding vote if there was any
Social Function , Health Utilities Index , SF-36 , EQ-5D . differing opinions.
Articles that assessed patients for differing modalities, such as
depression and cognitive function that could be said to contribute 3. Results
to overall quality of life , but are not necessarily measured in
conventional health-related quality of life assessments, at least 6 The primary Embase search returned 5167 articles. The
months post cardiac arrest (in hospital or out of hospital) were Cochrane Database of Systematic Reviews and the Central Register
included. Studies that looked at interventions post cardiac arrest of Clinical Trials did not return any relevant articles. The Ameri-
were also included and the control arm was utilised for quality of can Heart Association resuscitation endnote library search returned
life data. Exclusion criteria included studies that looked at survival 77 articles that were all duplicates of the primary search. Pubmed
only, those that used the same population of patients for multiple returned 1078 articles, only one of which was not a duplicate of
studies, neonatal arrests and reviews. primary search. 192 articles had their abstracts reviewed in detail
The titles of articles were reviewed for potential relevance inde- for relevance; 122 articles were discarded, leaving 70 articles for
pendently by two reviewers (VE/DR) and irrelevant articles were full and detailed review.
discarded. The remaining articles abstracts were reviewed and There were 9 inception (prospective) cohort studies (LOE P1)
those requiring detailed examination were identified. If consensus that address quality of life after cardiac arrest, 3 follow up of
could not be reached a 3rd reviewer (SB) had the deciding vote. untreated control groups in randomised control trials (LOE P2), 11
The reference list from the articles selected for detailed review retrospective cohort studies (LOE P3) and 47 case series (LOE P4)
were searched by hand to identify any further relevant papers not (Table 2).
captured in the original search. Overall, forty six studies support the hypothesis that resuscita-
tion after cardiac arrest leads to a good quality of life after discharge
2.2. Evidence appraisal from hospital; seventeen studies are neutral to the hypothesis and
seven studies provided evidence to the contrary (Table 2).
Studies were reviewed and classified as to their level of evidence
(LOE) (see Table 1) with respect to the research question identified 3.1. Study population
for this review; importantly this was not necessarily the primary
objective of the original study examined. With regard to this, quality The age of the participants (from 11 years upwards) and the
of evidence was rated as good , fair or poor based on the pres- number of participants per study (10 550) was variable and
V.J. Elliott et al. / Resuscitation 82 (2011) 247 256 249
Table 2
Summary of level of evidence, quality of studies, supporting, opposing, or neutral to the hypothesis.
LOE P1 LOE P2 LOE P3 LoeP4 LOE P5
Supportive studies
Van Alem57 Bergner65 Cronberg29
Granja58 Graf2 Raina69
Bunch8 Saner9 Stiell44
Nichol61 O Reilly11 Wernberg70
Stiell14 Rien de Vois66 Motzer71
Grubb62 Horsted27 Kamphius72
Miranda63 Tiainen13 Harve6
Good
Polo73
Graves32
Kuliman74
Hsu75
Sauve (133)76
Lederer31
Bertini67 Bedell77
Beuret68 Bottiger35
Earnest78
Gottschalk79
Hillis80
Martin-Castro81
Roewer82
Lettieri21 Longstreth64
Fair
Skogvoll36
Triano83
Arrich33
Dimopoulou20
Nunes30
Eisenberger15
Guerot84
Poor Kliegel85
Neutral studies
O Reilly12 Gamper28
Reinhard10 Wachelder88
Ladwig39 Pusswald16
Lundgren-Nilsson86
Good
Hofgren89
Drysdale40
Maryniak17
Wolfrum22
Sunnerhagan90
Enghdahl34
Iwami87
Fair
Gener37
Sauve (172)91
Sauve (127)92
Poor
Negative studies
Good
Mohr18
Ronco19
Fair
Schindler93
Callaham38
Guglin94
Poor
Paniagua23
Yarnell7
reported in a variety of ways. The length of follow up varied any- The outcome measures used to assess quality of life and other
where from 28 days to 15 years.6,7 patient centred outcomes- such as depression, anxiety and cog-
The characteristics of the studies are summarised in Table 3. nitive dysfunction were also highly variable (see Table 3 and
The study populations are heterogeneous, including survivors of electronic supplement detailing tools used to assess cognitive
in- and out- of hospital arrests,6,8 12 and survivors of PEA, VF function, Table 4).
and asystolic arrests.13,14 Some studies excluded survivors with
gross neurological impairment,8,9,15 whilst others excluded those 4. Discussion
that are neurologically intact.16 In some studies specifically identi-
fied patient populations were used including teenagers,17 nursing There was no overwhelming evidence from this review that
home residents,18 children under the age of 15 years,19 those post- resuscitating people after cardiac arrest led to a large pool of
cardiac surgery20 cardiac arrest in the context of acute myocardial patients that experienced an unbearably poor quality of life (QoL).
infarction21,22 and octogenarians.23 The majority of studies concluded that the provision of resuscita-
250 V.J. Elliott et al. / Resuscitation 82 (2011) 247 256
Table 3
Summary of studies and outcome measures used.
Study Age Time of follow up Control group No. in group Assessment tools
Arrich33 Mean 55 years 6 months None 550 CPC
Bedell77 6 months None 30
Bergner65 64 patients - <50 years 6 months Random sample 495 424 Sickness impact profile
125 patients - 50 59 years enrolles in a group General interview
134 patients - 60 69 years health co-operat
101 patients - >70 years
Bertini67 Patients with MI but no cardiac 30 CPC
arrest Neuropsychological battery
Healthy patients
Beuret68 Mean 62 years 12 30 months Control group from personal 10 Interview
series of 500 subjects after Neuropsychological assessment -
adjusting for age, sex, social not further elucidated
and educational level
Bottiger35 Mean 67 Ä… 12 years 1 year None 40 CPC
Bunch8 Mean 61.9 Ä… 15.9 4.8 Ä… 3 years Age and sex matched US 50 SF-36
population - healthy and diseas
Callaham38 6 12 months None 28 CPC
Cronberg29 Range 14 87 years Mean 7.2 months None 43 EQ-VAS
CPC
Neuropsychological Battery
Global Deterioration Scale
Hospital anxiety and depression
scale
Skane sleep index
MADR- 5
Self-reported Montgomery and
Astrand depression rating scale
Dimopoulou20 61 Ä… 11 years 4 years None 16 NYHA Nottingham Health Profile
Drysdale40 70 (66.2 73.8) years 3 years an MI, but not a cardiac arrest. 10 Rivermead Behavioural Memory
Test
Doors and People Test
Earnest78 3.5 years None 20 Patient interview
Physical Examination
Limited Neuropsychological tests
Eisenberger15 Range 47 71 years Median 24 month None 92 CPC
Questionnaire
Engdahl34 Median 70 years Variable-at disch None 19 CPC
Gamper28 Median 55 years 45 months None 143 Davidson Trauma
Score EQ-5D
CPC
Gener37 None 17 CPC
Gottschalk79 68.5 Ä… 12.9 years 6 months Early defibrillation Vs Non 103 CPC
early defibrillation Overall Performance category
Graf2 Mean 61 Ä… 13 years 5 years Normative HR-QoL data - 81 SF-36
healthy controls and patient General Questionnaire
with acute and chronic disease QALY
Granja58 Mean 47 years 6 months ICU patients - not having 19 EQ-5D
suffered a cardiac arrest.
Matched for age and APACHE II
score
Graves32 Median 67 years 1 14 years None 320 CPC
General examination/interview
and examination of medical
records
Grubb62 Age and sex matched MI 35 Hospital Anxiety and Depression
patients Scale
National Adult Reading Test
Digit Recall Test
Rivermead Behavioural Memory
Test
Guerot84 1 year None 8 CPC
Patient Interview
Guglin94 Not reported 1 year None 59 Diagnosis of anoxic brain damage
Vs no diagnosis of anoxic brain
damag
V.J. Elliott et al. / Resuscitation 82 (2011) 247 256 251
Table 3 (Continued)
Study Age Time of follow up Control group No. in group Assessment tools
Harve6 Mean 72 years 15 years Finnish age matched 10 Neuropsychological battery
QoL questionnaire (undefined)
Hillis80 0 32 months Patients not receiving 221 Sickness Impact Profile
pre-hospital defibrillation Dementia Rating Scale
No non-cardiac arrest control
group
Hofgren89 Mean 59 years 2 years None 22 National Institute of Health Stroke
Scale (NIHSS) MMSE
Barrow Neurological Screen for
Higher Cerebral Function (BNIS)
Functional Independence Measure
Horsted27 35 (51 70 years) 14 (71 90 6 10 months National Norms 33 SF-36
years) MMSE
Hsu75 Mean 60.3 years not stated None 35 MMSE
CPC
Beth Israel UCLA Functional Status
Questionnaire
Quality of Life Questionnaire
Iwami87 1 year Compared outcomes when 419 CPC
cardiac only resuscitation was
initiated post arrest Vs
standard resuscitation
Kamphius72 Mean 56.6 years 1 year Compared patients who 168 Rand 36 (analogue of SF 36)
received an ICD post cardiac Heart Patients Psychological
arrest and those receiving Questionnaire
other medical treatments Centre for Epidemiological Studies
Depression Scale
State Trait Anxiety Inventory
Interview
Kliegel85 NA None NA
Kuliman74 Mean 64.8 years 1 7 years None 132 Euroqol
Ladwig39 Mean 59.7 years Range 22 64 months Age matched patients with 21 CPC
severe angina, but no cardiac Hospital Anxiety and Depression
arrest Scale
Illness related aspects of quality of
life - abridged version of an
inventory covering personal
resilience and social activity
Impact Event Scale
WHO checklist for diagnosis of Post
Traumatic Stress Disorder
Telephone Interview
Zerssen Symptom List for Somatic
Complaints
Self assessment of overall somatic
and mental condition
Sleping disorder assessment
Lederer31 Mean 61.6 Ä… 12.9 5 10 years None 13 Validated life satisfaction
questionnaire
Lettieri21 Mean 60 Ä… 12 years 6 12 months Patients suffering a STEMI - 99 GCS
treated with emergency PCI, CPC
but not experiencing a cardiac
arrest
Longstreth64 3 months Compared placebo Vs 300 CPC
Magnesium Vs Diazepam post Assigned patients: Independent,
cardiac arre dependent, vegative, dead
Lundgren-Nilsson86 Mean 60 years 1 year Swedish reference values for 26 National Institute of Health Stroke
quality of life Scale (NIHSS)
MMSE
Functional Independence Measure
Instrumental Activity Measure
Nottingham Health Profile
Fugl-Meyer Questionnaire
Martin-Castro81 6 months None 8
Maryniak17 Mean 15 years 6 months None 10 CPC
Neuropsychological battery
Miranda63 6 months 69 Sickness Impact Profile
Mohr18 Mean 81.8 years Up to 10 months None 10 CPC
252 V.J. Elliott et al. / Resuscitation 82 (2011) 247 256
Table 3 (Continued)
Study Age Time of follow up Control group No. in group Assessment tools
Motzer71 30 85 years Not stated None 149 15-item Flanagan QoL scale
Burckhardt Percieved Support
Scale
5-item Duke Health Profile + Self
esteem Scale
Duke Health Profile Modified
Mental Health Scale
Duke Health Profile Modified Social
Function Scale
17-item Duke Health Profile
Nichol61 Mean 65 years 6 months Age and sex matched samples 86 MMSE
from National Population CPC
Health Survey of Canadian HUI3
Population
Nunes30 Mean 51 years 10 36 months None 11 Neuropsychological Battery
Blessed Dementia Scale
Self Rating Depression Scale
Non structured patient and family
interview
CPC
O Reilly11 Mean 60.5 years 8.2 months Survivors of out of hospital 35 Hospital Anxiety and Depression
cardiac arrest Survivors of Mi Scale
with no history of cardiac Wechsler Memory Scale Revisited
arrest Riverside Behavioural Memory Test
O Reilly12 Mean 59.7 years 9.6 months Patients who had suffered an 27 HADS
MI uncomplicated by a cardiac Post traumatic Diagnostic Scale
arrest matched for age, sex and Impact Event Scale
time from index event
Paniagua23 86 Ä… 4.8 years None 54 QALY
Polo73 Range 25 89 years 1 3 years None 130 Sickness Impact Profile
Pusswald16 Mean 50 years 25 months None 10 Neuropsychological Battery
CPC
Global Deterioration Scale
Extended ADL
Functional Ambulation Categories
6-point Goodglass and Kaplan Scale
Beck Depression Inventory
F-SOZU (K-22)
Semi-structured Interview (Family
and patient)
Raina69 56 Ä… 18 years 1 month None 21 CPC
Modified Rankin Score
HUI3
Reinhard10 Mean 56 Ä… 15.6 years 16 62 months Gender Patients with cardiac 44 Rand 36 (analogue of SF 36)
disease but no cardiac arrest
RiendeVos66 Mean 64 years 3 60 months Age matched patients who had 90 Sickness Impact Profile
suffered a stroke Elderly MMSE
patients attanding their GP Centre for Epidemiological Studies
surgery Depression
Scale
Rankin Scale for Independence
Roewer82 3 years None 38 CPC
Interview with patient or family
member
Ronco19 None 6 CPC
Saner9 Mean 60.3 Ä… 12.8 years 5 68 months Healthy age, gender and 50 Nottingham Health Profile
socio-economically matche Psychosocial self assessment test
Psychological General Well Being
Index
Everyday Life Questionnaire
Sauve76 Range 30 79 None 61 Semistructured
Interview
Severity of Illness Index
Health Status Questionnaire
Sauve (127)92 6 months None 45 Neuropsychological Battery -
assessing
cognitive and psychological status
Sauve (172)91 Average 59 Ä… 11 years 25 weeks None 17 Neuropsychological Battery
NYHA functional Class
Mental Health Index
V.J. Elliott et al. / Resuscitation 82 (2011) 247 256 253
Table 3 (Continued)
Study Age Time of follow up Control group No. in group Assessment tools
Schindler93 Median 2 years 12 months None 13 CPC (Paediatric version)
(range 3 days 18 years)
Skogvoll36 At discharge None 57 cpc
Stiell14 64.4 years 1 year samplesfrom National 268 HUI3
Population Health Survey of CPC
Canada
Stiell14 Mean 63.9 1 year None 305 HUI3
CPC
Sunnerhage90 Range 19 75 years 25.5 months None 26 Structured Interview and
Questionnaire
MMSE
Personal and Functional ADL
Nottingham Health Profile
Tianinen13 Mean 55 years 3 6 months Patients randomised to receive 18 MMSE
active cooling or standard CPC
treatment Neuropsychological battery
Beck Depression Inventory
Troiano83 Compared those receiving 65 CPC
by-stander CPR with those that Patient or family member
did not. interview assessing ability to live
No non-cardiac arrest control independently, memory loss and
group motor impairment
Van Alem57 Mean 62 Ä… 12 years 7 months Elderly Dutch population 174 Sickness Impact Profile
Age matched patients who had MMSE
suffered a stroke Rankin Independence Scale
CPC
Wachelder88 Mean 57.3 Ä… 12.5 year None 63 Community Intergration Questi
SF-36
NYHA
Fatigue Severity Scale
Cognitive Failures Scale
HADS
Impact of Event Scale
Barthel
Franchay Activities Index
Care Giver Strain Index
Wernberg70 Average 4.3 years None 34 CPC
NYHA Classification
Interview
Wolfrum22 Mean 56 years 6 months Patients previously treated in 16 CPC
an observational study after
cardiac arrest but not treated
with mild therapeutic
hypothermia
Yarnell7 Average 48yrs 0 28 days None 9 Clinical Neurological Examination
EEG
CSF Examination
tion after cardiac arrest does provide patients with a good quality The outcome measures used here to assess QoL were very
of life after discharge from hospital. varied; some authors used validated assessment tools such as
This review also demonstrated a remarkable heterogeneity HUI3, SF 36, EQ-5D.16,27,28 Other groups developed their own
of methodology amongst studies assessing QoL in cardiac arrest instruments including undefined QoL questionnaires, structured
survivors, with nothing approaching a consensus or consistent and un-structured family and patient interviews6,15,16,29 32 and
approach discernable. some used very basic scores like the Cerebral Performance Cat-
However, this may be unavoidable. Quality of life and its assess- egory (CPC).18,19,22,33 38 As well as generic quality of life data,
ment is complex. The modern concept of health related quality of we also evaluated studies that reported specific elements of
life (HRQoL) is a direct descendent of the WHO definition of health what might contribute to a sense of well-being or its converse,
( A state of complete physical, mental and social well-being and such as affective disorder28,39 and cognitive dysfunction,11,13,30,40
not merely the absence of disease or infirmity )24 in that HRQoL again there was a lot of heterogeneity in approach. Much of
is thought to encompass three fundamental domains (1) biological the data we have extracted comes from a body of literature not
functioning, (2) psychological functioning and (3) social function- specifically designed to answer our research question, thus this
ing therefore a large number of variables will impact on it and heterogeneity is not surprising. However, this lack of a stan-
a deficit/impairment that may be significant for one survivor may dardised approach to reporting is a problem, and is in marked
not be significant for another. As Ferrans and Powers state Qual- contrast to the approach recommended for other aspects of resus-
ity of life represents a person s sense of well-being that originates citation reporting.41 We are now in an era of intervention in
from satisfaction or dissatisfaction with the areas of life that are resuscitation research and of financial frugality more generally,
25,26
important to that person not easy to measure. thus such a standardised approach, which might include data
254 V.J. Elliott et al. / Resuscitation 82 (2011) 247 256
designed to inform a health economic evaluation, is urgently compared to population norms the QoL of the survivors was signif-
needed. icantly worse. However, those with cardiovascular disease rated
The International Liaison Committee on Resuscitation recom- their QoL similarly to the survivors of cardiac arrest altering com-
mends documenting the CPC at discharge from hospital, 6 months pletely whether one would rate the study as supportive, neutral
and 1 year post cardiac arrest (for those that survive to discharge)41; or negative with respect to the hypothesis. The most appropriate
it makes no further recommendation regarding detailed QoL control population has not been defined.
assessments in these patients. The Cerebral Performance Category Forty six of the seventy studies concluded that resuscitation
is a very gross functional score, but is very easy and simple to use after cardiac arrest produced a good QoL after discharge from hos-
and obtain and undoubtedly provides some useful information. It pital, seven studies concluded that QoL was poor after resuscitation
is not however designed to detect subtle psychological or social from cardiac arrest. The remaining seventeen studies were assigned
disabilities that may be very important to a patient and their family. as neutral, this was because many of the studies demonstrated
There are several validated tools available that assess generic significant deficits and/or reduction in quality of life through
health related quality of life. The Health Utilities Index 3 has parameters such as social isolation, cognitive impairment, daily
been shown to be reliable, reproducible and valid in a variety functioning, depression and anxiety (see Table 2), but what the
of patient populations.42 44 It is quick to use and can be used authors stopped short of doing was stating whether these issues
to interview family members/caregivers when patients are not meant that the patient s quality of life was unbearably poor. Most of
able to respond, which prevents those patients with the poorest these neutral studies might in fact be said to have mixed findings.
functional/cognitive outcome being excluded from these studies; A further difficulty was that when QoL was assessed the sur-
others have questioned the validity of using a proxy in this type of vivors were generally asked to compare their present life situation
assessment.45 with the quality of life they had prior to the cardiac arrest this
The SF-36 is a health survey that covers 8 domains, ranging leads to negativity in responses given. The alternative to their cur-
from physical functioning to general mental health and social rent situation (i.e. if no resuscitation had been provided) would be
functioning. It is widely used tool throughout healthcare and has the near certainty of being dead very few authors/studies address
also been validated and shown to be reliable and reproducible in this; however, Saner et al.9 reported that 49 of 50 patients judged
relevant populations.46 48 The EQ-5D is also a self reporting ques- their situation post resuscitation as worth living and Harve et al.6
tionnaire that has been validated to measure QoL in health related noted that 9 out of 10 of their cohort were happy with their per-
research,49 51 it has been found to correlate with SF-36 and HUI3 ceived quality of life. These are very simple, effective and important
scores in a variety of populations52,53 and in addition can be used statements with respect to the hypothesis and in addition have the
to calculate quality adjusted life years (QALYs). There is extensive ability to cut through all the noise and get to the very heart of the
experience with the EQ-5D in general critical illness survivors.54 56 matter.
Authors have reported differing definitions for a survivor ; e.g. There appears to be a good case for standardising patient cen-
Bunch et al.8 call those with a CPC greater than or equal to 3 non- tred outcome measures after resuscitation. Well validated tools
survivors. Saner et al.9 excluded those with severe hypoxic brain are available to assess generic health related quality of life, and
injury (but did not quantify how many of these were so damaged) symptoms associated with anxiety, depression, and post-traumatic
and Dimopoulou et al.20 excluded the sickest patients post cardiac stress disorder. Cognitive dysfunction however presents a particu-
surgery. In contrast Van Alem et al.57 provided a proxy question- lar challenge. Screening instruments lack sensitivity and specificity
naire for relatives to fill out when the patients were unable to do so. and more detailed evaluation at both ends of the disability spec-
Therefore results need to be interpreted carefully, based on which trum requires specialist expertise.59,60 Many health economies
survivors may or may not have been excluded; excluding those now require an economic analysis to inform decisions concern-
with CPC 3/4 is obviously likely to bias the results in a positive ing implementation of novel therapeutic manoeuvres; outcome
way. assessment and analysis plans for interventional studies should
A further significant caveat is that the literature and our inclu- now probably be organised with this in mind.
sion criteria would not have fully identified populations of patients Although we did not identify large populations of people with an
who experienced prolonged hospital (or intensive care) stays with unacceptable quality of life, it seems clear that a substantial burden
poor outcomes who were never discharged from hospital. Thus, of morbidity exists in the survivor population. Thus an important
the data concerning the population of people who regain a spon- clinical question is whether or not cardiac arrest survivors should
taneous circulation, but never recover sufficiently to be discharged be routinely evaluated to identify such morbidity and treatment
from primary hospital is sparse; this group should be factored into offered where possible. A further issue would be when any such
any health economic assessment of novel interventions. routine screening should occur. It has been shown that relevant
Importantly, Pusswald et al.16 demonstrated a striking discrep- changes in functional outcome will continue to occur after 1 month
ancy between patient reporting and carer reporting of disabilities post cardiac arrest,33 but it had not been established at what point
and activities of daily living rating the patients estimation tended in time these patients should be assessed or for how long they
to be inaccurate suggesting a potential lack of awareness. This should be followed up.
raises the question of whether data should be sought from fam-
ily members and carers for patients with cognitive impairment. 5. Authors conclusions and recommendations
Using surrogates to report on the quality of life of others is however
controversial. This review provides good evidence that survivors of cardiac
Within the studies that used a control or a comparator group arrest have an acceptable or good quality of life, although this is
(LOE P1 and LOE P3), there was a spectrum of different populations not necessarily the same quality of life that they experienced prior
used. Granja et al.58 used age and APACHE II matched patients ran- to their cardiac arrest.
domly selected from the ICU that had not had a cardiac arrest. Van The review process has demonstrated a requirement for consen-
Alem et al.57 used two control groups the Dutch elderly popula- sus development with regard to quality of life and patient centred
tion and patients who had experienced a stroke. Reinhard et al.10 outcome assessment after cardiac arrest. We would suggest that
also used two control groups Estonian population norms and urgent attention be given to developing consensus in the follow-
patients who suffered from angina or had experienced an MI but not ing areas, which could be considered for inclusion in the Utstein
a cardiac arrest. This had a significant impact on their results; when template:
V.J. Elliott et al. / Resuscitation 82 (2011) 247 256 255
" Generic health related quality of life instruments. 9. Saner H, Rodriguez EB, Kummer-Bangerter A, Schuppel R, von Planta M. Quality
of Life in long-term survivors of out-of-hospital cardiac arrest. Resuscitation
" Instruments to identify affective and post traumatic stress symp-
2002;53:7 13.
toms.
10. Reinhard V, Parna K, Lang K, Pisarev H, Sipria A, Starkopf J. Long-term outcome of
" Strategies for identifying and stratifying cognitive dysfunction. bystander-witnessed out of hospital cardiac arrest in Estonia from 1999 2002.
Resuscitation 2009;80:73 8.
" Strategies for health economic evaluation.
11. O Reilly SM, Grubb NR, O Carroll RE. In-hospital cardiac arrest leads to chronic
" Duration of follow-up and assessment intervals.
memory impairment. Resuscitation 2003;58:73 9.
" Control and comparator group.
12. O Reilly S, Grubb N, O Carroll RE. Long-term emotional consequences of in-
hospital cardiac arrest and myocardial infarction. Br J Clin Psychol 2004;43:
83 96.
Disclaimer
13. Tiainen M, Poutiainen E, Kovala T, Takkunen O, Happola O, Roine RO. Cogni-
tive and neurophysiological outcome of cardiac arrest survivors treated with
therapeutic hypothermia. Stroke 2007;38:2303 8.
This review includes information on resuscitation questions
14. Stiell IG, Nichol G, Wells G, et al. Health related quality of life is better for car-
developed through the C2010 Consensus on Science and Treat-
diac arrest survivors who received cardiopulmonary resuscitation. Circulation
ment Recommendations process, managed by the International 2003;53:241 8.
15. Eisenberger P, List M, Schorkhuber W, Walker R, Storz F, Laggner A. Long-term
Liaison Committee on Resuscitation (http://www.americanheart.
cardiac arrest survivors of the Vienna emergency medical service. Resuscitation
org/ILCOR). The questions were developed by ILCOR Task Forces,
1998;38:137 43.
using strict conflict of interest guidelines. In general, each ques- 16. Pusswald G, Fertl E, Faltl M, Auff E. Neurological rehabilitation of severely dis-
abled cardiac arrest survivors Part II. Life situation of patients and families after
tion was assigned to two experts to complete a detailed structured
treatment. Resuscitation 2000;47:241 8.
review of the literature, and complete a detailed worksheet. Work-
17. Maryniak M, Bielawska A, Walczak F, et al. Long-term cognitive outcome in
sheets are discussed at ILCOR meetings to reach consensus and will
teenage survivors of arrhythmic cardiac arrest. Resuscitation 2008;77:46 50.
18. Mohr M, Bomelburg K, Bahr J. Attempted CPR in nursing homes Life-
be published in 2010 as the Consensus on Science and Treatment
saving at the end of life? Anasthesiol Intensivmed Notfallmed Schmerzther
Recommendations (CoSTR). The conclusions published in the final
2001;36:566 72.
CoSTR consensus document may differ from the conclusions of in
19. Ronco R, King W, Donley DK, Tilden SJ. Outcome and cost at a children s hospital
following resuscitation for out-of-hospital cardiopulmonary arrest. Arch Pediatr
this review because the CoSTR consensus will reflect input from
Adolesc Med 1995;149:210 4.
other worksheet authors and discussants at the conference, and
20. Dimopoulou I, Anthi A, Michalis MD, Tzelepis GE. Functional status and quality
will take into consideration implementation and feasibility issues
of life in long-term survivors of cardiac arrest after cardiac surgery. Crit Care
Med 2001;29:1408 11.
as well as new relevant research.
21. Letteri F, Castiglioni B, Fabbiocchi F, et al. Emergency percutaneous coronary
intervention in patients with ST-elevation myocardial infarction complicated
Conflict of interest statement by out-of-hospital cardiac arrest: early and medium-term outcome. Am Heart J
2009;157:569 75.
22. Wolfrum S, Pierau C, Radke PW, Schunkert H, Kurowski V. Mild therapeutic
Vanessa Elliott and David L. Rodgers have no conflicts of interest
hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-
to declare.
segment elevation myocardial infarction undergoing immediate percutaneous
coronary intervention. Crit Care Med 2008;36:1780 6.
Stephen Brett receives a research grant from Carefusion for a
23. Paniagua D, Lopez-Jimenez F, Londono JC, Mangione CM, Fleischmann K, Lamas
technology evaluation project, around wireless monitoring. I have
GA. Outcome and cost-effectiveness of cardiopulmonary resuscitation after in-
received a speakers honorarium from Pfizer (lecture on pulmonary
hospital cardiac arrest in octogenarians. Cardiology 2002;97:6 11.
24. World Health Organisation. Constitution of World Health Organisation. Geneva:
hypertension), and consultancy fees from Baxter (beta blockers)
WHO; 1948.
and Pfizer (anti-fungals).
25. Ferrans CE. Development of a quality of life index for patients with cancer. Oncol
Nurs Forum 1990;17:15 21.
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ical Research Centre Scheme.
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Appendix A. Supplementary data
ical outcome after cardiac arrest and therapeutic hypothermia. Resuscitation
2009;80:1119 23.
Supplementary data associated with this article can be found, in
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the online version, at doi:10.1016/j.resuscitation.2010.10.030.
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