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. 2018 Mar;20(1):73–77. doi: 10.31887/DCNS.2018.20.1/dnaber

Psychiatric sequelae of cardiac arrest

Secuelas psiquiátricas del paro cardíaco

Les séquelles psychiatriques d'un arrêt cardiaque

Dieter Naber 1,*, Monika Bullinger 2
PMCID: PMC6016050  PMID: 29946214

Abstract

This manuscript summarizes the literature on mental health outcomes after cardiac arrest. Survivors of cardiac arrest show high rates of mental illness with more than 40% suffering from anxiety, 30% from depression, and 25% from posttraumatic stress disorder (PTSD). Mental health outcomes may differ depending on the setting in which the cardiac arrest occurred. A major problem is reduced neuropsychological functioning. Between 30% and 50% of survivors of cardiac arrest suffer from cognitive deficits. Deficits of attention, declarative memory, executive function, visual-spatial abilities, and verbal fluency have been observed. As a result of numerous psychopathological symptoms (depression in 14% to 45%, anxiety in 13% to 61%, and PTSD in 19% to 27%) and reduced cognitive functioning (about 20% to 60%), relevantly reduced quality of life is observed in about 20% of cardiac arrest survivors.

Keywords: cardiac arrest, cognitive functioning, psychiatric sequalae, PTSD

Introduction

Most studies addressing outcomes after cardiac arrest (CA) focus on the event occurring outside of the hospital setting, the so-called out-of-hospital cardiac arrest (OHCA), often associated with poor prognosis. Global prevalence of OHCA is estimated at 50 to 55 events per 100 000 person-years.1 Survival rates are low, in the range between 2% and 23 %,2 dependent on a variety of regional, social, and medical factors. The interest in the long-term functional outcomes of patients surviving OHCA initially focused mostly on neurological symptoms, but in the last decade, psychiatric symptoms or mental health outcomes and, particularly, quality of life (QoL) have become areas of scientific interest. Several methodological problems make it difficult to draw clear conclusions: an unclear differentiation between transient ischemic attack (TIA) and cardiac arrest at times, as well as the use of rather heterogeneous instruments to assess psychopathology, cognitive functioning, and QoL.

Psychiatric symptoms

Mental health is an area of significant concern for survivors of OHCA.3 In a recent review, high rates of psychological distress were reported: incidence of depression ranged from 14% to 45%, anxiety between 13% and 61%, and PTSD from 19% to 27%. Variability is related to methodological variations in measures, time since arrest, and research setting.

In a retrospective Dutch study with an average duration of 3 years after cardiac arrest, 74% of the patients reported a low participation level in society; over 50% , severe fatigue; 38%, feelings of anxiety and/or depression; and 24%, decreased QoL,4 There was a better outcome in an Australian study in young patients (18 to 39 years), 5 years after cardiac arrest.5 Of these, 84% were living at home independently, 68% had returned to work, and only 11% reported marked or severe disability. The majority of patients had no problems with mobility (75%), personal care (70%), usual activities (66%), or pain/discomfort (71%). However, 71% reported moderate (48%) or severe (30%) anxiety.5

Not only patients, but also caregivers may suffer from psychiatric symptoms. Wachelder4 reported clinically relevant PTSD symptoms in 50% of the carers of OHCA survivors, compared with 21% of the survivors, reflecting the emotional burden of such an event on patients and their families. Similarly, in a recent investigation in relatives of OHCA patients, PTSD was detected in 40%, with risk factors including delayed prognostic information, perceived insufficiency of self-management strategies, and conflict with intensive care unit (ICU) staff.6

Prevalence of PTSD in survivors of stroke and TIA was investigated in nine studies with 1138 patients; PTSD varied significantly across studies by timing of PTSD assessment. The rate was 23% within 1 year of the stroke or TIA and 11% after 1 year.7 Similar data were obtained from a German study8 reporting on 108 patients with TIA. PTSD was found in 30% of these patients. Risk factors were maladaptive coping strategies and subjectively rated high stroke risk, as well as younger age.

Prevalence of PTSD and the relevance of specific factors related to the development of PTSD, including sedation and analgesia during or after cardiac arrest, were investigated in 143 patients who were discharged with favorable neurological outcomes.9 Thirty-nine patients (27%) fulfilled criteria for PTSD, significantly associated with a lower QoL. The only independent risk factor for the development of PTSD was younger age; neither clinical factors nor sedation and/or analgesia were associated with the development of PTSD. In a systematic review on cardiac disease-induced PTSD (CD-PTSD), Vilchinsky et al10 found that the prevalence of CD-PTSD ranged between 0% and 38% and was highly dependent on the assessment tool used. The most consistent risk factors were of a psychological nature (eg, premorbid distress).

In an early psychiatric trial on PTSD patients after OHCA, the 45 survivors had levels of psychological adjustment similar to those of 35 cardiac patients without cardiac arrest. However, the diagnosis of PTSD (n=8) sharply separated favorable and nonfavorable outcomes.11 Long-acting sedation at illness onset significantly predicted a favorable outcome.

Cognitive functioning

The range of lasting cognitive impairment differs widely between reports, with between 6% and 100% of patients surviving OHCA,12,13 but most relevant studies reduce the range to 34% to 50%.12,14 Severity of memory impairment correlated significantly with the duration of cardiac arrest.14 Most commonly reduced neuropsychological domains include memory impairment, attention impairment, executive function, impairment of visual-spatial abilities, and verbal fluency.12,15 There is no consensus on whether cognitive deficits recover over time. Better prognosis in OHCA patients was observed by Beesems et al,16 who reported that the great majority of the 220 survivors had normal cognitive functioning 6 to 12 months after OHCA. Lundgren-Nilsson17 found not much improvement of neuropsychological deficits, but great improvement in QoL during the first year. In a recent Polish study, 100% (N=29) of OHCA survivors were cognitively impaired 3 days after arrest; 77% (N=21), at 3 months; 57% (N=17), at 6 months; and 57% (N=14), at 1 year after OCFIA.15

Quality of life

Systematic reviews of QoL after OCHA12,18 indicate that the majority of studies concluded that QoL after cardiac arrest was good. However, the authors reported remarkable methodological problems regarding the definition of QoL and the instruments used. Most studies indicate no relevant differences between survivors of OHCA and population norms.16,19-22 However, when individual scores rather than group averages were compared, 17% and 20% of Dutch OCHA survivors were impaired on physical and mental health components respectively.4 A Swedish study17 described only moderate positive changes in cognitive functioning, but great improvement in QoL during the first year after cardiac arrest.

Significant differences between patients and controls were observed in physical mobility, energy levels, emotional reactions, and sleep patterns, but none in anxiety, depression, vitality, general well-being, or selfcontrol.23 Bunch et al20 reported a significant correlation of patient self-rated memory impairment with the 36-Item Short Form Health Survey (SF-36) subscales for general health, mental health, physical functioning, and vitality. Also, Moulaert12 found self-reported cognitive deficits significantly contributed to both physical and mental components of QoL. In a study with a 17-year follow-up after cardiac arrest,24 reduced cognitive functioning was observed in 7 of 8 patients. However, despite low scores in cognitive testing and low self-reported QoL, participants were contented with their life situation. No depression, PTSD, or anxiety disorder was found.

The findings of a high degree of fatigue experienced by survivors of OCHA are consistent. Clinically significant levels of fatigue were found in up to 56% of patients, expert-rated4,13 or self-rated.5,17,23

Near-death experience

Near-death experience in cardiac arrest is an area of increasing scientific interest, but also of major disagreement. For many years, “opinion articles” dominated, but since 2000, the number of longitudinal and cross-sectional studies has increased,25 discussing the implications of near-death experiences for the mind-brain relationship. Neardeath experiences were reported by 10% of OCHA patients and by 1% of other cardiac patients.26 Patients with near-death experience were younger than other patients, reported previous paranormal experiences, and had greater “approach-oriented” death acceptance, Groups did not differ in sociodemographic variables, social support, QoL, and other social variables. In a Dutch study,27 344 cardiac arrest survivors were interviewed, and 14 patients, or 12%, reported near-death experiences. Hie first investigation to report cognitive processes during cardiac arrest was a small 1-year study showing that 6% of 63 OCHA patients reported lucid, well-structured thought processes, consistent with typical near-death experiences.28

Conclusion

The pathophysiology of psychiatric symptoms after OHCA has not been well investigated. Whereas reduced cognitive capacity appears to be associated with cerebral dysfunction, psychopathological symptoms might be more closely related to psychological distress. This is suggested by the study by Wachelder et al,4 in which the incidence of PTSD was higher in caregivers of OCHA survivors than in the survivors.

The limited knowledge about pathophysiology is paralleled by the sparse literature on treatment or prevention of psychiatric complications after OHCA. Some authors suggest early screening; however, no specific studies have been performed, and no data are available regarding the success of psychotherapy or pharmacotherapy, such as antidepressant medication.

Acknowledgments

The authors have no conflict of interest to declare.

Contributor Information

Dieter Naber, Department of Psychiatry, University of Hamburg, Germany.

Monika Bullinger, Institute of Medical Psychology, University of Hamburg, Germany.

REFERENCES

  • 1.Berdowski J., Berg RA., Tijssen JG., Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation. 2010;81(11):1479–1487. doi: 10.1016/j.resuscitation.2010.08.006. [DOI] [PubMed] [Google Scholar]
  • 2.Reynolds JC., Frisch A., Rittenberger JC., Callaway CW. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? Circulation. 2013;128(23):2488–2494. doi: 10.1161/CIRCULATIONAHA.113.002408. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Wilder Schaaf KP., Artman LK., Peberdy MA., et al. Anxiety, depression, and PTSD following cardiac arrest: a systematic review of the literature. Resuscitation. 2013;84(7):873–877. doi: 10.1016/j.resuscitation.2012.11.021. [DOI] [PubMed] [Google Scholar]
  • 4.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(5):517–522. doi: 10.1016/j.resuscitation.2009.01.020. [DOI] [PubMed] [Google Scholar]
  • 5.Deasy C., Bray J., Smith K., Harriss L., Bernard S., Cameron P. Functional outcomes and quality of life of young adults who survive out-of-hospital cardiac arrest. Emerg Med J. 2013;30(7):532–537. doi: 10.1136/emermed-2012-201267. [DOI] [PubMed] [Google Scholar]
  • 6.Zimmerli M., Tisljar K., Balestra GM., Langewitz W., Marsch S., Hunziker S. Prevalence and risk factors for post-traumatic stress disorder in relatives of out-of-hospital cardiac arrest patients. Resuscitation. 2014;85(6):801–808. doi: 10.1016/j.resuscitation.2014.02.022. [DOI] [PubMed] [Google Scholar]
  • 7.Edmondson D., Richardson S., Fausett JK., Falzon L., Howard VJ., Kronish IM. Prevalence of PTSD in survivors of stroke and transient ischemic attack: a meta-analytic review. PLoS One. 2013;8(6):e66435. doi: 10.1371/journal.pone.0066435. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Kiphuth IC., Utz KS., Noble AJ., Kohrmann M., Schenk T. Increased prevalence of posttraumatic stress disorder in patients after transient ischemic attack. Stroke. 2014;45(11):3360–3366. doi: 10.1161/STROKEAHA.113.004459. [DOI] [PubMed] [Google Scholar]
  • 9.Gamper G., Willeit M., Sterz F., et al. 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(2):378–383. doi: 10.1097/01.CCM.0000108880.97967.C0. [DOI] [PubMed] [Google Scholar]
  • 10.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.2017.04.009. [DOI] [PubMed] [Google Scholar]
  • 11.Ladwig KH., Schoefinius A., Dammann G., Danner R., Gurtler R., Herrmann R. Long-acting psychotraumatic properties of a cardiac arrest experience. Am J Psychiatry. 1999;156(6):912–919. doi: 10.1176/ajp.156.6.912. [DOI] [PubMed] [Google Scholar]
  • 12.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(3):297–305. doi: 10.1016/j.resuscitation.2008.10.034. [DOI] [PubMed] [Google Scholar]
  • 13.Green CR., Botha JA., Tiruvoipati R. Cognitive function, quality of life and mental health in survivors of out-of-hospital cardiac arrest: a review. Anaesth Intensive Care. 2015;43(5):568–576. doi: 10.1177/0310057X1504300504. [DOI] [PubMed] [Google Scholar]
  • 14.Grubb NR., O'Carroll R., Cobbe SM., Sirel J., Fox KA. Chronic memory impairment after cardiac arrest outside hospital. BMJ. 1996;313(7050):143–146. doi: 10.1136/bmj.313.7050.143. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Polanowska KE., Sarzynska-Dlugosz IM., Paprot AE., et al. Neuropsychological and neurological sequelae of out-of-hospital cardiac arrest and the estimated need for neurorehabilitation: a prospective pilot study. Kardiol Pol. 2014;72(9):814–822. doi: 10.5603/KP.a2014.0087. [DOI] [PubMed] [Google Scholar]
  • 16.Beesems SG., Wittebrood KM., de Haan RJ., Koster RW. Cognitive function and quality of life after successful resuscitation from cardiac arrest. Resuscitation. 2014;85(9):1269–1274. doi: 10.1016/j.resuscitation.2014.05.027. [DOI] [PubMed] [Google Scholar]
  • 17.Lundgren-Nilsson A., Rosen H., Hofgren C., Sunnerhagen KS. The first year after successful cardiac resuscitation: function, activity, participation and quality of life. Resuscitation. 2005;66(3):285–289. doi: 10.1016/j.resuscitation.2005.04.001. [DOI] [PubMed] [Google Scholar]
  • 18.Elliott VJ., Rodgers DL., Brett SJ. Systematic review of quality of life and other patient-centred outcomes after cardiac arrest survival. Resuscitation. 2011;82(3):247–256. doi: 10.1016/j.resuscitation.2010.10.030. [DOI] [PubMed] [Google Scholar]
  • 19.Bro-Jeppesen J., Kjaergaard J., Horsted Tl., et al. The impact of therapeutic hypothermia on neurological function and quality of life after cardiac arrest. Resuscitation. 2009;80(2):171–176. doi: 10.1016/j.resuscitation.2008.09.009. [DOI] [PubMed] [Google Scholar]
  • 20.Bunch TJ., White RD., Smith GE., et al. Long-term subjective memory function in ventricular fibrillation out-of-hospital cardiac arrest survivors resuscitated by early defibrillation. Resuscitation. 2004;60(2):189–195. doi: 10.1016/j.resuscitation.2003.09.010. [DOI] [PubMed] [Google Scholar]
  • 21.Geri G., Dumas F., Bonnetain F., 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.2017.01.028. [DOI] [PubMed] [Google Scholar]
  • 22.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(2):174–181. doi: 10.1161/CIRCULATIONAHA.114.011200. [DOI] [PubMed] [Google Scholar]
  • 23.Saner H., Borner Rodriguez E., Kummer-Bangerter A., Schuppel R., von Planta M. Quality of life in long-term survivors of out-of-hospital cardiac arrest. Resuscitation. 2002;53(1):7–13. doi: 10.1016/s0300-9572(02)00002-3. [DOI] [PubMed] [Google Scholar]
  • 24.Andersson AE., Rosen H., Sunnerhagen KS. Life after cardiac arrest: a very long term follow up. Resuscitation. 2015;91:99–103. doi: 10.1016/j.resuscitation.2015.01.009. [DOI] [PubMed] [Google Scholar]
  • 25.Sleutjes A., Moreira-Almeida A., Greyson B. Almost 40 years investigating near-death experiences: an overview of mainstream scientific journals. J Nerv Mental Dis. 2014;202(11):833–836. doi: 10.1097/NMD.0000000000000205. [DOI] [PubMed] [Google Scholar]
  • 26.Greyson B. Incidence and correlates of near-death experiences in a cardiac care unit. Gen Hosp Psychiatry. 2003;25(4):269–276. doi: 10.1016/s0163-8343(03)00042-2. [DOI] [PubMed] [Google Scholar]
  • 27.van Lommel P., van Wees R., Meyers V., Elfferich I. Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet. 2001;358(9298):2039–2045. doi: 10.1016/S0140-6736(01)07100-8. [DOI] [PubMed] [Google Scholar]
  • 28.Parnia S., Waller DG., Yeates R., Fenwick P. A qualitative and quantitative study of the incidence, features and aetiology of near death experiences in cardiac arrest survivors. Resuscitation. 2001;48(2):149–156. doi: 10.1016/s0300-9572(00)00328-2. [DOI] [PubMed] [Google Scholar]

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