Expanding the Chain:The 7th Link-Rehabilitation &RecoveryVince Mosesso, MDProfessor of Emergency MedicineUniversity of Pittsburgh School of Medicine
Disclosures Prior grants from Medtronic Inc and Medtronic Foundation Prior research support from Medtronic, Zoll, Philips, Heartsine, Cardiac Science, Welch- Allyn Honorarium from Biotronik Research support from Zoll LifeCor Corporation Medical director and co-founder, Sudden Cardiac Arrest Association
Post cardiac arrest syndromeNow recognized as specific condition with specific interventions
Post cardiac arrestsyndrome Post cardiac arrest brain injury Post cardiac arrest myocardial dysfunction Systemic ischemia & reperfusion response Underlying condition that caused arrest
CNS Loss of normal blood flow to brain Overall blood flow/pressure control Regional microvascular perfusion Neuronal cell death (necrosis/homicide) and triggering of self-death pathways (apoptosis/suicide) Clinical syndrome ranges from mild memory deficits to persistent vegetative state
After acute phase:Recovery & Rehabilitation Less well understood Most research has focused on severe neurological disabilities Lack of providers to help survivors and love ones cope with emotional, psychological and more subtle cognitive changes
Symptoms and problemsnoted by survivors Goes beyond typical organic dysfunction Appears to be a unique spectrum of cognitive and emotional experiences Many express need for support
Neuropsychological sequelaeafter cardiac arrest 155 survivors underwent neuro-psych evaluations at 3 and 12 months Moderate to severe cognitive dysfunction: 60% at three months 48% at one year Depression in 45% at one year Roine RO et al. JAMA. 1993.
Psychosocial distressafter ICD implantation 57 subjects surveyed every 6 months for 2 years Depression in 35% Anxiety in 45% Some decrease over time Thomas SA et al. Heart & Lung, 2009
SCAA: survey of survivors and theirloved onesBenjamin S. Abella, MD, MPhil Clinical Research Director CRS Center for Resuscitation Science Department of Emergency Medicine Center for Resuscitation Science University of PennsylvaniaSCAA Annual Meeting - October, 2008
Number responding 20 40 60 80 0 Touch Taste Smell 53% Sight Hearing MemoryCoordination None After SCA, what function has changed? Other
After SCA, what activity did you fear? 60 37% “holding loved ones” “swimming” “sleeping”Number responding 40 23% 30% 15% 20 5% 0 Driving Air travel Exercise Being alone Other
Emotional changes Lability (marked fluctuations) Spontaneous or easily-triggered crying Increased sensitivity to others’ losses Greater love of family and friends Fear—of ICD firing, or of not having one and needing it. Guilt—why did I survive, when so many others die?
Cognitive Various types and duration of memory loss Dementia (post-anoxic) Variable degrees of loss of executive function Continuous barrage of thoughts Quicker, smarter brain function
Sensory / Perception “Size up” people more quickly/easily Heightened sense of smell Altered pain tolerance / perception
Behavioral Sleep disturbances More outspoken when believe right More risk-taking “Been to the brink, nothing can hurt me more.”
Psychiatric/psychological Depression and/or apathy Perception of infallibility Perception of vulnerability Belief in destiny—things are happening for a purpose Sense of urgency—must do as much as possible right now
Family & Loved ones Also affected in many ways and to various degrees Both similar and different challenges One study: 60% with psychosomatic complaints 50% noted lack of social support Pusswald G et al. Resuscitation, 2000.
Dual causation Organic brain injury Psychological stress Treatment must address both of these causes and the various components
“Post cardiac arreststress disorder (PCSD)” -? Need to distinguish from PCAS Labeling facilitates: increasing awareness advocacy for more research and clinical therapy