Special to UM News

Ralph L. Sacco, M.D., M.S., and Robert J. Myerburg, M.D.

MIAMI, Fla. (July 7, 2015) — An expert committee assembled by the Institute of Medicine (IOM) has produced an important new report proposing methods for increasing survival rates and quality of life following cardiac arrest, and two prominent Miller School of Medicine physicians—cardiologist Robert J. Myerburg, M.D., and neurologist Ralph L. Sacco, M.D., M.S.—played key roles on the committee.

The report recommends seven courses of action, including a national database, new public education and training initiatives, and programs for improving response times in and out of hospitals.

Cardiac arrest strikes almost 600,000 people in the U.S. each year, killing the vast majority of them, according to the IOM report. Approximately 395,000 cardiac arrests occur in an out-of-hospital setting, of which less than 6 percent survive. Another 200,000 cardiac arrests occur in hospitals, and 24 percent of those patients survive. Estimates suggest that cardiac arrest is the third leading cause of death in the U.S., behind cancer and heart disease, as a general category.

“You have to put the statistics in perspective,” said Myerburg, professor of medicine and physiology and the American Heart Association Chair in Cardiovascular Research. “The out-of-hospital deaths account for approximately half of all cardiovascular deaths, and for half of them, death was the first manifestation of disease. This statistical pattern supports the notion that cardiac arrest can happen to anyone at any time.

“The key for out-of-hospital incidents is to have a good response system that gets there quickly,” Myerburg continued. “This is also why we need community buy-in. Public education and training in techniques like cardiopulmonary resuscitation [CPR] and automated external defibrillator [AED] deployment increase the likelihood of bystander intervention, which is critically important for improving outcomes, but underutilized.”

Following a cardiac arrest, each minute without treatment decreases the likelihood of surviving with good neurological outcomes, and survival rates depend greatly on where the cardiac arrest occurs, said the committee, which carried out the study over 18 months and wrote the report. In addition, there are wide variations in survival rates among communities and hospitals across the U.S.

“The goal is not just survival, but survival with good neurological recovery,” said Sacco, Professor and Olemberg Chair of Neurology and past President of the American Heart Association. “The longer it takes to perform CPR and get someone back into rhythm and into the nearest cardiovascular center for advanced post-cardiac arrest treatment, the more likely it is that they could have irreversible brain injury. Just as we have organized care for heart attacks, trauma, and stroke in this country, the report emphasizes that we need to do the same thing for cardiac arrest. In neurology, we say ‘time is brain,’ because every minute counts.”

Although the terms are often used interchangeably, cardiac arrest is different and medically distinct from a heart attack. A heart attack occurs when blood flow to an area of the heart is blocked by a narrowed or completely obstructed coronary artery, resulting in damage of heart muscle. Heart attack symptoms may include pain, dizziness, and shortness of breath, among others. Cardiac arrest results from a disturbance in the electrical activity of the heart that causes it to stop beating. The electrical disturbance can occur suddenly due to a heart attack, severe imbalance of electrolytes, or an inherited genetic mutation that predisposes to electric abnormalities. Symptoms include an almost instantaneous loss of consciousness. The treatment goal for a cardiac arrest is to facilitate the return of circulation and restore the electric rhythm, while for a heart attack, it is to reopen blocked arteries and restore blood flow.

Wide disparities in cardiac arrest outcomes have been documented — many due to variations in patient demographics and health status, geographic characteristics, and system-level factors affecting the quality and availability of care, such as rates of CPR knowledge among bystanders. For example, the committee found that more than 8 out of 10 cardiac arrests occur in a home setting, and 46 percent of in-home cardiac arrests are witnessed by another person. In addition, one study found that survival rates of cardiac arrests that occurred outside the hospital ranged from 7.7 percent to 39.9 percent across 10 North American sites. Risk-adjusted survival rates for cardiac arrests that occur in the hospital also vary by a 10.3 percent range between bottom- and top-decile hospitals.

Effective treatment for cardiac arrest demands an immediate response from an individual to recognize cardiac arrest, call 911, start CPR, and use an AED, the committee said. Decreasing the time between cardiac arrest onset and the first chest compression is critical. The likelihood of surviving decreases by 10 percent with every passing minute between collapse and return of spontaneous circulation, although new research offers hope in extending this time.

Although evidence indicates that bystander CPR and AED use can significantly improve survival and outcomes from cardiac arrest, each year less than 3 percent of the U.S. population receives CPR training, leaving many bystanders unprepared to respond to cardiac arrest. Furthermore, EMS systems vary in capacities and resources to respond to complex medical needs, such as cardiac arrests. National EMS-system oversight contributes to fragmentation and lack of coordination and planning in response to cardiac arrest, but some communities have demonstrated that focused leadership and accountability can overcome these barriers, the committee said. Educating and training EMS providers to administer “high-performance CPR” — which emphasizes team-related factors such as communication and collaboration to attain high-quality CPR — and provide dispatcher-assisted CPR can help increase the likelihood of positive outcomes.

To improve survival and quality of life following cardiac arrest, the committee recommended several actions:

• Establish a national registry of cardiac arrests to monitor performance, identify problems and track progress, nationally and within individual communities.
• Educate and train the public on how to recognize cardiac arrest, contact emergency responders, administer CPR and use AEDs, as well as facilitate state and local education departments to include CPR and AED training as middle- and high-school graduation requirements.

• Enhance performance of EMS systems, with an emphasis on dispatcher-assisted CPR and high-performance CPR.

• Develop strategies to improve systems of care within hospital settings, including setting national accreditation standards related to cardiac arrest for hospitals and health care systems.

• Adopt continuous quality improvement programs for cardiac arrest to promote accountability, encourage training and continued competency, and facilitate performance comparisons within hospitals and EMS and health care systems.

• Expand research in cardiac arrest resuscitation and promote innovative technologies and treatments, in addition to increased support for basic and translational science addressing the pathobiology of cardiac arrest and its mechanisms.

• Create a national cardiac arrest collaborative to unify the field and identify common goals.

“IOM reports are taken very seriously,” said Sacco. “All eyes will be on the responses of the stakeholders. It’s now a matter of setting priorities and timelines to get these recommendations established in the community. The implementation phase is beyond IOM, and it’s up to the external stakeholders to make things happen.”

The study was sponsored by the American Heart Association, American Red Cross, American College of Cardiology, Centers for Disease Control and Prevention, National Institutes of Health, and the U.S. Department of Veterans Affairs. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.