She had gone to bed after a normal day. They had been together for years. It was unusual that he was awake; maybe it was the gagging sound that woke him. She wasn't breathing, her color gone. His mind raced. He called 911 and began pushing. Rhythmically. Tears came, but he pushed on and on. Ten minutes, 20. Finally, the paramedics came with their machine.
Days later in the hospital, she and I went over the internal recording from that device. Ventricular fibrillation had gone on for too many minutes for her full recovery to seem like anything less than a miracle. When we talked, her face beamed with the joy that comes with having a second chance—which, of course, meant that circulatory support had worked. It seemed impossible to me that she was well.
Life and nothingness, separated by mere minutes. This is sudden death; this is cardiac arrest. And it happens to more than 300 000 Americans each year. So it is appropriate that the first day of the American Heart Association 2013 Scientific Sessions is dedicated to a resuscitation symposium.
An old picture (circa 1980s) of a Holter monitor taken from a golfer who died suddenly from ventricular fibrillation. No CPR was initiated.
The treatment of cardiac arrest is a worthy topic on so many levels. First, there is the matter of dismal medical treatment. In developed countries; fewer than one in 10 patients survive an out-of-hospital cardiac arrest. Second is the fact that survival rates can be easily improved: all one needs is the most powerful potion of all—knowledge. Third is the need for teamwork. Out-of-hospital cardiac-arrest victims can't help themselves; neither can their doctors.
Which team, then? Here it gets really good. Consider that modern society works because of a tacit social contract, like driving without texting and getting vaccinated. What if learning basic life support and intervening in the event of an arrest became part of that contract? Because sudden death most often happens at home, the life saved is most likely to be that of a loved one.
Finally, in the matter of benefit/risk trade-offs, it's hard (for even for the most skeptical) to see much downside in promoting effective early intervention in cardiac arrest.
With that in mind, two studies from the resuscitation symposium deserve mention.
Can a One-Minute Video Save Lives?
The first was a simple but elegant study carried out in a shopping mall. Dr Ashish Panchal (Ohio State University Medical Center, Columbus) and colleagues in Arizona set out to determine whether an ultrabrief video on compression-only CPR was an effective instrument to teach laypersons CPR, and more important, whether this one-minute ad would lead to superior responsiveness in a simulated cardiac arrest. The two study groups included 47 volunteer shoppers who were shown a one-minute video compared with 48 volunteers who sat idle. Subjects were then taken to a private area where a simulated cardiac arrest was ongoing. Study subjects were instructed to do what they "thought was best."
The results were striking. Bystanders with just one minute of training performed better on all measures of CPR quality. Compared with controls, educated bystanders called 911 more frequently, initiated compressions sooner, had less hands-off time, and performed more effective compressions. These findings allowed the investigators to conclude that an "ultrabrief video may have potential as a ubiquitous intervention for public venues to help improve bystander reaction to cardiac arrest.""
Thirty-Eight Minutes of CPR?
Japanese investigators used a large prospective registry of out-of-hospital cardiac arrest between 2005 and 2011 to evaluate the relationship between favorable outcomes and time interval from collapse to return of circulation (ROC).
Results: The study group included 284 814 patients with witnessed arrest, of which 31 845 (11%) achieved return of circulation and 8714 had favorable neurologic outcomes. Analysis revealed that shorter collapse-to-ROC time predicted favorable outcomes. Not unexpectedly, the likelihood of neurologic recovery decreased 5% for every one-minute increment in collapse-to-ROC time. A threshold at 38.5 minutes resuscitation time was found, wherein favorable neurologic outcomes could still be had. The authors concluded that, based on this large nationwide registry, resuscitation efforts may be needed for as long as 38 minutes.
In the struggle to improve survival of cardiac arrest, education looms large.
Bolstering my view that public education matters comes from this French study published earlier this year in the European Heart Journal. Researchers looked at regional variation in outcomes from cardiac arrest at sporting events. They found that "major regional disparities exist in survival rates (up to 10-fold) after [sudden cardiac arrest] during sports. [Sudden-cardiac-arrest] cases from regions with the highest levels of bystander resuscitation had the best survival rates to hospital admission and discharge."
This was a powerful study because survival rates varied in bordering French counties. That means there were not likely other confounders that could have resulted in disparate survival rates. Consider this quote from the discussion:
T he Côte d'Or region in Burgundy and the Nord region, which had the highest survival rates among all regions, have been the two most active in terms of public education, with the first [automated external defibrillator] AED deployments and associated community-based sessions, which started in 1993, 14 years before the registration of public AEDs in France.
Regular readers of this column know that I think modern cardiology practice overemphasizes therapy of established disease. We should never stop promoting the idea that if we eat and sleep well and we move and smile a lot, there would be far fewer cardiac arrests to treat. Humans, with their ability to make simple choices, have great control over the factors that cause cardiac arrest, like plaque rupture, inflammation, and electrical instability.
But . . . in the treatment of cardiac arrest we can have success in both—prevention and intervention. While we promote healthy lifestyles and see fewer cardiac arrests, we can still work hard at promoting the early and effective intervention in cardiac arrest. That this requires education of and teamwork with the public constitutes a win-win-win situation.
It's good for cardiac arrest victims, it's good for the bystander who intervenes, and it's good for society in general. Plus, it's easy!
Good job, American Heart Association!