Sudden cardiac death prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Edzel Lorraine Co, DMD, MD[3] Nehal Eid, M.D.[4]

Overview

  • Sudden cardiac arrest (SCA) occurs due to sudden disturbance in cardiac electrical propagation or failure of the heart to pumping the blood into vital organs.
  • Patients may progress to develop cardiac arrest, sudden collapse, loss of effective circulation, and loss of consciousness.
  • Prompt treatment is needed to prevent death which may occur within minutes to weeks, and prevent serious complications.
  • Prognosis of in-hospital cardiac arrest is generally better than out-of- hospital cardiac arrest and the 1-year survival rate of patients who survived to hospital discharge was approximately 25% in the GWTG-R registry.
  • A retrospective cohort study from the CARES registry reported 101968 out-of-hospital cardiac arrests in the US between 2006 and 2013, approximately 6% of the incidents occurred among individuals between 20 through 39 years; survival rate to hospital discharge ranged from 11%(30-39years) to 16%(20-24years).[1] Approximately 85% to 95% of out-of-hospital cardiac arrest survivors were discharged with good neurological outcome, as defined by a Cerebral Performance Categories scale of 1 or 2.[1] [2]
  • The overall survival rate of young adults experiencing out-of-hospital cardiac arrest was 9% in a US study from 2005 through 2007 involving 665 persons aged 20 through 39 years, and increased to 34.8% for those with bystander-witnessed VT or VF who were more likely to receive prompt initial cardiopulmonary resus citation (CPR) or automated external defibrillator use.[3]
  • In an Australian registry conducted between 2000 and 2009 involving 3912 patients with ages between 16 and 39 years with out-of-hospital cardiac arrest,the survival rate was 8.8%.[2]

Natural History of Sudden Cardiac Death

Natural History

Incidence and Predictors of Entering Into a Vegetative State versus Making a Full Neurologic Recovery

Initial Neurologic Findings

24 Hour Neurologic Findings
  • Most patients who survive become alert by 24-48 hours.
  • In one series, of those patients who were in a coma through day 2, only 2 of the 27 (7%) survived.[9] In a second series, no patient who remained in a coma by the third day survived.[10]
  • Absent motor responses, the presence of posturing (extensor /flexor motor responses) and the lack of spontaneous eye movements that were either orienting or roving conjugate was associated with a lack of independent recovery in 92 of 93 patients. [5].
  • In contrast, of the 30 patients who showed improvement in their eye-opening responses, obeyed commands or had withdraw to pain, 19 (63%) regained independent function.[5].
  • Seizures that occur after the initial 24 hours are associated with poorer outcomes. In one study only 3 of 15 patients who seized recovered consciousness, and only one patient lived a year[11]. The presence of status epilepticus at any time following cardiac arrest is associated with a very poor prognosis as all nine patients with status epilepticus died in one series.[12]
  • The absence of spontaneous eye-opening and intermittent visual fixation by the end of the first day is associated with a poor prognosis.
  • Although eye-opening is necessary for a good outcome, it alone is not sufficient, as many patients who have spontaneous eye-opening still go on to have a poor prognosis. * Roving eye movements in the absence of visual fixation is often indicative of extensive bilateral cerebral hemispheral damage and portends a poor prognosis.
  • If the gaze is sustained in an upward direction, this carries a poor prognosis as well.[13][14]


Prognosis of Sudden Cardiac Arrest Survivors

  • Prognosis of in-hospital cardiac arrest is generally better than out-of-hospital cardiac arrest and the 1-year survival rate of patients who survived to hospital discharge was approximately 25% in the GWTG-R registry.[15].Survival after out of hospital cardiac arrest and in hospital cardiac arrest has continued to improve over time according to the guideline.
  • 60% to 78% of young adults hospitalized after resuscitation from sudden cardiac arrest do not survive to hospital discharge.[16],[3],[17] This in-hospital mortality rate is similar to that of older adults who were resuscitated to hospitalization (≈65%).[18]
  • The 10-year survival rate of sudden cardiac arrest survivors aged 40 years or younger was 90% in an Australian registry.[19]The rate of recurrent arrest (both out of and in the hospital) or death in survivors aged 18 to 39 years in a Swedish registry was approximately 15% a year after the out-of-hospital cardiac arrest.[20]

One-year overall mortality of subcutaneous ICD recipients aged 15 to 34 years was 4.3% in one cohort,90 whereas the VT or VF recurrence rate estimated by subcutaneous ICD recording in secondary prevention recipients (age not reported) in a separate study was 9.9% at 1year and15.8% at 3years.[21]


  • Factors associated with better prognosis after in-hospital cardiac arrest include:

References

  1. ↑ 1.0 1.1 Andersen LW, Bivens MJ,Giberson T,et al. The relationship between age and outcome in out-of-hospital cardiac arrest patients. Resuscitation. 2015;94:49-54. doi:10.1016/j.resuscitation.2015.05. 015
  2. ↑ 2.0 2.1 Gustafsson L, Rawshani A,Råmunddal T, et al. Characteristics, survival and neurological outcome in out-of-hospital cardiac arrest in young adults in Sweden:a nationwide study. Resusc Plus. 2023;16:100503.doi:10.1016/j.resplu.2023.100503
  3. ↑ 3.0 3.1 Rea TD, Cook AJ, Stiell IG, et al; Resuscitation Outcomes Consortium Investigators. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. AnnEmergMed.2010; 55(3):249-257. doi:10.1016/j.annemergmed.2009. 09.018
  4. ↑ Mellion ML (2005). "Neurologic consequences of cardiac arrest and preventive strategies". Medicine and Health, Rhode Island. 88 (11): 382–5. PMID 16363390. Unknown parameter |month= ignored (help)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Thomassen A, Wernberg M (1979). "Prevalence and prognostic significance of coma after cardiac arrest outside intensive care and coronary units". Acta Anaesthesiologica Scandinavica. 23 (2): 143–8. PMID 442945. Unknown parameter |month= ignored (help)
  6. ↑ Snyder BD, Loewenson RB, Gumnit RJ, et al: Neurologic prognosis after cardiopulmonary arrest: II. Level of consciousness. Neurology 1980;30:52-58.
  7. ↑ Snyder BD, Gumnit RJ, Leppik IE, et al: Neurologic prognosis after cardiopulmonary arrest: IV. Brainstem refl exes. Neurology 1981;31: 1092-1097
  8. ↑ Roine RO: Neurological Outcome of Out-of-Hospital Cardiac Arrest [dissertation]. University of Helsinki, 1993.
  9. ↑ Snyder BD, Loewenson RB, Gumnit RJ, et al: Neurologic prognosis after cardiopulmonary arrest: II. Level of consciousness. Neurology 1980;30:52-58.
  10. ↑ Bell JA, Hodgson HJF: Coma after cardiac arrest. Brain 1974;97:361-372.
  11. ↑ Roine RO: Neurological Outcome of Out-of-Hospital Cardiac Arrest [dissertation]. University of Helsinki, 1993.
  12. ↑ Roine RO: Neurological Outcome of Out-of-Hospital Cardiac Arrest [dissertation]. University of Helsinki, 1993.
  13. ↑ Keane JR: Sustained upgaze in a coma. Annals of Neurology 1981;9:409-412.
  14. ↑ Ballew KA (1997). "Cardiopulmonary resuscitation". BMJ. 314 (7092): 1462–5. PMC 2126720. PMID 9167565. Unknown parameter |month= ignored (help)
  15. ↑ Virani, Salim S.; Alonso, Alvaro; Benjamin, Emelia J.; Bittencourt, Marcio S.; Callaway, Clifton W.; Carson, April P.; Chamberlain, Alanna M.; Chang, Alexander R.; Cheng, Susan; Delling, Francesca N.; Djousse, Luc; Elkind, Mitchell S.V.; Ferguson, Jane F.; Fornage, Myriam; Khan, Sadiya S.; Kissela, Brett M.; Knutson, Kristen L.; Kwan, Tak W.; Lackland, Daniel T.; Lewis, Tené T.; Lichtman, Judith H.; Longenecker, Chris T.; Loop, Matthew Shane; Lutsey, Pamela L.; Martin, Seth S.; Matsushita, Kunihiro; Moran, Andrew E.; Mussolino, Michael E.; Perak, Amanda Marma; Rosamond, Wayne D.; Roth, Gregory A.; Sampson, Uchechukwu K.A.; Satou, Gary M.; Schroeder, Emily B.; Shah, Svati H.; Shay, Christina M.; Spartano, Nicole L.; Stokes, Andrew; Tirschwell, David L.; VanWagner, Lisa B.; Tsao, Connie W. (2020). "Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association". Circulation. 141 (9). doi:10.1161/CIR.0000000000000757. ISSN 0009-7322.
  16. ↑ Deasy C, Bray JE, Smith K, Harriss LR, Bernard SA, Cameron P. Out-of-hospital cardiac arrests in young adults in Melbourne,Australia. Resuscitation. 2011;82(7):830-834. doi:10.1016/j.resuscitation.2011. 03.008
  17. ↑ Fovaeus H, Holmen J, Mandalenakis Z, Herlitz J, Rawshani A, Castellheim AG.Out-of-hospital cardiac arrest: survival in children and young adults over 30 years,a nationwide registry-based cohort study. Resuscitation. 2024;195:110103. doi:10.1016/ j.resuscitation.2023.110103
  18. ↑ Ricceri S, Salazar JW, Vu AA, Vittinghoff E, Moffatt E, Tseng ZH. Factors predisposing to survival after resuscitation for sudden cardiac arrest. J AmColl Cardiol. 2021;77(19):2353-2362. doi:10.1016/j.jacc.2021.03.299
  19. ↑ Andrew E, Nehme Z, Wolfe R, Bernard S, Smith K. Long-term survival following out-of-hospital cardiac arrest. Heart. 2017;103(14):1104-1110. doi: 10.1136/heartjnl-2016-310485
  20. ↑ Hellsén G, Rawshani A, Skoglund K, et al. Predicting recurrent cardiac arrest in individuals surviving out-of-hospital cardiac arrest. Resuscitation. 2023;184:109678. doi:10.1016/j.resuscitation.2022. 109678
  21. ↑ Boersma LV, Barr CS, Burke MC ,et al; EFFORTLESS and IDE Study Investigators. Performance of the subcutaneous implantable cardioverter-defibrillator in patients with a primary prevention indication with and without a reduced ejection fraction versus patients with a secondary prevention indication. Heart Rhythm. 2017;14(3): 367-375. doi:10.1016/j.hrthm.2016.11.025
  22. ↑ Chan, Paul S. (2012). "A Validated Prediction Tool for Initial Survivors of In-Hospital Cardiac Arrest". Archives of Internal Medicine. 172 (12): 947. doi:10.1001/archinternmed.2012.2050. ISSN 0003-9926.
  23. ↑ Ebell MH, Afonso AM (October 2011). "Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis". Fam Pract. 28 (5): 505–15. doi:10.1093/fampra/cmr023. PMID 21596693.
  24. ↑ Topjian AA, Localio AR, Berg RA, Alessandrini EA, Meaney PA, Pepe PE, Larkin GL, Peberdy MA, Becker LB, Nadkarni VM (May 2010). "Women of child-bearing age have better inhospital cardiac arrest survival outcomes than do equal-aged men". Crit Care Med. 38 (5): 1254–60. doi:10.1097/CCM.0b013e3181d8ca43. PMC 3934212. PMID 20228684.
  25. ↑ Eisenberg MS, Mengert TJ (2001). "Cardiac resuscitation". N. Engl. J. Med. 344 (17): 1304–13. PMID 11320390. Unknown parameter |month= ignored (help)
  26. ↑ Bunch TJ, White RD, Gersh BJ; et al. (2003). "Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation". N. Engl. J. Med. 348 (26): 2626–33. doi:10.1056/NEJMoa023053. PMID 12826637. Unknown parameter |month= ignored (help)

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Patients with anoxic injury due to cardiac arrest are at risk of death from a variety of causes including recurrent sudden cardiac death, congestive heart failure, pneumonia, sepsis from a variety of sources and pulmonary embolism.

Prognosis of Sudden Cardiac Death

Predictors of Survival

Improved Prognosis with In-Hospital versus Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) has a worse survival rate (2-8% survival at discharge) than in-hospital cardiac arrest (15% survival at discharge).

Improved Prognosis with VT/VF versus PEA or Asystole

A major determining factor in survival is the initially documented electrocardiographic rhythm. Patients with ventricular fibrillation (VF) or ventricular tachycardia (VT) (aka VT/VF) have a 10-15 fold greater chance of survival than patients with pulseless electrical activity (PEA) or asystole. VT and VF are responsive to defibrillation, whereas asystole and PEA are not.

Rapid Defibrillation is Associated with Improved Survival

Incidence and Predictors of Entering Into a Vegetative State versus Making a Full Neurologic Recovery

Cardiac arrest is the third leading cause of coma. Approximately 80% of patients who suffered a cardiac arrest who survived to be admitted to the hospital will be in coma for varying lengths of time. Of these patients, approximately 40% will enter into a persistent vegetative state and 80% die within 1 year. In contrast, those rare patients who survive until discharge without significant neurological impairment can expect a fair to good quality of life.

The duration of hypoxia/ischemia determines the extent of neuronal injury i.e. in patients who suffer hypoxia for less than 5 minutes, are less likely to have permanent neurologic deficits, while with prolonged, global hypoxia, patients may develop myoclonus or a persistent vegetative state.[1]

The duration of coma is an important predictor of the recovery of neurologic function. In a 1979 study of 181 cardiac arrest patients who survived to hospital admission, 84% were comatose for more than 1 hour and 56% were comatose for more than 24 hours[2]. There was minimal neurologic deficit if coma lasted less than 24 hours. However, among the 85 patients who were comatose for more than 24 hours, only 7 of them were discharged alive. The severity of neurological impairment increased with increased duration of coma. Of the patients who were in coma for more than 7 days, none regained consciousness. It should be noted that 80 patients died in a coma.

A JAMA article in 1985 attempted to identify the multivariate predictors neurologic prognosis in 210 patients with coma due to cerebral hypoxia. A total of 13% of patients regained neurologic function and independent function at some time during the first year.

24 Hour Neurologic Findings

  • Most patients who survive become alert by 24-48 hours. In one series, of those patients who were in a coma through day 2, only 2 of the 27 (7%) survived.[3] In a second series, no patient who remained in a coma by the third day survived.[4]
  • Absent motor responses, the presence of posturing (extensor /flexor motor responses) and the lack of spontaneous eye movements that were either orienting or roving conjugate was associated with a lack of independent recovery in 92 of 93 patients. [2].
  • In contrast, of the 30 patients who showed improvement in their eye-opening responses, obeyed commands or had withdraw to pain, 19 (63%) regained independent function.[2].
  • Seizures that occur after the initial 24 hours are associated with a poorer outcomes. In one study only 3 of 15 patients who seized recovered consciousness, and only one patient lived a year[5]. The presence of status epilepticus at any time following cardiac arrest is associated with a very poor prognosis as all nine patients with status epilepticus died in one series.[6]
  • The absence of spontaneous eye opening and intermittent visual fixation by the end of the first day is associated with a poor prognosis. Although eye opening is necessary for a good outcomes, it alone is not sufficient, as many patients who have spontaneous eye opening still go on to have a poor prognosis. Roving eye movements in the absence of visual fixation is often indicative of extensive bilateral cerebral hemispheral damage and portends a poor prognosis. If the gaze is sustained in an upward direction, this carries a poor prognosis as well.[7]

In a 1990s study from the UK, resuscitation for cardiac arrest was attempted in 10,081 patients. Of these only 1476 (14.6%) survived to be admitted to the hospital [8][9]. Of these small number of patients who survived to admission, 59.3% died during that admission, half of these within the first 24 hours. 46.1% survived to hospital discharge (this is 6.75% of those who had been resuscitated by ambulance staff). Of those who were successfully discharged from hospital, 70% were still alive 4 years after their discharge.

In a review of 68 studies through 1997, the incidence of survival to discharge was higher at 14% with a wide range of 0-28%.[10]

References

  1. ↑ Mellion ML (2005). "Neurologic consequences of cardiac arrest and preventive strategies". Medicine and Health, Rhode Island. 88 (11): 382–5. PMID 16363390. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 2.2 Thomassen A, Wernberg M (1979). "Prevalence and prognostic significance of coma after cardiac arrest outside intensive care and coronary units". Acta Anaesthesiologica Scandinavica. 23 (2): 143–8. PMID 442945. Unknown parameter |month= ignored (help)
  3. ↑ Snyder BD, Loewenson RB, Gumnit RJ, et al: Neurologic prognosis after cardiopulmonary arrest: II. Level of consciousness. Neurology 1980;30:52-58.
  4. ↑ Bell JA, Hodgson HJF: Coma after cardiac arrest. Brain 1974;97:361-372.
  5. ↑ Roine RO: Neurological Outcome of Out-of-Hospital Cardiac Arrest [dissertation]. University of Helsinki, 1993.
  6. ↑ Roine RO: Neurological Outcome of Out-of-Hospital Cardiac Arrest [dissertation]. University of Helsinki, 1993.
  7. ↑ Keane JR: Sustained upgaze in coma. Annals of Neurolology 1981;9:409-412.
  8. ↑ Lyon RM, Cobbe SM, Bradley JM, Grubb NR (2004). "Surviving out of hospital cardiac arrest at home: a postcode lottery?". Emerg Med J. 21 (5): 619–24. doi:10.1136/emj.2003.010363. PMC 1726412. PMID 15333549. Unknown parameter |month= ignored (help)
  9. ↑ Cobbe SM, Dalziel K, Ford I, Marsden AK (1996). "Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest". BMJ. 312 (7047): 1633–7. PMC 2351362. PMID 8664715. Unknown parameter |month= ignored (help)
  10. ↑ Ballew KA (1997). "Cardiopulmonary resuscitation". BMJ. 314 (7092): 1462–5. PMC 2126720. PMID 9167565. Unknown parameter |month= ignored (help)

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