Cardiac Arrest Survivors Have Better Outlook Than Doctors Think
Every day something like 550 hospitalized Americans suffer cardiac arrest. That's bad news. Only about one in five will live to leave the hospital.
But for the lucky 44,000 a year who are resuscitated and survive, the outlook is much better than expected, authors of a new study say.
A year later, 60 percent of these survivors will still be alive, the study finds – substantially more than most doctors probably think. The vast majority won't have another cardiac arrest in that time, and a third won't need to be hospitalized again.
"That's huge," study author Paul Chan, a cardiologist at Mid-America Heart Institute in Kansas City, Mo., tells Shots. "That means the majority of patients are going to have at least reasonably meaningful quality of life for the first year."
According to Chan, they have a 45 percent chance of living for three years. "We have worse odds with cancer," Chan says, "and we're aggressively treating [that] with all sorts of complicated chemotherapies."
He notes the odds of surviving cardiac arrest three years after hospital discharge are about the same as for patients with heart failure, on whom medical resources such as heart-assist devices and intensive supportive care are lavished.
Chan's juxtaposition of cardiac arrest with cancer and heart failure is deliberately provocative.
His point is that there's a big disconnect between the gloomy attitude most doctors have about the "futility" of resuscitation attempts for patients with cardiac arrest versus their aggressive go-all-out stance toward even advanced cancers.
"We know that patients with advanced cancer often want to live, even if their expected survival [from treatment] is one or two months," Chan says.
Doctors' "nihilistic" attitude toward cardiac arrest, he says, strongly colors the attitudes of patients and their families, who often opt for "do not resuscitate" orders when they have a reasonable chance of surviving a year or more with acceptable quality of life.
The new calculations of the long-term prospects for survivors of in-hospital cardiac arrest are the first ever from a large national data base – a registry of 7,000 such episodes from 300 hospitals. The study is in this week's New England Journal of Medicine.
Asked if he thinks the new numbers might alter doctors' and patients' thinking about when to opt for a DNR order, Chan says: "I think they ought to."
The implications – at a time when the medical community is trying to minimize futile care and channel resources where they will do the most good – are potentially vast.
But to understand the meaning of the newly calculated survival odds, you need to look at the whole picture – from the cardiac arrest to the chances of being discharged from the hospital to the likelihood of being alive a year or two or three later.
A hospitalized person whose heart stops currently has a 22 percent chance of being successfully resuscitated and surviving to discharge, Chan says. That's substantially better than the 14 percent it was about a decade ago, but the stark fact is that nearly four out of five such patients don't make it.
Among those who do, the new data suggest that 40 percent will die in the year after discharge and 60 percent will survive.
Bottom line: For the person who suffers cardiac arrest in the hospital, the odds of being among the one-year survivors works out to about 12 percent, or one in eight.
"Twelve percent is not great odds," Chan says, "but it's not zero odds."
He says he didn't expect the odds to be as good as they are. Before the study, he thought one-year survival among those who leave the hospital would be around 25 percent, not 60 percent.
He was also surprised that survival was so good even among the oldest patients. "Even if you're 85 and older, you have a 50 percent chance of living to one year" if you make it to hospital discharge, Chan says.
Not everybody has an equal chance, though. African-Americans have lower survival, and the Kansas City researchers are trying to figure out if that's because they don't get as good care, before or after the leave the hospital.
Women do slightly better than men. And neurologic status matters a lot: 73 percent of those with mild or no brain damage are alive a year after discharge, versus 61 percent of those with moderate damage, 42 percent with severe damage and only 10 percent of those who were in coma after their cardiac arrest.
Chan says there's enormous variation from one hospital to another in the proportion of cardiac arrest patients who make it to discharge – only 10 percent for some hospitals, versus 40 percent at others.
That suggests there's a lot of room for overall improvement, if researchers can figure out how the top performers do it and replicate their best practices.
One further note: All the survival numbers above pertain only to patients whose hearts stop while they're in the hospital, where resuscitation attempts are supposed to occur within one minute, according to current guidelines.
Those whose arrest occurs at home or elsewhere in the community fare much worse. Only about four percent of them even make it to the hospital.