Cynthia M. Dougherty

Regional Systems of Care for Out-of-Hospital Cardiac Arrest. A Policy Statement From the American Heart Association

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Psychological reactions and family adjustment in shock versus no shock groups after implantation of internal cardioverter defibrillator

PURPOSE The purpose of this study was to compare psychological reactions and family adjustment after sudden cardiac arrest (SCA) and internal cardioverter defibrillator (ICD) implantation in survivors who did and did not experience defibrillatory shocks the first year of recovery. METHODS Data were collected as part of a longitudinal prospective study that examined patient and family adjustment after SCA. SCA survivors and one family member per patient were interviewed and completed questionnaires three times within the first year (hospital discharge, 6 months, and 12 months) after SCA. SAMPLE Fifteen SCA survivors (13 men and 2 women) between the ages of 30 and 74 (mean 57 years) and one respective family member, usually the spouse, (mean age 53 years) participated. All SCA survivors had had primary ventricular fibrillation outside the hospital, had automatic defibrillators implanted while hospitalized, and were monitored for 1 year. RESULTS Participants were divided into shock and no shock groups based on activation of their ICD the first year. The mean number of shocks received in the shock group survivors was 26, with a range of 3 to 100. Anxiety, depression, anger, and stress levels were higher for both survivors and their family members in the group that received defibrillator shocks. Denial was high throughout the entire year in all survivors. Dyadic adjustment and family coping were not found to be significantly different between the no shock and shock groups. A trend toward reduction in family social support and dyadic satisfaction was noted in both groups with time. CONCLUSIONS Both SCA survivors and their family members experience more psychological distress in the first year after ICD implantation if the defibrillator fires. Families in both shock and no shock groups report lower levels of family support and marital satisfaction the first year after SCA and ICD implantation.

Comparison of heart rate variability in survivors and nonsurvivors of sudden cardiac arrest

Imbalances in autonomic nervous system function have been posed as a possible mechanism that produces ventricular fibrillation and sudden cardiac arrest in patients with cardiovascular disease. Heart rate (HR) variability is described in survivors and nonsurvivors of sudden cardiac arrest within 48 hours after resuscitation using time and frequency domain analytic approaches. HR data were collected using 24-hour ambulatory electro-cardiograms in 16 survivors and 5 nonsurvivors of sudden cardiac arrest, and 5 control subjects. Survivors of sudden cardiac arrest were followed for 1 year, with recurrent cardiac events occurring in 4 patients who died within that year. Analysis of 24-hour electrocardiograms demonstrated that control subjects had the highest HR variability (standard deviation of all RR intervals = 155.2 +/- 54 ms), with nonsurvivors demonstrating the lowest HR variability (standard deviation of all RR intervals = 52.3 +/- 6.1 ms) and survivors of sudden cardiac arrest falling between the other 2 groups (standard deviation of all RR intervals = 78 +/- 25.5 ms, p less than or equal to 0.0000). Two other indexes of HR variability (mean number of beat to beat differences in RR intervals greater than 50 ms/hour and root-mean-square of successive differences in RR intervals) did not demonstrate the expected pattern in this sample, indicating that perhaps patterns of HR variability differ between groups of patients with cardiovascular disorders. Spectral analytic methods demonstrated that survivors of sudden cardiac arrest had reduced low- and high-frequency spectral power, whereas nonsurvivors demonstrated a loss of both low- and high-frequency spectral power.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term outcomes of a telephone intervention after an ICD.

Background: The purpose of this study was to determine the long‐term benefits of participating in a structured, 8‐week educational telephone intervention delivered by expert cardiovascular nurses post‐ICD. The intervention was aimed to (1) increase physical functioning, (2) increase psychological adjustment, (3) improve self‐efficacy in managing the challenges of ICD recovery, and (4) lower levels of health care utilization over usual care in the first 12 months post‐ICD. This article reports on the 6‐ and 12‐month outcomes of the nursing intervention trial.

Short-term efficacy of a telephone intervention by expert nurses after an implantable cardioverter defibrillator.

The ICD is a common therapy for treatment of ventricular arrhythmias and prevention of sudden cardiac death. After ICD therapy, 50% of survivors are known to have significantly elevated anxiety, depression, anger, and fear in getting back to normal physical activities. Despite these problems, few interventions to improve adjustment have been rigorously evaluated within a clinical trial format. This article reports the short‐term efficacy of a structured weekly educational telephone intervention (8 weeks) delivered by expert cardiovascular nurses to recipients of an ICD. To test these effects, a two‐group (n = 84/group) randomized clinical trial design was used with measures at baseline (hospital discharge), 1 month, and 3 months after ICD therapy. The study sample were first time ICD recipients for secondary prevention of sudden cardiac arrest. Primary outcomes included (1) physical functioning (Patient Concerns Assessment [PCA], Short‐Form Health Survey [SF‐12], ICD shocks), (2) psychological adjustment (State‐Trait Anxiety Inventory [STAI]), Centers for Epidemiologic Studies‐Depression (CES‐D), (3) knowledge (Sudden Cardiac Arrest [SCA] knowledge assessment), and (4) health care use (emergency room visits, outpatient visits, hospitalizations). The intervention group, as compared to the control group, significantly reduced mean PCA symptoms at 1 month (11.3–8.8 vs 9.7–9.3, respectively, P < 0.02), and reduced state anxiety (36.1–31.9 vs 33.1–33.0, respectively, P < 0.08), and enhanced knowledge (21.8–22.4 vs 21.4–21.7, respectively, P < 0.02) at 3 months. The intervention did not significantly impact short‐term health care use. A structured telephone intervention delivered during the first 8 weeks after ICD therapy by expert cardiovascular nurses decreased ICD related physical symptoms and anxiety, and increased SCA knowledge over 3 months.

Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners A Consensus Document From the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

Sexual counseling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

Aerobic exercise improves fitness and heart rate variability after an implantable cardioverter defibrillator.

PURPOSE The purpose of this study was to determine the effects of an 8-week aerobic exercise program on (1) cardiopulmonary fitness and activity, (2) heart rate variability (HRV), (3) health outcomes, and (4) high sensitivity C-reactive protein (hsCRP) in survivors of sudden cardiac arrest who have an implantable cardioverter-defibrillator (ICD). METHODS A single group pre-post exercise program with a 6-month follow-up was used in 10 ICD recipients. The exercise intervention consisted of supervised outpatient aerobic exercise 3 hours per week plus home walking 2 hours per week for 8 weeks. Patients were told to walk for 30 minutes on all or most days of the week for the remaining 4 months. Measures were taken at baseline, 8 weeks, and 24 weeks. RESULTS Cardiopulmonary fitness (exercise time, oxygen uptake at anaerobic threshold, metabolic equivalents), HRV (standard deviation of all R-R intervals, root-mean square of successive differences, high-frequency power), health outcomes (Short Form-12 physical and mental health, anxiety, depression), and hsCRP were improved after 8 weeks of exercise. Sustained effects of the exercise program were noted in daily activity (RT3 vector magnitude per minute), HRV (standard deviation 5-minute segments, root-mean square of successive differences, percent R-R change by 50 milliseconds high frequency power), and health outcomes (Short Form-12 physical health). CONCLUSION Sudden cardiac arrest survivors who have an ICD are a group of cardiac patients who can potentially benefit the most from exercise by stabilizing autonomic function and reducing the incidence of arrhythmias. Although causal conclusions cannot be drawn from this study, further testing of aerobic exercise interventions in this population appears warranted.

Family-focused interventions for survivors of sudden cardiac arrest.

This paper 1) describes what is known about recovery for families of patients who survive sudden cardiac arrest (SCA) and undergo internal cardioverter defibrillalor (ICD) implantation, 2) discusses empirical evidence for interventions aimed at affecting recovery following SCA and ICD implantation, 3) presents additional data that suggest interventions for cardiac arrest survivors and their families, and 4) makes recommendations for the development of future intervention programs for SCA survivors and their families. Research supporting the use of educational and support interventions designed for SCA survivors and families is reviewed. Recommendations are made for future design and testing of interventions in this population.

Descriptive study of partners’ experiences of living with severe heart failure

PURPOSE This qualitative study sought to describe the experiences of living with severe heart failure (HF) from the perspective of the partner. METHODS In-depth, semistructured interviews were conducted with 14 partners of individuals diagnosed with severe HF. Content analysis was performed to derive the main themes and subthemes of responses. RESULTS Three main themes were derived from the data: (1) My Experience of HF in My Loved One, (2) Experience With Healthcare Providers, and the (3) Patients Experience of HF as Perceived by the Partner. CONCLUSION The severity of the patients disease limited the partners lifestyle, resulting in social isolation and difficulties in planning for the future for both the patient and the partner. The partners were unprepared to manage the disease burden at home without consistent information and assistance by healthcare providers. Moreover, end-of-life planning was neither encouraged by healthcare providers nor embraced by patients or partners.

Domains of concern of intimate partners of sudden cardiac arrest survivors after ICD implantation.

Purpose:There is limited research that describes the experiences of intimate partners of sudden cardiac arrest (SCA) survivors. The purposes of this article are to (1) describe the domains of concern of intimate partners of SCA survivors during the first year after internal cardioverter defibrillator (ICD) implantation and (2) outline strategies used by partners of SCA survivors in dealing with the concerns and demands of recovery in the first year after ICD implantation. Methods:This is a secondary analysis of interview data collected for the primary study “Family Experiences Following Sudden Cardiac Arrest.” A grounded theory method was used to identify experiences of SCA survivors and their family members from hospitalization through the first year after ICD implantation. Data were collected from the SCA survivor and one intimate partner at 5 times: hospital discharge, and at 1, 3, 6, and 12 months postdischarge. Results:Eight Domains of Concern were identified for intimate partners following SCA and ICD implantation during the first year. These included (1) Care of the survivor, (2) My (partner) self-care, (3) Relationship, (4) ICD, (5) Money, (6) Uncertain future, (7) Health care providers, and (8) Family. Five categories of strategies to deal with the Domains of Concerns were identified (1) Care of the survivor, (2) My (partner) self-care, (3) Relationship, (4) Uncertain future, and (5) Controlling the environment. Implications:Nursing intervention programs should include the intimate partner of SCA survivors and contain education and support in the following areas: (1) information on the function of the ICD, (2) normal progression of physical and emotional recovery experiences, (3) safety and maintenance of the ICD, (4) activities of daily living after an ICD, (5) strategies to assist with the survivors care, and (6) strategies to assist with partner self care.