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WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS

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WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS Powered By Docstoc
					67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                           Page 1 of 26



               WORKSHEET for PROPOSED Evidence-Based GUIDELINE RECOMMENDATIONS
NOTE: Save worksheet using the following filename format: Taskforce.Topic.Author.Date.Doc where Taskforce is a=ACLS,
b=BLS, p=Pediatric, n=neonatal and i=Interdisciplinary. Use 2 or 3 letter abbreviation for author’s name and 30Jul03 as sample
date format.
Worksheet Author:                                      Taskforce/Subcommittee: __BLS __ACLS __PEDS X ID __PROAD
David L. Rodgers, Ed.S., NREMT-P
                                                       __Other:
Author’s Home Resuscitation Council:
X AHA __ANZCOR __CLAR __ERC __HSFC                                          Date Submitted to Subcommittee:
                                                                            July 20, 2004; Revised 06Aug04
__HSFC __RCSA              ___IAHF      ___Other:

STEP 1: STATE THE PROPOSAL. State if this is a proposed new guideline; revision to current guideline; or deletion of current guideline.
Existing guideline, practice or training activity, or new guideline:

There is no existing guideline; therefore, this worksheet represents a new guideline.

Step 1A: Refine the question; state the question as a positive (or negative) hypothesis. State proposed guideline recommendation as a specific, positive
hypothesis. Use single sentence if possible. Include type of patients; setting (in- /out-of-hospital); specific interventions (dose, route); specific outcomes
(ROSC vs. hospital discharge).

Hypothesis – The provision of CPR, defibrillation, and emergency cardiovascular care to victims of cardiac arrest in the general population, both for out-of-hospital
and in-hospital patients, is a worthwhile treatment considering the quality of life for survivors of cardiac arrest events.

Step 1B: Gather the Evidence; define your search strategy. Describe search results; describe best sources for evidence.

Utilizing the text search parameters of “Quality of Life” and “Cardiac Arrest,” relevant libraries and databases were searched. Note, quote marks were omitted for the
search process to allow for a wider return of potentially useful articles. Abstracts and/or articles were reviewed to determine relevance and match inclusion/exclusion
criteria.

List electronic databases searched (at least AHA EndNote 7 Master library [http://ecc.heart.org/], Cochrane database for systematic reviews and Central Register
of Controlled Trials [http://www.cochrane.org/], MEDLINE [http://www.ncbi.nlm.nih.gov/PubMed/ ], and Embase), and hand searches of journals, review articles,
and books.

Searches completed week of May 12 – 19, 2004
- MEDLINE (PubMed) – 186 returns (Primary search)
- AHA EndNote 7 Master Library (April 2004 Edition) – 41 returns, all duplicates of primary PubMed search with exception of 1 return
- Cochrane Database for Systematic Reviews – None
- Central Register of Controlled Trials – Not Applicable to this search
- EMBASE – 196 Returns, 43 not found in primary search
- Academic Search Premier (included alternative search of MEDLINE) – 127 returns, all duplicates of primary PubMed search with exception of 2 returns
- Hand search of relevant recent articles not found in above searches – 5 additional articles
Total combined unique returns - 237

• State major criteria you used to limit your search; state inclusion or exclusion criteria (e.g., only human studies with control group? no animal studies? N subjects >
  minimal number? type of methodology? peer-reviewed manuscripts only? no abstract-only studies?)

- Exclusion criteria – No abstract only studies, no editorial or comment/discussion articles, excluded special populations (e.g., severely burned, perinatal arrests), no
    case studies. Excluded articles that addressed cardiac arrest survival as a result of ICD devices. Excluded articles that only addressed survival issues and did not
    address quality of life issues. Excluded articles that used same subject group for more than one study.
- Inclusion criteria – Peer-reviewed manuscripts only, primary focus was general population (including both out-of-hospital and in-hospital cardiac arrest patients),
    both prospective and retrospective studies included.

• Number of articles/sources meeting criteria for further review: Create a citation marker for each study (use the author initials and date or Arabic numeral, e.g.,
“Cummins-1”). . If possible, please supply file of best references; EndNote 6+ required as reference manager using the ECC reference library.

- 34 articles met inclusion criteria
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                 Page 2 of 26




                        STEP 2: ASSESS THE QUALITY OF EACH STUDY
 Step 2A: Determine the Level of Evidence. For each article/source from step 1, assign a level of evidence—based on
 study design and methodology.
     Level of                                                          Definitions
     Evidence                                                (See manuscript for full details)
      Level 1     Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects
      Level 2     Randomized clinical trials with smaller or less significant treatment effects
      Level 3     Prospective, controlled, non-randomized, cohort studies
      Level 4     Historic, non-randomized, cohort or case-control studies
      Level 5     Case series: patients compiled in serial fashion, lacking a control group
      Level 6     Animal studies or mechanical model studies
      Level 7     Extrapolations from existing data collected for other purposes, theoretical analyses
      Level 8     Rational conjecture (common sense); common practices accepted before evidence-based guidelines



  Step 2B: Critically assess each article/source in terms of research design and methods.
  Was the study well executed? Suggested criteria appear in the table below. Assess design and methods and provide an overall
  rating. Ratings apply within each Level; a Level 1 study can be excellent or poor as a clinical trial, just as a Level 6 study could be
  excellent or poor as an animal study. Where applicable, please use a superscripted code (shown below) to categorize the primary
  endpoint of each study. For more detailed explanations please see attached assessment form.

 Component of
 Study and Rating               Excellent                  Good                    Fair                   Poor            Unsatisfactory
 Design &                 Highly appropriate     Highly appropriate          Adequate,            Small or clearly       Anecdotal, no
                          sample or model,       sample or model,            design, but          biased population or   controls, off
                          randomized, proper     randomized, proper          possibly biased      model                  target end-points
                          controls               controls
 Methods                  AND                    OR                          OR                   OR                     OR
                          Outstanding            Outstanding accuracy,       Adequate under       Weakly defensible in   Not defensible in
                          accuracy,              precision, and data         the                  its class, limited     its class,
                          precision, and data    collection in its class     circumstances        data or measures       insufficient data
                          collection in its                                                                              or measures
                          class

A = Return of spontaneous circulation           C = Survival to hospital discharge             E = Other endpoint
B = Survival of event                           D = Intact neurological survival

  Step 2C: Determine the direction of the results and the statistics: supportive? neutral? opposed?

 DIRECTION of study
 by results & statistics:      SUPPORT the proposal                  NEUTRAL                            OPPOSE the proposal
                               Outcome of proposed guideline         Outcome of proposed guideline      Outcome of proposed guideline
 Results                       superior, to a clinically important   no different from current          inferior to current approach
                               degree, to current approaches         approach
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                           Page 3 of 26




Step 2D: Cross-tabulate assessed studies by a) level, b) quality and c) direction (ie, supporting or neutral/
opposing); combine and summarize. Exclude the Poor and Unsatisfactory studies. Sort the Excellent, Good, and Fair quality
studies by both Level and Quality of evidence, and Direction of support in the summary grids below. Use citation marker (e.g. author/
date/source). In the Neutral or Opposing grid use bold font for Opposing studies to distinguish them from merely neutral studies.
Where applicable, please use a superscripted code (shown below) to categorize the primary endpoint of each study.


                                                              Supporting Evidence
Note: Studies listed utilized a variety of combinations to measure quality of life as an endpoint including intact neurological outcomes, physiological data, and testing
or scoring methods to measure aspects of quality of life (All citations were “E”).

Hypothesis – The provision of CPR, defibrillation, and emergency cardiovascular care to victims of cardiac arrest in the general population, both for out-of-hospital
and in-hospital patients, is a worthwhile treatment considering the quality of life for survivors of cardiac arrest events.

                                                                               Bunch (2003);          Eisenburger
                                                          Nichol (1999);       De Vos (1999);         (1998);
                        Excellent
                                                          Stiell (2003);       Hugo (2002);           Graves (1997);
                                                          Van Alem (2004)      Saner (2002);          Kuilman (1999);
  Quality of Evidence




                                                                               Sauve (1995)           Polo (2000)


                                                                                                      Kamphuis (2002);
                                                                                                      Motzer (1996);
                         Good
                                                          Granja (2002)        Hsu (1996)             Nunes (2003);
                                                                                                      Paniagua (2002);
                                                                                                      Roewer (1985)


                                                                                                      Guerot (2001);
                                                          Dimopoulou
                                                                                                      Beuret (1993);
                          Fair                            (2001);
                                                                               Bertini (1990)         Earnest (1980);
                                                          Martin-Castro
                                                                                                      Kliegel (2002);
                                                          (1999)
                                                                                                      Kuilman (1999)

                                    1          2                  3                     4                      5                  6                7              8
                                                                               Level of Evidence
A = Return of spontaneous circulation                   C = Survival to hospital discharge                         E = Other endpoint
B = Survival of event                                   D = Intact neurological survival
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                             Page 4 of 26




                                                    Neutral or Opposing Evidence
Note: Studies listed utilized a variety of combinations to measure quality of life as an endpoint including intact neurological outcomes, physiological data, and testing
or scoring methods to measure aspects of quality of life (All citations were “E”). Negative studies indicated in BOLD

Hypothesis – The provision of CPR, defibrillation, and emergency cardiovascular care to victims of cardiac arrest in the general population, both for out-of-hospital
and in-hospital patients, is a worthwhile treatment considering the quality of life for survivors of cardiac arrest events.


                        Excellent
                                                       Gamper (2004)         Ladwig (1999)
  Quality of Evidence




                         Good                                                Sunnerhagen
                                                                                                   Wernberg (1979)
                                                                             (1996)




                                                                                                   Guerot (1996);
                          Fair
                                                                                                   Bilsky (1992);
                                                                                                   Mohr (2001)


                                    1        2                 3                      4                     5                  6                 7                  8
                                                                               Level of Evidence
A = Return of spontaneous circulation                   C = Survival to hospital discharge                       E = Other endpoint
B = Survival of event                                   D = Intact neurological survival


 STEP 3. DETERMINE THE CLASS OF RECOMMENDATION. Select from these summary
 definitions.
                  CLASS                                       CLINICAL DEFINITION                                REQUIRED LEVEL OF EVIDENCE
  Class I                                           • Always acceptable, safe                           • One or more Level 1 studies are present (with rare
  Definitely recommended. Definitive,               • Definitely useful                                   exceptions)
  excellent evidence provides support.              • Proven in both efficacy & effectiveness           • Study results consistently positive and compelling
                                                    • Must be used in the intended manner for
                                                      proper clinical indications.
  Class II:                                         • Safe, acceptable                                  • Most evidence is positive
  Acceptable and useful                             • Clinically useful                                 • Level 1 studies are absent, or inconsistent, or lack
                                                    • Not yet confirmed definitively                      power
                                                                                                        • No evidence of harm
   • Class IIa: Acceptable and useful               • Safe, acceptable                                  • Generally higher levels of evidence
  Good evidence provides support                    • Clinically useful                                 • Results are consistently positive
                                                    • Considered treatments of choice
   • Class IIb: Acceptable and useful               • Safe, acceptable                                  • Generally lower or intermediate levels of evidence
  Fair evidence provides support                    • Clinically useful                                 • Generally, but not consistently, positive results
                                                    • Considered optional or alternative
                                                      treatments
  Class III:                                        • Unacceptable                                      • No positive high level data
  Not acceptable, not useful, may be                • Not useful clinically                             • Some studies suggest or confirm harm.
  harmful                                           • May be harmful.
                                                    • Research just getting started.                    • Minimal evidence is available
  Indeterminate                                     • Continuing area of research                       • Higher studies in progress
                                                    • No recommendations until                          • Results inconsistent, contradictory
                                                      further research                                  • Results not compelling
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                          Page 5 of 26




 STEP 3: DETERMINE THE CLASS OF RECOMMENDATION. State a Class of Recommendation for the Guideline Proposal.
 State either a) the intervention, and then the conditions under which the intervention is either Class I, Class IIA, IIB, etc.; or b) the condition, and then whether
 the intervention is Class I, Class IIA, IIB, etc.


 Hypothesis – The provision of CPR, defibrillation, and emergency cardiovascular care to victims of cardiac arrest in the general population, both for out-of-hospital
 and in-hospital patients, is a worthwhile treatment considering the quality of life for survivors of cardiac arrest events.

 Indicate if this is a __ Condition or X Intervention
 Final Class of recommendation: _
 __Class I-Definitely Recommended
 X_Class IIa-Acceptable & Useful; good evidence
 __Class IIb-Acceptable & Useful; fair evidence
 __Class III – Not Useful; may be harmful
 __Indeterminate-minimal evidence or inconsistent
 An argument could be made that this situation represents one of the rare examples where a Class I recommendation could be made in the absence of Level 1
 evidence. Given the strong support for the hypothesis from a series of prospective and retrospective studies that utilized matched control groups, there is clear
 support for the hypothesis. Additionally, as noted in later comments in this worksheet, the only two negative studies were marginally acceptable given the
 inclusion/exclusion criteria. Some reviewers may wish to exclude both of these studies since they dealt with specialized populations (nursing home and
 rehabilitation center patients).



REVIEWER’S PERSPECTIVE AND POTENTIAL CONFLICTS OF INTEREST: Briefly summarize your professional background, clinical specialty,
research training, AHA experience, or other relevant personal background that define your perspective on the guideline proposal. List any potential conflicts of
interest involving consulting, compensation, or equity positions related to drugs, devices, or entities impacted by the guideline proposal. Disclose any research
funding from involved companies or interest groups. State any relevant philosophical, religious, or cultural beliefs or longstanding disagreements with an individual.

 Reviewer – David L. Rodgers: Education – Doctoral student in Education (Curriculum and Instruction) with Marshall University (Huntington, WV, USA); Education
 Specialist degree in Curriculum and Instruction; Marshall University; Master of Arts in Communication Studies (Emphasis in Organizational Communication),
 Marshall University; Bachelor of Science in Journalism (emphasis in News and Editorial Writing), West Virginia University (Morgantown, WV, USA). Clinical
 Background - National Registered Emergency Medical Technician – Paramedic. AHA Volunteer Activity – AHA ACLS Regional Faculty (WV); AHA BLS Regional
 Faculty (WV); AHA instructor in ACLS, BLS & PALS; member AHA Program Administration Subcommittee (2001 – 2004); member AHA Education Work Group
 (2004 – present); various regional level leadership positions.

 Disclosure – David Rodgers is an employee of Charleston Area Medical Center Health Education and Research Institute that, in addition to being an AHA Training
 Center, is a distributor in the public access defibrillation market for Zoll Medical Inc. AEDPlus. Mr. Rodgers receives no compensation in the form of additional
 salary, bonuses, or commissions in relation to the Zoll AEDPlus distributorship.
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                         Page 6 of 26




REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK: Summarize your final evidence integration and the rationale for the
class of recommendation. Describe any mismatches between the evidence and your final Class of Recommendation. “Mismatches” refer to selection of a class of
recommendation that is heavily influenced by other factors than just the evidence. For example, the evidence is strong, but implementation is difficult or expensive;
evidence weak, but future definitive evidence is unlikely to be obtained. Comment on contribution of animal or mechanical model studies to your final
recommendation. Are results within animal studies homogeneous? Are animal results consistent with results from human studies? What is the frequency of adverse
events? What is the possibility of harm? Describe any value or utility judgments you may have made, separate from the evidence. For example, you believe
evidence-supported interventions should be limited to in-hospital use because you think proper use is too difficult for pre-hospital providers. Please include relevant
key figures or tables to support your assessment.

As reflected in section 2D of this worksheet, the majority of studies included in this worksheet found cardiac arrest survivors had a positive quality of
life (QoL) after cardiac arrest. The survivors’ QoL was measured by a variety of parameters including formal testing instruments, chart reviews, and
interviews with cardiac arrest survivors. However, a potential limitation to these studies in virtually all cases was the comparison of QoL after the
arrest with QoL prior to the arrest event. Given that most studies compared post-event QoL with pre-event QoL, even minor detrimental changes in
functional status had the potential to negatively impact the respondent’s view of QoL. Few studies addressed QoL after the event in a manner that
compared it to the possibility of being dead. Saner, et al. (2002) commented “49 of the 50 arrest patients judged their situation after resuscitation
worth living.” This is one of the few examples where questioning allowed for the comparison of life after the arrest event with death.

The findings of this worksheet support the hypothesis and indicate the provision of CPR, defibrillation, and emergency cardiovascular care to victims
of cardiac arrest in the general population, both for out-of-hospital and in-hospital patients, is a worthwhile treatment considering the quality of life for
survivors of cardiac arrest events. Among the supporting evidence for this conclusion are the following Level 3 and/or excellent quality studies:
Bunch (2003); De Vos (1999); Dimopoulou (2001); Eisenburger (1998); Granja (2002): Graves (1997); Hugo (2002); Kuilman (1999); Martin-Castro
(1999); Nichol (1999); Polo (2000); Saner (2002); Sauve (19950; Stiell (2003); and Van Alem (2004).

While no Level 1 or 2 (RCT) evidence exists, there is a substantial amount of positive evidence supporting the above hypothesis. The ability to
conduct RCTs to confirm this hypothesis may not be possible. While data exist to conduct meta-analysis (which would also be considered Level 1
evidence), to date, no meta-analysis has been performed. The extensive availability of data on this subject would lend itself well to a meta-analysis
or possibly a Cochrane systematic review.

Four key articles were identified that represented strong findings and superior methodology.

 Nichol, et al. (1999) – Nichol and colleagues focused on both in-hospital and out-of-hospital arrest survivors in a prospective study. Using an
  interview instrument, 86 survivors were included in the study. Their instrument scored the results on a scale that indicated 1.0 as perfect health
  and 0.0 as death. QoL measurements were conducted at six-month survival milestone. The mean survivor score was 0.72. Although comparison
  against the general population with a mean score of 0.85 did indicate a significant difference, overall the 0.72 score reflected a relatively high QoL.

 Stiell, et al, (2003) – Stiell and colleagues prospectively evaluated 268 adult out-of-hospital survivors at the one year survival milestone. Using the
  same instrument as Nichol, et al. (1999) they scored 8 attributes of health (vision, hearing, speech, ambulation, dexterity, emotion, cognition,
  pain). Stiell found a median score of 0.80 which compared well to an age-adjusted comparison group that scored 0.83. 1 year survival showed
  cerebral performance category (CPC) scores of 86% good, 9% moderate, 6% severe, and no vegetative state or brain dead subjects.

 van Alem, et al. (2004) – van Alem and colleagues prospectively evaluated 174 out-of-hospital cardiac arrest survivors at the six month post-event
  milestone. Both QoL and cognitive functioning were evaluated with assessment instruments and comparison groups were established from a
  population of stroke survivors and a broader general population. In reviewing several dimensions (psychosocial, physical, eating, recreation,
  communication, alertness, ambulation, social interaction, mobility home management, self care, emotional behavior, sleep, and an overall total
  score), cardiac arrest survivors exhibited a lower score than the general population; however, all dimensions were within one standard deviation of
  the general population score. Arrest survivors had a significantly better QoL in several dimensions when compared against a group of stroke
  survivors.

 Bunch, et al. (2003) – Bunch and colleagues produced a series of retrospective studies using the same subject group. This entry into the literature
  in 2003 provided their strongest comments. This study reviewed one year survival of 145 subjects against both an age-, sex-, and disease-
  matched local control group and a similar national norm. It found one year survival was equivalent to the local group but differed negatively from
  the national norm. Additionally, 50 subjects completed a QoL assessment instrument that measured dimensions of pain, general health, mental
  health, physical functioning, emotional role, physical role, social functioning, vitality, overall mental component, and overall physical component. In
  comparison against the general population, only one dimension (vitality) scored as significantly lower.
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                           Page 7 of 26



In summarizing the literature, these findings supported the hypothesis:

 Studies that indicated a good physiological functioning as determined by medical assessment - Bertini et al. (1990); Dimopoulou, Anthi, Michalis,
  & Tzelepis (2001); Wernberg & Thomassen (1979).

 Studies that showed a high degree of independent living capabilities - Bertini et al. (1990); de Vos, de Haes, Koster, & de Haan (1999);
  Dimopoulou et al. (2001); Earnest, et al. (1980); Graves et al. (1997).

 Studies that showed a strong feeling of being positive about life among cardiac arrest survivors - Eisenburger et al. (1998); Hsu, Madsen, &
  Callaham (1996); Kliegel et al. (2002); Roewer, Kloss, & Puschel (1985); Saner, Borner Rodriguez, Kummer-Bangerter, Schuppel, & von Planta
  ( 2002).

Some studies indicated mixed or negative findings regarding QoL issues. Among the problems noted were:

 Decrease in social support - Sunnerhagen, Johansson, Herlitz, & Grimby (1996); Wernberg & Thomassen (1979). However, Saner, et al. (2002)
  reported the opposite.

 Onset of depression - de Vos et al. (1999); Eisenburger et al. (1998); Kamphuis, De Leeuw, Derksen, Hauer, & Winnubst (2002); Kliegel et al.
  (2002); Ladwig et al. (1999); Lederer et al. ( 2004); Roewer et al. (1985). However, Saner, et al. (2002) and Hugo, Borner Rodriguez, Kummer-
  Bangerter, Schuppel, & Von Planta (2002) reported the opposite, that depression was not a significant issue.

 Onset of posttraumatic stress syndrome - Gamper et al. (2004); Ladwig et al. (1999). Conversely, Bertini, et al. (1990) and Dimopoulou, et al.
  (2001) reported no significant emotional problems in cardiac arrest survivors.

The two articles listed as indicating a negative effect on QoL [Bilsky & Banja (1992); Mohr, et al. (2001)] both dealt with special populations (nursing
homes patients and rehab patients) that differed from the general population. Since the hypothesis stated the focus was on the general population,
there is potential to exclude these studies for that reason. This suggests that some specific populations may not benefit from resuscitation efforts.
However, both Bilsky & Banja (1992) and Mohr, et al. (2001) were Level 5 studies of fair quality; thus the impact of these studies’ conclusions should
be viewed with some caution.

Preliminary draft/outline/bullet points of Guidelines revision: Include points you think are important for inclusion by the person assigned to
write this section. Use extra pages if necessary.

 Publication:          Chapter:              Pages:

 Topic and subheading:

 Quality of Life after Resuscitation –

 Although survival to hospital discharge is low following out-of-hospital and in-hospital cardiac arrest, a large number of studies in human (LOE 3 to 5) confirm that in
 the general population, survivors of cardiac arrest often lead productive and positive lives after resuscitation. This indicates that resuscitation does not result in a
 sizeable population of patients with poor quality of life who become a burden to their families and who do not enjoy life.

 The provision of CPR, defibrillation, and emergency cardiovascular care to victims of cardiac arrest in the general population, both for out-of-hospital and in-hospital
 patients, is a worthwhile treatment considering the quality of life for survivors of cardiac arrest events (Class IIa, LOE 3-5).


Attachments:
       Bibliography in electronic form using the Endnote Master Library. It is recommended that the bibliography be provided in annotated
        format. This will include the article abstract (if available) and any notes you would like to make providing specific comments on the
        quality, methodology and/or conclusions of the study.
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                        Page 8 of 26




                                                                    Citation List

        Citation Marker                                                   Full Citation*
Bertini (1990)                       Bertini, G., C. Giglioli, et al. (1990). "Neuropsychological outcome of survivors of out-of-hospital cardiac arrest." Journal of
                                     Emergency Medicine 8(4): 407-12.

                                     Comments: Level 4, Fair quality, Supporting. Retrospective study with matched group comparison. 30 subjects (low
                                     number compared to other studies).

                                     Abstract: Thirty patients resuscitated from out-of-hospital cardiac arrest (15 with and 15 without postanoxic coma on
                                     admission) underwent a clinical examination and neuropsychological testing. In order to assess quality of life, they were
                                     compared to two matched control groups; 15 patients with previous myocardial infarction and 15 healthy subjects. None of
                                     the survivors showed severe neurologic impairment, and all had returned to self-sufficient physical activity. However, the
                                     behavior rating scale scores were significantly worse in patients with postanoxic coma. The processing ability linked to
                                     memory was significantly worse in the postanoxic coma group. Mood disorders were also observed in this group, but they
                                     did not have pathological significance. The remarkably low incidence of neurologic and psychological sequelae in these
                                     resuscitated patients, particularly in those with early clinical evidence of severe cerebral damage, is an encouraging result
                                     that supports the therapeutic systems development and efforts in the management of out-of-hospital cardiac arrest.
                                     Comments:

Beuret (1993)                        Beuret, P., F. Feihl, et al. (1993). "Cardiac arrest: prognostic factors and outcome at one year." Resuscitation 25(2): 171-
                                     9.

                                     Comments: Level 5, Fair quality, Supporting. Retrospective study with no group comparison. 23 subjects (low number
                                     compared to other studies). Long-term survivors had ability to live independently.

                                     Abstract: This study was designed to determine by multivariate statistical methods the influence of 38 variables on
                                     outcome after cardiopulmonary resuscitation (CPR) and to assess neuropsychological status in long-term survivors. The
                                     charts of 181 consecutive patients resuscitated in a 1,100-bed University Hospital over a 2-year period were analyzed
                                     retrospectively. Of the 181 resuscitated patients, 23 (13%) could be discharged. Outcome was significantly affected by the
                                     following variables: presence of shock or renal failure before cardiac arrest (CA) (odds ratio = 10.6; 95% confidence
                                     interval = 1.3-85.8 and odds ratio = 13.8; 95% confidence interval = 1.7-109.2, respectively), administration of epinephrine
                                     (odds ratio = 11.2; 95% confidence interval = 3.2-39.2) or prolonged CPR (> 15 min) (odds ratio = 4.9; 95% confidence
                                     interval = 1.7-13.7). By contrast, when CA occurred in uncomplicated acute myocardial infarction a significantly better
                                     prognosis could be demonstrated (odds ratio = 0.2; 95% confidence interval = 0.0-0.6). The 10 long-term survivors
                                     investigated lead an independent life and all returned to former occupation. The most common complaint was moderate
                                     memory disturbance (five patients). The conclusion is that this study confirms the critical influence of cellular anoxia on
                                     prognosis and allows the improved delineation of the situations in which cardiopulmonary resuscitation appears to be
                                     hopeless or likely to be successful. The follow up in a small number of survivors has shown a good quality of life and
                                     minor neuropsychological sequellae.

Bilsky (1992)                        Bilsky, G. S. and J. D. Banja (1992). "Outcomes following cardiopulmonary resuscitation in an acute rehabilitation
                                     hospital: Clinical and ethical implications." American Journal of Physical Medicine and Rehabilitation 71(4): 232-235.

                                     Comments: Level 5, Fair quality, Negative. Retrospective study with no cohort group comparison. 17 subjects (low
                                     number compared to other studies). Patient population was from a rehab hospital and most patients had a high degree of
                                     comorbidities. Considered excluding this citation since it did not reflect general population. It seems to me that the
                                     hypothesis has to be carefully worded to reflect the apparent conclusion that QoL may not be good in specific patient
                                     populations following resuscitation.

                                     Abstract: This retrospective study examines cases of cardiac arrest requiring cardiopulmonary resuscitation (CPR) in an
                                     acute rehabilitation hospital. All admissions to the Center for Rehabilitation Medicine at Emory University, a 56-bed facility,
                                     are reviewed. Seventeen cases of true cardiac arrest are identified for analysis of ultimate disposition over a 10-yr period.
                                     Only one patient (5.9%) survived CPR to discharge from the rehabilitation hospital, but he died subsequent to his transfer
                                     to the acute hospital. Though the sample size is small, it reflects the total population of patients eligible for CPR who
                                     suffered a cardiac arrest. We conclude that CPR is generally not successful in the elderly inpatient rehabilitation
                                     population. The growing clinical complexity of the rehabilitation patient demands that health-care providers and their
                                     patients more regularly address decision-making issues pertinent to CPR.
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                         Page 9 of 26



Bunch (2003)                         Bunch, T. J., R. D. White, et al. (2003). "Long-term outcomes of out-of-hospital cardiac arrest after successful early
                                     defibrillation." New England Journal of Medicine 348(26): 2626-2633.

                                     Comments: KEY ARTICLE - Level 4, Excellent quality, Supporting. Retrospective study with cohort group comparison. 79
                                     subjects used in long-term survival study and 50 subjects in QoL study (high number compared with other studies). Five-
                                     year survival rate matched control group. “A nearly normal quality of life and return to work were reported by majority of
                                     survivors.”

                                     Note: This same subject group was used to prepare additional articles reporting QoL and survival after cardiac arrest in
                                     the following publications:

                                      Bunch, T. J., R. D. White, et al. (2004). "Impact of age on long-term survival and quality of life following out-of-hospital
                                       cardiac arrest." Critical Care Medicine 32(4): 963-7.
                                      Bunch, T. J., R. D. White, et al. (2004). "Long-term subjective memory function in ventricular fibrillation out-of-hospital
                                       cardiac arrest survivors resuscitated by early defibrillation." Resuscitation 60(2): 189-95.
                                      Bunch, T. J., R. D. White, et al. (2004). "Outcomes and in-hospital treatment of out-of-hospital cardiac arrest patients
                                       resuscitated from ventricular fibrillation by early defibrillation." Mayo Clinic Proceedings 79(5): 613-9.

                                     These publications provide additional measures for QoL that support CPR/ECC intervention in cardiac arrest.

                                     Abstract: BACKGROUND: Mortality after out-of-hospital cardiac arrest from ventricular fibrillation is high. Programs
                                     focusing on early defibrillation have improved the rate of survival to hospital discharge. We conducted a population-based
                                     analysis of the long-term outcome and quality of life of survivors. METHODS: All patients who had an out-of-hospital
                                     cardiac arrest between November 1990 and January 2001 who received early defibrillation for ventricular fibrillation in
                                     Olmsted County, Minnesota, were included. The survival rate was compared with that of an age-, sex-, and disease-
                                     matched (2:1) control population of residents who had not had an out-of-hospital cardiac arrest and with that of age- and
                                     sex-matched controls from the general U.S. population. The quality of life was assessed with use of the Medical
                                     Outcomes Study 36-item Short-Form General Health Survey (SF-36) and compared with U.S. population norms.
                                     RESULTS: Of 200 patients who presented with an out-of-hospital cardiac arrest with ventricular fibrillation, 145 (72
                                     percent) survived to hospital admission (7 died in the emergency department) and 79 (40 percent) were neurologically
                                     intact (good overall capability or moderate overall disability) at discharge. The mean (+/-SD) length of follow-up was 4.8+/-
                                     3.0 years. Nineteen patients died after discharge from the hospital. The expected five-year survival rate (79 percent) was
                                     identical to that among age-, sex-, and disease-matched controls (P=0.68) but lower than that among the age- and sex-
                                     matched U.S. population (86 percent, P=0.02). Fifty patients completed SF-36 surveys at the end of follow-up, and the
                                     majority had a nearly normal quality of life, with the exception of reduced vitality. CONCLUSIONS: Long-term survival
                                     among patients who have undergone rapid defibrillation after out-of-hospital cardiac arrest is similar to that among age-,
                                     sex-, and disease-matched patients who did not have out-of-hospital cardiac arrest. The quality of life among the majority
                                     of survivors is similar to that of the general population.


De Vos (1999)                        de Vos, R., H. C. de Haes, et al. (1999). "Quality of survival after cardiopulmonary resuscitation." Archives of Internal
                                     Medicine 159(3): 249-54.

                                     Comments: Level 4, Excellent quality, Supporting. Retrospective study with cohort group comparison. 90 subjects (high
                                     number compared to other studies). QoL after cardiac arrest is related to QoL prior to arrest event. 75% remained
                                     independent after event and only 3% entered vegetative state.

                                     Abstract: BACKGROUND: Outcome of cardiopulmonary resuscitation (CPR) can be poor, in terms of life expectancy and
                                     quality of life. OBJECTIVES: To determine the impact of patient characteristics before, during, and after CPR on these
                                     outcomes, and to compare results of the quality-of-life assessment with published studies. METHODS: In a cohort study,
                                     we assessed by formal instruments the quality of life, cognitive functioning, depression, and level of dependence of
                                     survivors after inhospital CPR. Follow-up was at least 3 months after discharge from the hospital (tertiary care center).
                                     RESULTS: Of 827 resuscitated patients, 12% (n = 101) survived to follow-up. Of the survivors, 89% participated in the
                                     study. Most survivors were independent in daily life (75%), 17% were cognitively impaired, and 16% had depressive
                                     symptoms. Multivariate regression analysis showed that quality of life and cognitive function were determined by 2 factors
                                     known before CPR-the reason for admission and age. Factors during and after resuscitation, such as prolonged cardiac
                                     arrest and coma, did not significantly determine the quality of life or cognitive functioning of survivors. The quality of life of
                                     our CPR survivors was worse compared with a reference group of elderly individuals, but better than that of a reference
                                     group of patients with stroke. The quality of life did not importantly differ between the compared studies of CPR survivors.
                                     CONCLUSIONS: Cardiopulmonary resuscitation is frequently unsuccessful, but if survival is achieved, a relatively good
                                     quality of life can be expected. Quality of life after CPR is mostly determined by factors known before CPR. These findings
                                     may be helpful in informing patients about the outcomes of CPR.
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Dimopoulou (2001)                    Dimopoulou, I., A. Anthi, et al. (2001). "Functional status and quality of life in long-term survivors of cardiac arrest after
                                     cardiac surgery." Critical Care Medicine 29(7): 1408-11.

                                     Comments: Level 3, Fair quality, Supporting. Prospective study with no control group comparison. 16 subjects (low
                                     number compared to other studies). No neurological defects and high degree of independent living in long-term survivors.
                                     Population focus was on cardiac surgery patients, considered excluding this citation since it represented a special
                                     population.

                                     Abstract: OBJECTIVE: To assess long-term survival, functional status, and quality of life in patients who experienced
                                     cardiac arrest after cardiac surgery. DESIGN: Prospective, observational study. SETTING: An 18-bed, adult cardiac
                                     surgery intensive care unit in a tertiary teaching center. PATIENTS: Twenty-nine cardiac surgery patients who suffered an
                                     unexpected cardiac arrest in the immediate postoperative period. INTERVENTIONS: The New York Heart Association
                                     classification and a questionnaire based on the Nottingham Health Profile were used to evaluate functional status and
                                     quality of life 4 yrs after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of the 29 patients who experienced
                                     cardiac arrest during the first 24 hrs after cardiac surgery, 27 patients (93%) were successfully resuscitated and 23
                                     patients (79%) survived to hospital discharge. Evaluation 4 yrs postdischarge showed that, of the 29 patients, 16 patients
                                     (55%) were still alive (long-term survivors). Functional status assessment of long-term survivors revealed that 12 patients
                                     (75%) were grouped in New York Heart Association class I, 3 patients (19%) in class II, and 1 patient (6%) in class III.
                                     None of them had a neurologic deficit. They all were living independently at home, without need of any nursing care. No
                                     patient reported any abnormal emotional reactions, and six patients (38%) had mild sleep disturbances, such as early
                                     awaking. Regarding activities of daily living, 20% returned to work, 94% were able to look after their home, 96% had a
                                     social life, 63% were sexually active, 81% were involved in their hobbies, and 75% had gone on holidays.
                                     CONCLUSIONS: Cardiac surgery patients who experience an unexpected cardiac arrest in the immediate postoperative
                                     period have a 55% chance of being alive 4 yrs postdischarge. The majority of these long-term survivors has a good
                                     outcome with respect to functional status and quality of life.


Eisenburger (1998)                   Eisenburger, P., M. List, et al. (1998). "Long-term cardiac arrest survivors of the Vienna emergency medical service."
                                     Resuscitation 38(3): 137-43.

                                     Comments: Level 5, Excellent quality, Supporting. Retrospective study with no matched group comparison. 92 subjects
                                     (high number compared to other studies). 84% enjoy life.

                                     Abstract: The purpose of this study was to describe the life of survivors after successful resuscitation and to see if there
                                     was an association with the type of emergency cardiac care. The 'Utstein-style' data of patients surviving non-traumatic
                                     cardiac arrest 24 (14-32) months were prospectively collected. The everyday activities and psychological concerns of
                                     patients with a cerebral performance category (CPC) of 1 and 2 using a questionnaire were analyzed. The chi2-square
                                     test was used for statistical analysis. The questionnaires of 92 patients (median age 59, IQR 51-68; females 36) were
                                     evaluated. Patients enjoy life (84%; n=73), have depression (36%; n=31), consider their survival a 'second chance' (84%;
                                     n=73) and fear that they may suffer cardiac arrest again (56%; n = 45). The average quality of life is 7 on a scale from 0
                                     (worst) to 10 (perfect). The majority of cardiac arrest survivors have a satisfactory life. No significant correlation between
                                     the type of emergency cardiac care and post cardiac arrest life was found. The fact that there was no association with the
                                     type of emergency cardiac care may be due to the narrow selection of patients (CPC 1 and 2), the small number of
                                     patients or factors contributing to post cardiac arrest life other than emergency treatment.


Earnest (1980)                       Earnest, M.P.;,Yarnell, P.R.;, Merrill, S.L.; Knapp, G.L.. (1980). “Long-term survival and neurologic status after
                                     resuscitation from out-of-hospital cardiac arrest.” Neurology. 30(12):1298-1302.

                                     Comments: Level 5, Good Quality, Supporting. Retrospective study, small number of patients (20). Relied on three
                                     mechanisms for determining QoL: Personal interview, physical examination, or – for patients who had died subsequent to
                                     their initial discharge – survey completion by family members. Findings showed that a majority of survivors were able to
                                     function independently and many were able to return to work. However, even among those who were functioning
                                     independently, most had some degree of neurologic abnormality.

                                     Abstract: Thirty-eight survivors from among 117 patients hospitalized after out-of-hospital cardiac arrest were evaluated
                                     approximately 3 1/2 years later. Twenty patients were living; 18 had died. Fifty-three percent had resumed independent
                                     social activities, but only 32% had returned to work. Eight of 14 patients tested were normal on limited neuropsychologic
                                     tests. Satisfactory long-term outcome was associated statistically with the patient's being awake on admission or
                                     awakening to follow simple commands within 2 days, and with good neurologic status at the time of discharge from the
                                     hospital. None of nine patients with poor neurologic function at discharge subsequently resumed working or independent
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                         Page 11 of 26



                                     living.

Gamper (2004)                        Gamper, G., M. Willeit, et al. (2004). "Life after death: posttraumatic stress disorder in survivors of cardiac arrest--
                                     prevalence, associated factors, and the influence of sedation and analgesia." Critical Care Medicine 32(2): 378-83.

                                     Comments: Level 3, Excellent quality, Neutral. Prospective study with cohort group comparison. 143 subjects (high
                                     number compared to other studies). Focused on posttraumatic stress disorder as a measure of QoL. Showed high degree
                                     (27%) of PTSD in cardiac arrest survivors. PTSD had direct effect on other measures of QoL (mobility, pain, depression,
                                     independent care). Termed this study as neutral since 73% of survivors did not experience PTSD and had a relatively
                                     high QoL.

                                     Abstract: OBJECTIVE: Cardiac arrest is possibly one of the most traumatizing conditions for patients, but to date, its
                                     influence on psychic morbidity remains unknown. Posttraumatic stress disorder is a unique symptom configuration after
                                     an extreme event consisting of intrusion re-experiencing, avoidance and numbness, and hyperarousal symptoms. We
                                     studied a) the prevalence of posttraumatic stress disorder (PTSD) in long term survivors of cardiac arrest; b) the role of
                                     specific stress factors related to cardiac arrest for the development of PTSD; and c) the influence of sedation and
                                     analgesia during or after cardiac arrest on the occurrence of PTSD. DESIGN: Prospective, cohort study. SETTING:
                                     University teaching hospital. PATIENTS: Analysis was performed in cardiac arrest survivors who were discharged with
                                     favorable neurologic outcome during an 8-yr period (1991-1999). INTERVENTIONS: All patients received the Davidson
                                     Trauma Score for the assessment of PTSD and a modified German version of the EuroQol questionnaire for assessment
                                     of quality of life. Cardiac arrest circumstances and administration of sedation and analgesia were assessed.
                                     MEASUREMENTS AND MAIN RESULTS: Of 1,630 initially resuscitated patients, 270 patients were discharged with good
                                     neurologic outcome. A total of 226 patients were contacted, and 143 patients (63% of all eligible patients) completed the
                                     study. Mean time from cardiac arrest to follow up was 45 months (range, 24-66). Thirty-nine patients (27%; 95%
                                     confidence interval, 21% to 35%) had a Davidson Trauma Score >40 and fulfilled criteria for PTSD. Patients with PTSD
                                     had a significantly lower quality of life. The only independent risk factor for the development of PTSD was younger age.
                                     There was no difference between patients with or without PTSD regarding the use of sedation and analgesia during or
                                     after cardiac arrest. CONCLUSION: The prevalence of PTSD in cardiac arrest survivors is high. Besides younger age,
                                     neither clinical factors nor the use of sedation and analgesia were associated with development of PTSD.


Granja (2002)                        Granja, C., G. Cabral, et al. (2002). "Quality of life 6-months after cardiac arrest." Resuscitation 55(1): 37-44.

                                     Comments: Level 3, Good quality, Supporting. Prospective study with matched group comparison. 19 subjects
                                     (moderately low number compared to other studies). No significant differences found in QoL in cardiac arrest survivors
                                     versus control group.

                                     Abstract: BACKGROUND: Evaluation of outcome after cardiac arrest focuses mainly on survival. Survivors of cardiac
                                     arrest end up in different states of health and survival alone may not be a sensitive measure for successful
                                     cardiopulmonary resuscitation (CPR). OBJECTIVES: To evaluate health-related quality of life (HR-QOL) of cardiac arrest
                                     survivors with EQ-5D, a generic instrument developed by the EuroQol group. PATIENTS AND METHODS: From April
                                     1997 to December 2000, all cardiac arrest adult patients admitted to an eight-bed medical/surgical (ICU) of a tertiary care
                                     hospital were enrolled. At 6-months after ICU discharge survivors attended a follow-up interview and answered EQ-5D
                                     questionnaire. A match-control group was created choosing for each survivor of cardiac arrest two controls, with similar
                                     age range (+/-5 years) and similar Apache II (+/-3 Apache II units), that were randomly selected among other ICU
                                     patients. RESULTS: From a total of 1106 patients, 97 (9%) patients were admitted after cardiac arrest. Forty-seven
                                     patients (48%) were discharged from ICU. Of these, 11 patients died in the ward. Thirty-six (37%) patients were
                                     discharged from hospital. Twelve patients died after hospital discharge but before 6-month evaluation. Five patients were
                                     not evaluated, three because they were living in distant locations and two for unknown reasons. Nineteen patients
                                     attended the follow-up consultation. Eight of these patients were actively working and six of them had managed to return
                                     to their previous activity. Eleven patients were retired and seven of these managed to return to their previous level of
                                     activity while four patients presented with anoxic encephalopathy: one with mild and one with moderate neurological
                                     dysfunction, two with severe anoxic neurological dysfunction. Although a higher percentage of cardiac arrest survivors
                                     reported more extreme problems in some dimensions than other ICU patients, no significant differences were found on
                                     HR-QOL, when evaluated by EQ-5D. CONCLUSIONS: When evaluated with EQ-5D at 6-months after ICU discharge,
                                     survivors of cardiac arrest exhibit a HR-QOL similar to other ICU survivors. These results agree with previous reports
                                     stating that CPR is frequently unsuccessful but if survival is achieved a fairly good quality of life can be expected.


Graves (1997)                        Graves, J. R., J. Herlitz, et al. (1997). "Survivors of out of hospital cardiac arrest: their prognosis, longevity and functional
                                     status." Resuscitation 35(2): 117-21.

                                     Comments: Level 5, Excellent quality, Supporting. Retrospective study with no matched group comparison. 324 subjects
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                                     (very high number compared to other studies). 73% alive at one year returned to pre-arrest functioning.

                                     Abstract: This paper reports, consistent with Utstein Style definitions, 13 years experience observing out-of-hospital
                                     cardiac arrest survivors' prognosis, longevity and functional status. We report for all patients, available outcome
                                     information for out-of-hospital cardiac arrest survivors in Goteborg Sweden between 1980 and 1993. Patients were
                                     followed for at least 1 year and some for over 14 years. From 1980 to 1993 Goteborg EMS treated 3754 out-of-hospital
                                     cardiac arrests. 9% (n = 324) were discharged from the hospital alive. Survivors' median age was 67 and 21% (n = 67)
                                     were women. Mortality rate was: 21% (n = 61) at 1 year; 56% (n = 78) by 5 years; and 82% (n = 32) by 10 years following
                                     the arrest. During the first 3 years, 16% (n = 46) experienced another cardiac arrest, 19% (n = 53) had an acute
                                     myocardial infraction and a total of 81% (n = 232) were rehospitalized for various conditions. 14% (n = 40) returned to
                                     previous employment, and 74% (n = 229) had retired before their arrest occurred. Cerebral performance categories (CPC)
                                     scores were: At hospital discharge N = 324; Data available for 320-1 = 53% (n = 171), 2 = 21% (n = 66), 3 = 24% (n = 77),
                                     4 = 2% (n = 6). One year post arrest N = 263; Data available for 212-1 = 73% (n = 156), 2 = 9% (n = 18), 3 = 17% (n =
                                     36), 4 = 1% (n = 2). Overall, 21% (n = 61) of cardiac arrest survivors died during the first year, and an additional 16% (n =
                                     46) experienced another arrest. 73% of those patients who were still alive after 1 year returned to pre-arrest function.


Guerot (2001)                        Guerot, E., N. Deye, et al. (2001). "[Evaluation of outcome of patients hospitalized after pre-hospital cardiac arrest]."
                                     Archives des maladies du coeur et des vaisseaux 94(9): 989-94.

                                     Comments: Level 5, Fair quality, Supporting. Retrospective study with no matched group comparison. 8 subjects (low
                                     number compared to other studies). Eights survivors from group of 89 arrest patients alive at 1 year and living
                                     independently.

                                     Abstract: The aim of this study was to assess management of patients resuscitated after pre-hospital cardiac arrest,
                                     initially indicated to preserve neurological status, the aetiological investigation only being undertaken when the outcome is
                                     favourable. Eighty-nine pre-hospital cardiac arrests were analysed retrospectively. The hospital survival was 16%, death
                                     being due to neurological lesions (55%), uncontrollable haemodynamic instability -39%) or other causes (7%). One year
                                     after the initial episode, none of the survivors had died, all living autonomously without (8 patients) or with minimal
                                     neurological sequellae (5 patients). These results are concordant with reports in the literature. The 11 cases of cardiac
                                     arrest with a favourable outcome of presumed cardiac origin underwent coronary angiography (6 cases) or endocavitary
                                     electrophysiological investigation (8 cases). These investigations showed or suggested an ischaemic process in 4 cases,
                                     an arrhythmia in 6 cases and severe valvular heart disease in 1 case. The independent predictive factors of survival were
                                     a Glasgow score of 6 or more on admission, the persistence of a light reflex and benign EEG appearances according to
                                     Synek's classification. The authors conclude that these results are comparable to those reported in the literature with
                                     aetiological investigations reserved for cases of favourable neurological outcome. The investigations including coronary
                                     angiography and electrophysiological investigation are essential as shown by the diversity of the cardiac pathologies
                                     identified.


Guerot (1996)                        Guerot, E., J. L. Diehl, et al. (1996). "[Long-term survival after extra-hospital cardiac arrest]." Presse Medicale 25(31):
                                     1430-4.

                                     Comments: Level 5, Fair quality, Neutral. Retrospective study with no matched group comparison. Mixed results.

                                     Abstract: Survival rate after out-of-hospital cardiac arrest varies according to evaluation criteria. It can be estimated that in
                                     22 to 63% of the cases, effective hemodynamic performance is restored although hospital mortality is much higher,
                                     reaching 63%. Death, frequent after prolonged cardiac arrest, is usually due to recurrent cardiac arrest or the effects of
                                     prolonged anoxia. Mortality in patients who survive the hospitalization period is approximately 20% during the year
                                     following discharge. Consequently one year after out-of-hospital cardiac arrest, only 5% of the patients are still alive. The
                                     quality of life varies greatly in these survivors; the course of neurological sequellae may be favorable in approximately half
                                     but leads to death in others. The primary factor predicting survival is the underlying pathology, highly influenced by age.
                                     Inversely, factors predicting a more favorable outcome include ventricular tachycardia as the origin of cardiac arrest,
                                     presence of other people at onset and rapid recovery of spontaneous hemodynamic activity. Loss of consciousness for
                                     more than 24 hours, defective bulbar reflexes and anomalies on the electroencephalogram are signs of gravity as are high
                                     blood glucose, major brain edema and abolition of somesthesic and auditive evoked potentials.


Hsu (1996)                           Hsu, J. W., C. D. Madsen, et al. (1996). "Quality-of-life and formal functional testing of survivors of out-of-hospital cardiac
                                     arrest correlates poorly with traditional neurologic outcome scales." Annals of Emergency Medicine 28(6): 597-605.

                                     Comments: Level 4, Good quality, Supporting. Retrospective study with a historical control group comparison. 48 subjects
                                     (moderate number compared to other studies). 66% said their QoL was as good or better than it was prior to arrest.
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                                     Abstract: STUDY HYPOTHESIS: The traditional (and unvalidated) five-point Cerebral Performance Category (CPC) score
                                     at hospital discharge does not correlate with the results yielded by a validated functional status instrument and subjective
                                     quality-of-life assessment. METHODS: We compared CPC scores with the results of prospective standardized testing
                                     after discharge in survivors of out-of-hospital cardiac arrest. Consenting survivors were tested with the validated
                                     Functional Status Questionnaire (FSQ), a subjective quality-of-life assessment, and traditional CPC scoring. RESULTS:
                                     Of the 3,130 arrests during the 52 months of the study, 93 patients survived. Thirty-five patients were tested (71% of
                                     those eligible at the time of follow-up). Of these patients, 34% said their quality of life was worse, 38% said it was the
                                     same, and 28% said it was better than before the cardiac arrest. Fifty-four percent of patients scored normally on all FSQ
                                     subscales, but the remainder had an average 2.1 areas (of 6) with significant impairment. CPC score correlated very
                                     poorly with quality-of-life rating and with all scores and subscores on the FSQ. A CPC of 1 on discharge (supposedly
                                     normal function) had a sensitivity of 78%, a specificity of 43%, a positive predictive value of 64%, and a negative
                                     predictive value of 60% for quality of life the same as or better than that before arrest. With regard to ability to predict the
                                     presence of any major areas of impairment on the FSQ, the respective figures were 32%, 43%, 43%, and 32%.
                                     CONCLUSION: The CPC score, relied on as a measure of functional outcome in cardiac arrest, correlates poorly with
                                     subsequent subjective quality of life and with validated objective functional testing instruments, and conclusions based on
                                     it are suspect. Future researchers should employ standardized testing instruments.


Hugo (2002)                          Hugo, S., E. Borner Rodriguez, et al. (2002). "Quality of life in long-term survivors of out-of-hospital cardiac arrest."
                                     Resuscitation 53(1): 7-13.

                                     Comments: Level 4, Excellent quality, Supporting. Consecutive case series of 50 patients who survived cardiac arrest with
                                     comparison group. 49 of 50 felt life was worth living and there were no significant differences psychological tests between
                                     groups. There were differences in overall health, but these differences did not affect psychological outlook.

                                     Abstract: Study objective: The quality of life in long-term survivors of out-of-hospital cardiac arrest may be a good
                                     outcome measure after resuscitation. Therefore, the psychosocial situation and quality of life in such patients after
                                     successful resuscitation was evaluated. Methods: Patients with out-of-hospital cardiac arrest in a community referred to a
                                     single tertiary care centre were compared with matched controls. Quality of life was evaluated in 50 consecutive arrest
                                     cases (40 males, 10 females; 60(plus or minus)13 years) 5-68 months (mean 31.7) after resuscitation according to
                                     American Heart Association protocols. Results: The Psychological General Well-being Index questionnaire indicated no
                                     significant differences in anxiety, depression, vitality, general well-being, or self-control between patients and controls.
                                     However, the Nottingham Health Profile questionnaire demonstrated significant decreases in physical mobility (14.5(plus
                                     or minus)18.1 vs. 4.0(plus or minus)8.5, P=0.0001), energy levels (25.3(plus or minus)31.0 vs. 2.0(plus or minus)8.0,
                                     P=0.0001), emotional reactions (11.3(plus or minus)16.6 vs. 4.0(plus or minus)10.2, P=0.009), and sleep patterns
                                     (19.2(plus or minus)28.6 vs. 8.4(plus or minus)16.7, P=0.023) in the arrest patients. Little differences were measured with
                                     the Everyday-Life Questionnaire. 49 of the 50 arrest patients judged their situation after resuscitation worth living; no
                                     significant changes in familial, and psychosocial parameters occurred. Conclusions: The quality of life was associated with
                                     few changes in psychosocial profile after successful resuscitation. The subjective negative factors bore little impact on the
                                     quality of daily living in our patients. Thus, continued efforts to improve out-of-hospital resuscitation measures for cardiac
                                     arrest are justified since long-term survivors can expect a good quality of life after successful resuscitation.

Kamphuis (2002)                      Kamphuis, H. C., J. R. De Leeuw, et al. (2002). "A 12-month quality of life assessment of cardiac arrest survivors treated
                                     with or without an implantable cardioverter defibrillator." Europace 4(4): 417-25.

                                     Comments: Level 5, Good quality, Supporting. 168 cardiac arrest survivors were surveyed. Primary focus was to study
                                     two different treatments for post-cardiac arrest patients. Both treatments showed a good quality of life.

                                     Abstract: BACKGROUND: Previous studies indicate that the implantable cardioverter defibrillator (ICD) has a large impact
                                     on the quality of life of patients. The effects of having an ICD over longer periods of times has been less studied.
                                     OBJECTIVE: To assess the quality of life and well-being of cardiac arrest survivors who have received an implantable
                                     cardioverter defibrillator (ICD) or other treatment. METHODS: 168 patients were monitored for 1 year and completed four
                                     questionnaires. RESULTS: No differences were found between the two treatments regarding quality of life (except for
                                     pain, ICD patients perceived less pain) and well-being. A significant improvement in physical and social function, and in
                                     mental health was found in the first 6 months. Older patients (60 years or older) perceived less improvement in their
                                     health than younger patients. Women reported having poorer social function. The prevalence of anxiety and probable
                                     depression was high irrespective of the treatment received: anxiety and depressive symptoms did not change significantly
                                     between 1 and 12 months after discharge. Patients with higher anxiety scores experienced less improvement in health
                                     and patients with more depressive symptoms experienced poorer social function. CONCLUSIONS: The prevalence of
                                     anxiety and probable depression was high in cardiac arrest survivors. Probable depression affected social function. Those
                                     patients who felt anxious experienced less health improvement. Quality of life and well-being were not affected by the type
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                                     of treatment. We conclude that surviving an out-of-hospital cardiac arrest has a greater impact on patients than the
                                     treatment received.


Kliegel (2002)                       Kliegel, A., W. Scheinecker, et al. (2002). "Hurrah - We are still alive! A different dimension in post-resuscitative care: The
                                     annual gathering of cardiac arrest survivors at a typical Viennese wine tavern." Resuscitation 52(3): 301-304.

                                     Comments: Level 5, Fair quality, Supporting. Anecdotal reporting of group of cardiac arrest survivors at reunion with
                                     caregivers. Photograph of group of survivors standing and waving to camera could be construed to demonstrate strong
                                     evidence of the value of CPR/ECC.

                                     Abstract: Active follow-up after patients are transferred from the emergency department is frequently difficult, but
                                     essential to our aim of bringing about an improvement in the patients outcome and quality of life. In our experience, many
                                     survivors of cardiac arrest experience difficulties in returning to a normal lifestyle after the incident. Fear, loneliness and
                                     depression are common symptoms and close family members are sometimes unable to improve matters. On the other
                                     hand, we have seen patients in the post-resuscitation phase who regain the will to live, with resilience and good spirits.
                                     Some patients see the incident as an opportunity to start life anew and generate a new mental capacity. They view life
                                     from a different perspective and are able to enjoy the time at their disposal more than ever before. In our attempts to get
                                     to know as many facets of life after resuscitation as possible, we have managed to involve an appreciable number of
                                     cardiac arrest survivors and their families in specific projects. For the most part, the projects are related to CPR training,
                                     including the family use of an automated external defibrillator (AED). This year, we also initiated the foundation of a
                                     support group for cardiac arrest survivors and immediate members of their families. This group is led by four patients.

Kuilman (1999)                       Kuilman, M., J. K. Bleeker, et al. (1999). "Long-term survival after out-of-hospital cardiac arrest: an 8-year follow-up."
                                     Resuscitation 41(1): 25-31.

                                     Comments: Level 5, Excellent quality, Supporting. Retrospective study with no matched control group. Examined survival
                                     at 1, 3, 5, & 7 years and determined QoL was satisfactory for survivors at each milestone.

                                     Abstract: Between 1988 and 1994, 441 patients were successfully resuscitated outside hospital in the city of Rotterdam,
                                     of whom 276 (63%) were discharged from hospital alive. Long-term survival was studied amongst those who were
                                     discharged alive. The duration of follow-up averaged 6.71 years. A survival rate of 88% after 1 year, 81% after 3 years,
                                     77% after 5 years and 73% after 7 years was found. After multivariate analysis, age, diagnosis and gender were found to
                                     be independent and significant predictors of survival. No significant difference in survival was found in patients who had
                                     been resuscitated by emergency personnel, physicians and bystanders. Patients who were still alive were sent a EuroQol-
                                     questionnaire. No differences in outcomes between the four groups were found. Since long-term prognosis after out-of-
                                     hospital resuscitation is satisfactory, learning programmes for resuscitation should be continued.


Ladwig (1999)                        Ladwig, K.-H., A. Schoefinius, et al. (1999). "Long-acting psychotraumatic properties of a cardiac arrest experience."
                                     American Journal of Psychiatry 156(6): 912-919.

                                     Comments: Level 4, Excellent quality, Neutral. Retrospective study of 45 cardiac arrest survivors with a comparison
                                     group. Focused on posttraumatic stress disorder as a measure of functioning. Most measures of comparison showed
                                     nonsignificant results with exception of posttraumatic stress disorder and the ability to concentrate. Authors stated there
                                     was a “prevalence of emotional disability and impairment of quality of life in cardiac arrest survivors.” I characterized this
                                     study as neutral due to balance of significant versus nonsignificant findings.

                                     Abstract: Objective: Progress in resuscitation medicine allows an increasing proportion of patients to survive an out-of-
                                     hospital cardiac arrest. However, little is known about long-term adaptation to the vital breakdown. The present study
                                     assessed the long-term prevalence and severity of emotional disability of cardiac arrest survivors and ascertained
                                     whether survivors suffer from recurrent and intrusive recollections of the cardiac arrest. Method: Follow-up analysis was
                                     performed on all cardiac arrest survivors discharged from the hospital over a 5-year interval (1990-1994) in a defined
                                     inner city and suburban area. From 118 initially hospitalized cardiac arrest survivors, 45 patients were discharged alive
                                     from the hospital. After a mean follow-up period of 39 months (range=22-64), 25 patients exhibited sufficient cerebral
                                     performance for psychodiagnostic assessment; 21 patients were assessed. Results: Despite an impaired ability to
                                     concentrate, cardiac arrest survivors had levels of psychological adjustment at follow-up that were similar to those of 35
                                     cardiac patients whose clinical course was not complicated by cardiac arrest. However, the diagnosis of psychotraumatic
                                     symptoms in cardiac arrest survivors led to a sharp separation between favorable and nonfavorable outcome in affective
                                     regulation and level of functioning. Of the cardiac arrest patients, those with high scores of intrusion and avoidance (N=8)
                                     reported an enduring sense of demoralization with significantly more somatic complaints, depression, anxiety, lack of
                                     confidence in the future, and narrowing of social activities than those with low scores (N=11). Long-acting sedation at
                                     illness onset significantly predicted a favorable outcome. Conclusions: This study provides the first empirical evidence that
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                          Page 15 of 26



                                     the application of the posttraumatic stress disorder paradigm in the long-term evaluation of cardiac arrest survivors
                                     significantly contributes to defining a patient population at high risk for serious emotional disability.

Lederer (2004)                       Lederer, W., C. Lichtenberger, et al. (2004). "Long-term survival and neurological outcome of patients who received
                                     recombinant tissue plasminogen activator during out-of-hospital cardiac arrest." Resuscitation 61(2): 123-9.

                                     Comments: Level 5, Fair quality, Supporting. Retrospective study with no matched control group. 27 Subjects (low
                                     number compared to other studies). Patient group was somewhat specialized as they all received TPA. Majority reported
                                     good overall QoL.

                                     Abstract: Objective: The long-term outcome in patients who received recombinant tissue plasminogen activator during
                                     cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) of non-traumatic aetiology was assessed.
                                     Methods: The neurological outcome in survivors and their level of performance, subjective well-being and quality of life
                                     were evaluated. Results: A follow-up study of 27 cardiac arrest survivors was conducted; four patients (15%) died during
                                     the first year, a total of seven patients (26%) within 5 years. Twenty-two patients (81%) were discharged from hospital
                                     without neurological deficit (cerebral performance category (CPC) score: 1), three patients scored CPC 2 and two patients
                                     CPC 3. Heart failure classification on discharge was, according to the New York Heart Association (NYHA) criteria
                                     [Formula: see text]. Fifteen patients (56%) managed to return to their previous level of activity. At the time of follow-up 18
                                     patients (67%) were still alive, of whom 15 responded to a survey regarding life satisfaction. Thirteen patients (87%)
                                     judged their situation to be worth living and twelve (80%) considered their survival a second chance, while five (33%)
                                     feared they could suffer another cardiac arrest. Reactions from close relatives included fear/anxiety ( [Formula: see text];
                                     78%), a sustained burden on family life ( [Formula: see text]; 67%), and occasional depression ( [Formula: see text];
                                     39%). Conclusions: Thrombolytic therapy during cardiopulmonary resuscitation may produce a favourable neurological
                                     outcome. The majority of long-term survivors reported a good subjective quality of life. In one-third of close family
                                     members some negative factors had a lasting impact on the quality of daily living.


Martin-Castro (1999)                 Martin-Castro, C., M. Bravo, et al. (1999). "[Survival and the quality of life in extrahospital cardiorespiratory arrest]."
                                     Medicina Clinica 113(4): 121-3.

                                     Comments: Level 3, Fair quality, Supporting. Prospective study with no matched control group. 9 Subjects (very low
                                     number compared to other studies). Patient group was somewhat specialized as they all received TPA. Majority reported
                                     good overall QoL.

                                     Abstract: BACKGROUND: There are few data in Spain on out-of-hospital cardiac arrest and the efficacy of emergency
                                     systems. The objectives of the present study were to evaluate an emergency system, comparing survival at hospital
                                     discharge according to the origin, cardiac or non-cardiac, of cardiac arrest in out-of-hospital critically ill patients, and to
                                     describe the quality of life of the survivors. PATIENTS AND METHODS: Prospective study on 282 patients treated during
                                     1995 and 1996 by ICU ambulances units of the Andalusian Public Health Emergency Company (061) in Granada, Almeria
                                     and El Ejido-Poniente (Spain). The Utstein style was followed, gathering the mortality at different times up to 6 months
                                     after hospital discharge and the origin (cardiac/non-cardiac) of the arrest. Quality of life 6 months after discharge was
                                     collected among survivors. RESULTS: Advanced cardiopulmonary resuscitation (CPR) was applied to 176 (62.4%)
                                     patients. The survival rate to discharge was 4.9% for patients with cardiac etiology (7/142 x 100) and 5.9% for those with
                                     non-cardiac etiology (2/34 x 100), with non-significant differences between the two groups. An optimal quality of life in all
                                     domains, except for pharmacological dependence in seven, was found in the eight survivors 6 months after hospital
                                     discharge. CONCLUSIONS: The origin (cardiac/non-cardiac) of out-of-hospital cardiac arrest is not associated with
                                     survival at hospital discharge. The survivors exhibit an optimal quality of life 6 months after discharge.


Motzer (1996)                        Motzer, S. U. and B. J. Stewart (1996). "Sense of coherence as a predictor of quality of life in persons with coronary heart
                                     disease surviving cardiac arrest." Research in Nursing & Health 19(4): 287-98.

                                     Comments: Level 5, Good quality, Supporting. Retrospective study with no matched control group. 149 Subjects (high
                                     number compared to other studies). Subjects reported a strong score (5.3 out of 7.0) for their QoL.

                                     Abstract: The unique contribution of sense of coherence to explained variance in quality of life was studied in 149 persons
                                     with coronary heart disease who survived cardiac arrest. Using hierarchical multiple regression, 16 predictors, including 5
                                     social status variables related to poor health vulnerability, perceived social support, self-esteem, and 9 variables reflecting
                                     instability and work of the chronic illness trajectory, accounted for 50% of variance in quality of life. The addition of sense
                                     of coherence resulted in a 15% increment to the explained variance (total R2 = .64). As a strong independent predictor of
                                     quality of life, sense of coherence has promise as a variable that might be strengthened by nursing interventions and
                                     merits continued study.
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Mohr (2001)                          Mohr, M., K. Bomelburg, et al. (2001). "Attempted CPR in nursing homes - Life-saving at the end of life?" Anasthesiologie
                                     Intensivmedizin Notfallmedizin Schmerztherapie 36(9): 566-572.

                                     Comments: Level 5, Fair quality (small number of subjects in study, population was outside general population –
                                     considered excluding for this reason), Negative. Retrospective with no comparison group. Nursing home patients were
                                     focus of study. Of 46 patients who were not pronounced dead at scene, only 13 had ROSC. Only 2 survived to DC but
                                     both had severely impaired functioning.

                                     Abstract: Aim: We studied the course and success rate of cardiopulmonary resuscitation (CPR) attempted on nursing
                                     home residents by a physician-staffed pre-hospital advanced cardiac life support (ACLS) team. Methods: Ambulance
                                     records of nursing home residents from Goettingen/Germany who had a cardiac arrest were examined retrospectively.
                                     Results: During a seven-year period (1992-1998) the ACLS team was called to 71 residents (mean age 81.8 years) who
                                     sustained cardiac arrest. In 25 patients no CPR was attempted: 20 were pronounced dead by the arriving emergency
                                     physician, though only in 7 patients obvious clinical signs of death were present. Five patients suffered from a continuous
                                     deterioration of their health status and the ACLS team arrived after the process of dying had already started. No CPR
                                     attempt was initiated. The ACLS team performed CPR on 46 nursing home residents. In 33 patients (72% of CPR
                                     attempts) no return of spontaneous circulation (ROSC) was achieved. In three patients (6%) palpable pulse returned only
                                     transiently. Ten patients (22%) who showed ROSC were transported to the hospital. Six patients died within 24 hours
                                     after having been admitted to the hospital, two patients within the next 8 days. Two patients survived to hospital
                                     discharge. The first was a 79-year old woman who returned to the nursing home after three weeks and survived severely
                                     mentally disabled another five days. The second was an 83-year-old man who was hospitalised for 20 days, returned in a
                                     persistent vegetative state to the nursing home and died 10 months later. A comparison of the arrest characteristics
                                     demonstrated that in patients with successful CPR there was a higher incidence of a witnessed collapse, bystander CPR,
                                     ventricular fibrillation and cardiac aetiology of arrest. Conclusion: In a high rate (35%) the ACLS team with the emergency
                                     physician at the scene withheld CPR efforts in nursing home residents. Even if CPR was initiated, the benefits were very
                                     limited with only two patients (4,3%) surviving severely disabled to hospital discharge.

Nichol (1999)                        Nichol, G., I. G. Stiell, et al. (1999). "What is the quality of life for survivors of cardiac arrest? A prospective study."
                                     Academic Emergency Medicine 6(2): 95-102.

                                     Comments: KEY ARTICLE - Level 3, Excellent quality, Supporting. Prospective study with control group. 86 Subjects
                                     (high number compared to other studies). Good QoL based on testing instrument.

                                     Abstract: OBJECTIVE: To evaluate the quality of life of survivors of in-hospital and out-of-hospital cardiac arrest, and to
                                     correlate quality of life with clinically important parameters. METHODS: Cohort followed at least six months after hospital
                                     discharge. Eligible patients had survived to hospital discharge after sudden cardiac arrest in 1) EDs, wards, and intensive
                                     care units of five university hospitals and 2) all locations outside hospitals in two midsized cities. Of 126 patients
                                     discharged alive, 30 died before they could be interviewed. Of the 96 patients remaining, 86 (90% of available patients,
                                     68% of survivors to discharge) completed the interview. Quality of life was assessed with the Health Utilities Index Mark 3,
                                     which describes health as a utility score on a scale from perfect health (equal to 1.0) to death (equal to 0.) RESULTS:
                                     Mean age (+/- SD) of interviewed survivors was 65 +/- 14 years, and 47 (55%) were male; mean time between collapse
                                     and initiation of CPR was 2.2 +/- 2.6 minutes. Mean utility was 0.72 (+/- 0.22). Utilities were significantly higher among
                                     patients who had a shorter duration of resuscitation (mean = 0.81 for those who received less than 2 minutes of CPR,
                                     0.76 for those who received 3 to 10 minutes, and 0.65 for others, p = 0.05, r2 = 0.07). Mean utilities of survivors were
                                     worse than those of the general population (mean = 0.85 +/- 0.16, p < 0.01) and those whose activities were not limited by
                                     chronic disease (mean = 0.91 +/- 0.08, p < 0.01). CONCLUSIONS: Although overall survival was poor, most survivors had
                                     acceptable health-related quality of life. Therefore, concerns about poor quality of life are not a valid reason to abandon
                                     efforts to improve the health care system's response to victims of sudden cardiac arrest. Further research is necessary to
                                     identify effective strategies for improving both survival and quality of life after cardiac arrest.


Nunes (2003)                         Nunes, B., J. Pais, et al. (2003). "Cardiac arrest: long-term cognitive and imaging analysis." Resuscitation 57(3): 287-97.

                                     Comments: Level 5, Fair quality, Supporting. Retrospective study with no matched control group. 11 Subjects (low
                                     number compared to other studies). Most had good CPC scores.

                                     Abstract: BACKGROUND: Neurological and cognitive sequelae resulting from cardiac arrest (CA), despite their potential
                                     personal and social impact, are usually not considered as major outcome measures in long-term analysis of survivors.
                                     The aim of this study is to analyze the contribution of neuropsychological testing and cerebral imaging to the development
                                     of a long-term classification of neurological impairment. PATIENTS AND METHODS: A total of 19 patients admitted over
                                     a 3 years period in an eight-bed intensive care unit of a tertiary care hospital with a diagnosis of CA were alive and
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                                     attended a 6-month follow-up consultation. Eleven of these patients agreed to participate in this study carried out between
                                     1 and 3 years after CA. Patients were classified using the Cerebral Performance Categories (CPC), neurological
                                     examination, detailed cognitive testing and computerized tomography (CT) scan with qualitative and quantitative imaging
                                     analysis. RESULTS: Six of the 11 patients had good cerebral performance. Verbal and visuo-spatial short-term memory
                                     scores were associated with CPC. All patients with at least moderate cerebral disability had abnormal verbal memory test
                                     results compared with only one survivor with CPC 1; visuo-spatial short-term memory was abnormal in four moderately
                                     affected survivors and normal in those with CPC 1. The bicaudate ratio evaluated in the CT scan was correlated with the
                                     verbal memory score while the III ventricle diameter correlated with the executive functions score, suggesting involvement
                                     of different brain areas in these functions. CONCLUSIONS: Neuropsychological and CT scan measurements are proxy
                                     measures of long-term impairment of CA survivors, providing a dichotomized global evaluation of CA survivors in close
                                     agreement with CPC.

Paniagua (2002)                      Paniagua, D., F. Lopez-Jimenez, et al. (2002). "Outcome and cost-effectiveness of cardiopulmonary resuscitation after in-
                                     hospital cardiac arrest in octogenarians." Cardiology 97(1): 6-11.

                                     Comments: Level 5, Good quality, Supporting. Retrospective study with no matched control group. 54 Subjects with
                                     survival (moderate number compared to other studies). Patient group was specialized (patient age greater than 80).
                                     Number needed to treat for long-term survival was 29.

                                     Abstract: CONTEXT: Octogenarians are the fastest growing segment of the population and little is known about the
                                     results of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest in this population. OBJECTIVE: We sought
                                     to investigate the clinical benefit and cost-effectiveness of CPR after in-hospital cardiac arrest in octogenarians. MAIN
                                     OUTCOME MEASURE: Years of life saved. DESIGN: Effectiveness data were obtained from a review of 91,372 hospital
                                     discharges from January 1st, 1993 until June 30th, 1996. Cardiac arrest was reported in 956 patients. The study group
                                     consisted of 474 patients > or = 80 years old. CPR costs included equipment and training, physician and nursing time and
                                     medications. Post-CPR expenses included in-hospital true cost, repeat hospitalizations, physician office visits, nursing
                                     home, rehabilitation, and chronic care hospital costs. Life expectancy of the patients who were still alive at the end of the
                                     study was estimated from census data. A utility of 0.8 was used to calculate quality-adjusted-life years saved (QALYS).
                                     We used a societal perspective for analysis. RESULTS: The study population was 86 +/- 4.8 years old (range 80-103),
                                     and 42% were male. Fifty-four patients (11%) were discharged alive, 35 to a chronic care facility and 19 to their home.
                                     Assuming that a cardiac arrest without CPR has 100% mortality, 12 octogenarians required treatment with CPR in order
                                     to save one life to hospital discharge. Similarly, 29 octogenarian patients with cardiac arrest have to be treated with CPR
                                     to net one long-term survivor (mean survival 21 months, with a range from 9 to 48 months). The cost-effectiveness ratio,
                                     after estimating the life expectancy of octogenarian survivors, was USD 50,412 per year of life saved, and USD 63,015
                                     per QALYS. However, a utility of 0.5 yielded a cost of USD 100,825 per QALYS. CONCLUSION: In comparison with other
                                     life-saving strategies, CPR in octogenarians is effective. The favorable cost-effectiveness ratio is highly dependent on the
                                     patients' preference for quality rather than quantity of life, as expressed by the utility assumptions.


Polo (2000)                          Polo, V., G. Ardeleani, et al. (2000). "[3-year-survival and quality of life after out-of-hospital heart arrest]." Annali Italiani di
                                     Medicina Interna 15(4): 255-62.

                                     Comments: Level 5, Excellent quality, Supporting. Retrospective study with no matched control group. 468 Subjects (very
                                     high number compared to other studies). 64% of survivors had satisfactory QoL.

                                     Abstract: Although the long- and short-term aspects of the outcome of advanced cardiopulmonary resuscitation on
                                     patients have been studied to evaluate the percentage of survival up to the moment of discharge from hospital, little
                                     information has been published concerning the patients' long-term quality of life. In order to verify the efficiency of our
                                     group we retrospectively evaluated 468 subjects admitted to the Emergency Room of Rho Hospital (Milan, Italy) for out-of-
                                     hospital cardiac arrest that had occurred over a 90-month period. We studied the correlations between some variables:
                                     epidemiological (sex and age), objective (time required for advanced cardiopulmonary resuscitation and type of
                                     arrhythmias in the Emergency Room) and instrumental (left ventricular ejection fraction) and post-discharge survival. We
                                     also considered the state of health of the survivors by means of a questionnaire on their quality of life. Our data show that:
                                     a) 10.25% of the patients were discharged alive; b) younger men (< 65 years old) admitted with a ventricular fibrillation (p
                                     = 0.01) and those who had undergone advanced cardiopulmonary resuscitation for less than 25 min (p = 0.001) had a
                                     better survival rate at 3 years from discharge; c) 64% of the survivors have a satisfactory quality of life; d) younger age (p
                                     = 0.01) and cardiac left ventricular ejection fraction (> 40%) (p = 0.05) are positive predictors for future work capacity. In
                                     conclusion, we believe that the critical moment following advanced cardiopulmonary resuscitation is hospitalization
                                     because after discharge survival percentage abruptly increased from 10.25 to 65%.


Roewer (1985)                        Roewer, N., T. Kloss, et al. (1985). "[Long-term result and quality of life following preclinical cardiopulmonary
                                     resuscitation]." Anasthesie, Intensivtherapie, Notfallmedizin 20(5): 244-50.
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                                     Comments: Level 5, Good quality, Supporting. Retrospective study with no matched control group. 38 Subjects (moderate
                                     number compared to other studies). 32 of 38 had no deficits. Of 28 survivors interviewed, 68% said meaning of life
                                     unchanged and 7% said meaning improved.

                                     Abstract: The value of successful cardiopulmonary resuscitation (CPR) must be considered in the light of late outcome of
                                     survivors, including the neurological situation as well as the subsequent quality of life. We followed up the fates of 168
                                     patients (pts) primary successfully resuscitated by rescue helicopter and mobile intensive care unit of the rescue centre at
                                     the military hospital of Hamburg and admitted to emergency hospitals after heart action became stabilised. 130 pts died
                                     during hospitalisation and 38 pts (7.9% of 480 resuscitation attempts total) were discharged from hospital. 32 of them had
                                     no essential neurologic damage. Within the next 3 years after discharge from hospital 15 of the 38 survivors died (3-year-
                                     survival rate: 4.8% of all attempts of CPR or 60% of survivors). 4 of the 6 survivors with persistent cerebral damage died
                                     within 6 months after discharge from hospital. Interviews (n = 28) with survivors or their relatives provided information on
                                     social situation, physical and psychical condition after CPR as well as recollection of CPR. 29% (n = 8) became
                                     incapacitated for work after CPR. 68% considered meaning of life unchanged, 25% as limited and for 7% the incident had
                                     a positive effect concerning their outlook on life. 18% (n = 5) suffered from depressions after CPR. Reductions of physical
                                     efficiency (64%), of memory (68%) and of concentration capacity (61%) were realised. The majority of survivors did not
                                     remember anything, neither experiences of intubation nor of external cardiac massage. Only one patient thought he
                                     remembered the incident and reported about "blows on the chest". 89% considered resuscitation to be a sensible and
                                     important provision.(ABSTRACT TRUNCATED AT 250 WORDS)

Saner (2002)                         Saner, H., E. Borner Rodriguez, et al. (2002). "Quality of life in long-term survivors of out-of-hospital cardiac arrest."
                                     Resuscitation 53(1): 7-13.

                                     Comments: KEY ARTICLE - Level 4, Excellent quality, Supporting. Retrospective study with matched control group. 50
                                     subjects (high number compared to other studies). 49 of 50 subjects stated life was worth living after resuscitation.

                                     Abstract: STUDY OBJECTIVE: The quality of life in long-term survivors of out-of-hospital cardiac arrest may be a good
                                     outcome measure after resuscitation. Therefore, the psychosocial situation and quality of life in such patients after
                                     successful resuscitation was evaluated. METHODS: Patients with out-of-hospital cardiac arrest in a community referred to
                                     a single tertiary care centre were compared with matched controls. Quality of life was evaluated in 50 consecutive arrest
                                     cases (40 males, 10 females; 60+/-13 years) 5-68 months (mean 31.7) after resuscitation according to American Heart
                                     Association protocols. RESULTS: The Psychological General Well-being Index questionnaire indicated no significant
                                     differences in anxiety, depression, vitality, general well-being, or self-control between patients and controls. However, the
                                     Nottingham Health Profile questionnaire demonstrated significant decreases in physical mobility (14.5+/-18.1 vs. 4.0+/-
                                     8.5, P=0.0001), energy levels (25.3+/-31.0 vs. 2.0+/-8.0, P=0.0001), emotional reactions (11.3+/-16.6 vs. 4.0+/-10.2,
                                     P=0.009), and sleep patterns (19.2+/-28.6 vs. 8.4+/-16.7, P=0.023) in the arrest patients. Little differences were measured
                                     with the Everyday-Life Questionnaire. 49 of the 50 arrest patients judged their situation after resuscitation worth living; no
                                     significant changes in familial, and psychosocial parameters occurred. CONCLUSIONS: The quality of life was associated
                                     with few changes in psychosocial profile after successful resuscitation. The subjective negative factors bore little impact
                                     on the quality of daily living in our patients. Thus, continued efforts to improve out-of-hospital resuscitation measures for
                                     cardiac arrest are justified since long-term survivors can expect a good quality of life after successful resuscitation.

Sauve (1995)                         Sauve, M. J. (1995). "Long-term physical functioning and psychosocial adjustment in survivors of sudden cardiac death."
                                     Heart and Lung: Journal of Critical Care 24(2): 133-144.

                                     Comments: Level 4, Excellent , Supporting. Retrospective study with cohort group comparison. 61 subjects (high number
                                     compared to other studies). While reporting several areas of decreased functioning, overall status of the group was not
                                     deemed to have severe psychologic distress.

                                     Abstract: Objective: To identify and describe a range of functional health outcomes in a sample of sudden cardiac death
                                     survivors. Design: Cross-sectional survey. Setting: Northern California tertiary medical center. Subjects: Sixty-one sudden
                                     cardiac death survivors at least 6 months but not more than 4 years after cardiac arrest. Subjects were excluded if they
                                     had uncontrolled congestive heart failure unstable angina, other debilitating cardiac or concomitant illness, or evident
                                     cognitive deficits. Methods: Chart reviews, patient interviews, and a standardized questionnaire. Results: Survivors
                                     reported significantly poorer physical functioning than normal subjects (p < 0.001), although none were limited in self-care.
                                     Mental Health Index Scores and subscale scores for psychologic well-being were within established norms. However,
                                     mean scores for the psychologic distress subscale were elevated (p < 0.001). Initial work return was 72%. Of the 37
                                     (61%) survivors who were sexually active before their arrests, 78% resumed coitus. Twenty-five survivors reported mild to
                                     moderately sever impairments in memory or other cognitive skills. Poor physical functioning was associated with illness
                                     severity, change in work status, and increased anxiety. Psychologic distress was associated with change in work status
                                     and poor physical functioning, but not illness severity. Conclusions: Despite significant decreases in physical functioning
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                            Page 19 of 26



                                     and reports of mild to moderately severe cognitive impairments, only a minority of sudden cardiac death survivors are
                                     severely psychologically distressed. Illness severity is a strong predictor of physical functioning, but its contribution to
                                     psychologic distress is indirect, acting largely through the aegis of poor physical functioning and loss of prearrest work
                                     status.

Stiell (2003)                        Stiell, I., G. Nichol, et al. (2003). "Health-related quality of life is better for cardiac arrest survivors who received citizen
                                     cardiopulmonary resuscitation." Circulation 108(16): 1939-44.

                                     Comments: KEY ARTICLE - Level 3, Excellent quality, Supporting. Prospective study with cohort group comparison. 268
                                     subjects (very high number compared to other studies). Scored 8 attributes of health (vision, hearing, speech, ambulation,
                                     dexterity, emotion, cognition, pain). 1 year survival showed CPC scores of 86% good, 9% moderate, 6% severe, and no
                                     vegetative state or brain dead subjects. Scoring instrument showed no significant difference between cardiac arrest
                                     survivors and general population.

                                     Abstract: BACKGROUND: This study evaluated the prehospital factors associated with better health-related quality of life
                                     for survivors of out-of-hospital cardiac arrest. METHODS AND RESULTS: This prospective, 20-community, cohort study
                                     involved consecutive, adult out-of-hospital cardiac arrest patients who survived to 1 year. Patients were contacted by
                                     telephone and evaluated for the Health Utilities Index Mark III (HUI3), which describes health as a utility score on a scale
                                     from 0 (dead) to 1.0 (perfect health). The 8091 cardiac arrest patients had overall survival rates of 5.2% to hospital
                                     discharge and 4.0% to 1 year. We successfully contacted and evaluated 268 of 316 (84.8%) of known 1-year survivors.
                                     The median HUI3 score was 0.80 (interquartile range, 0.50 to 0.97), which compares well with age-adjusted values for the
                                     general population (0.83). Logistic regression identified 2 factors independently associated with very good quality of life
                                     (HUI3 >0.90) and their odds ratios (95% CIs), as follows: age 80 years or older, 0.3 (0.1 to 0.84), and citizen-initiated
                                     cardiopulmonary resuscitation (CPR), 2.0 (1.2 to 3.4) (Hosmer-Lemeshow goodness-of-fit statistic, 0.74).
                                     CONCLUSIONS: This study is the largest ever conducted for out-of-hospital cardiac arrest survivors, clearly shows that
                                     these patients have good quality of life, and is the first to demonstrate that citizen-initiated CPR is strongly and
                                     independently associated with better quality of life. These results emphasize the importance of optimizing community
                                     citizen CPR readiness. Given the low rate of citizen-initiated CPR in many communities, we believe that local and national
                                     initiatives should vigorously promote the practice of bystander CPR.

Sunnerhagen (1996)                   Sunnerhagen, K. S., O. Johansson, et al. (1996). "Life after cardiac arrest; a retrospective study." Resuscitation 31(2):
                                     135-40.

                                     Comments: Level 4, Good quality, Neutral. Retrospective study with no matched cohort group. Questionnaire and
                                     interviews indicated high degree of ability for independent living among survivors.

                                     Abstract: AIM: We decided to evaluate the life situation of the survivors after out-of-hospital cardiopulmonary resuscitation
                                     (CPR). METHOD: CPR survivors who were 75 years or younger at the time and who were discharged alive from the
                                     hospital were identified consecutively. Average follow-up time was 25.5 months, and at follow-up 24% were deceased and
                                     9% were lost. A questionnaire was completed by 93% and 71% were positive to an interview. RESULTS: Cognitive
                                     functions were reduced as well as capacity to perform activities in daily living. This resulted in dependence on other
                                     persons for living (nursing homes) and a low return to work. Social isolation was a common complaint. The survivors also
                                     reported lower pain awareness than the reference population. As far as other aspects of health-related quality of life, this
                                     small group show many similarities with previously evaluated post-infarction patients. CONCLUSION: Lower pain
                                     awareness should be taken into consideration when the CPR patients have ischemic heart disease. If possible, try to
                                     prevent social isolation.


Van Alem (2004)                      van Alem, A. P., R. A. Waalewijn, et al. (2004). "Assessment of quality of life and cognitive function after out-of-hospital
                                     cardiac arrest with successful resuscitation." American Journal of Cardiology 93(2): 131-5.

                                     Comments: KEY ARTICLE - Level 3, Excellent quality, Supporting. Prospective study with cohort group comparison. 174
                                     subjects (high number compared to other studies). QoL testing instrument compared against general population. 77% of
                                     patients had independent functioning.

                                     Abstract: This prospective cohort study evaluated the impact of the time-related elements of the "chain of survival" on the
                                     quality of life of patients, taking their characteristics into account. Between 1995 and 2002, consecutive, out-of-hospital
                                     cardiac arrest patients from Amsterdam and the surrounding areas were included in this study. A total of 227 patients
                                     (12%) survived to hospital discharge and 174 were definitive survivors who were available for assessment at 6 months.
                                     Quality of life was measured with the 136-item Sickness Impact Profile (SIP); cognitive functioning was assessed through
                                     the Mini Mental State Examination. SIP profiles were compared with profiles of an open Dutch population of the elderly
                                     and patients who experienced a stroke. Time intervals of the chain of survival were calculated from the estimated moment
67fbdd79-49f2-43cc-b3de-e3aaf6e01801.doc                                                                                                            Page 20 of 26



                                     of collapse and related to outcome using regression analysis. The SIP profile of survivors was a little above the reference
                                     profile, indicating a slightly poorer quality of life, and below the profile of patients after stroke, indicating a better quality of
                                     life. Impaired cognitive function was associated with delay in the start of cardiopulmonary resuscitation (odds ratio 4.3,
                                     95% confidence interval 1.0 to 19). Absence of the need for advanced cardiopulmonary life support was associated with
                                     better cognitive functioning (odds ratio 0.3, 95% confidence interval 0.1 to 0.9). Female gender and older age were
                                     associated with impaired physical functioning. Trends were found for better outcomes after early access, immediate
                                     resuscitation, early defibrillation, and early advanced care.


Wernberg (1979)                      Wernberg, M. and A. Thomassen (1979). "Long- and short-term mortality rates in patients who primarily survive cardiac
                                     arrest compared with a normal population." Acta Anaesthesiologica Scandinavica 23(3): 211-6.

                                     Comments: Level 5, Good quality, Supporting. Retrospective study with matched control group. 180 Subjects (very high
                                     number compared to other studies). Mixed results that showed mortality at 3 years post event was similar with general
                                     population and cardiac function was satisfactory, but only 50% resumed prior level of activity. .

                                     Abstract: This is a follow-up study of 180 survivors after cardiac arrest outside intensive care and coronary care units. The
                                     follow-up extended over 0.5 to 8.5 years (averaged 4.3 years) after the primary cardiac arrest. Of the patients, 72 (40%)
                                     were discharged from hospital, 13 with anoxic brain damage. Thirty-ourred in 43% after 2 years, and in 50% after 3 years.
                                     After that time, the mortality was similar to that of a comparable normal population. At the end of the study, 34 patients
                                     were still alive, including eight with neurological sequelae. Their present cardiac function was satisfactory in the majority
                                     (59%) of the patients falling into group I or II of the American Heart Association classification. Their social situation,
                                     however, left much to be desired, as only 50% had fully or partly regained their previous level of activity.


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