On Monday, Bronny James, the 18-year-old son of basketball superstar LeBron James, suffered a cardiac arrest during a routine workout at the University of Southern California. According to ESPN News, he was transferred to the hospital, was initially in the ICU but is now in stable condition.
Cardiac arrest is a rare event; however, according to the Los Angeles Times, this was the second cardiac arrest in about a year for the men’s basketball team. Last July, center Vince Iwuchukwu collapsed at a practice last July after suffering a cardiac arrest. And in January of this year, millions watched as Damar Hamlin, a 24-year-old safety for the Buffalo Bills, experienced a cardiac arrest, dropping to the ground after what appeared to be a routine tackle.
As a result of these events, the public has learned a great deal about cardiac arrest – what can cause it, who is at risk, how often it occurs. However, the media coverage often brushes over an important aspect of this experience.
What are the psychological aftereffects of cardiac arrest? This is a sudden, unexpected, life-threatening and life-changing event. Although primarily a cardiac event, sudden cardiac arrest is more appropriately conceptualized as a chronic condition associated with neurological, functional, and psychological challenges.
Alexander Presciutti, MA, MSCS, PhD from the Center for Health Outcomes and Interdisciplinary Research (CHOIR) has been studying the psychological effects of cardiac arrest. His work has focused on the impact of cardiac arrest on survivors and their families, and has explored the role of psychological interventions in improving outcomes and reducing the risk of adverse psychological effects.
In order to gain a more nuanced understanding of the challenges faced by cardiac arrest survivors and their perspective on how to improve the recovery process, Presciutti and his colleagues have been examining the experiences of long-term cardiac arrest survivors and their caregivers. For this project, members of the Sudden Cardiac Arrest Foundation, an online support group network of cardiac arrest survivors, were invited to participate in an online survey, and a subset of long-term survivors completed one-on-one interviews as part of a qualitative study.
Significant Risk of Psychiatric Symptoms in Survivors and Caregivers
As part of the online survey, 169 survivors (mean age at arrest 50.8 years, 49.7% women, mean time since arrest 62.8 months) and 52 caregivers (mean age 48.7 years at the time of their loved one’s arrest, 86.5% women, mean time since arrest 43.2 months) completed questionnaires assessing post-traumatic symptoms, depression, anxiety, and quality of life.
About 1 in 4 cardiac arrest survivors (24.9%) showed significant post-traumatic stress; even more caregivers (34.6%) reported post-traumatic stress symptoms. On the Patient Health Questionnaire-4 (PHQ-4), 21.3% of the survivors and 21.2% of the caregivers reported significant depressive symptoms, and 29.6% of the survivors and 36.5% of the caregivers reported significant anxiety. Higher levels of post-traumatic stress, depression, and anxiety were associated with worse quality of life.
While the emergence of psychiatric symptoms, especially post-traumatic stress, is common after a life-threatening event, these symptoms may impact health outcomes. Previous studies have observed that early, elevated post-traumatic symptoms in cardiac arrest survivors were associated with a threefold greater likelihood of experiencing major adverse cardiovascular events and mortality within one year after discharge. It is also noteworthy that this study indicates the persistence of symptoms in survivors well beyond (2 to 8 years) the acute event. Especially concerning is a growing body of research from other studies indicating that depressive symptoms and anxiety may not only impact quality of life, but may negatively affect subsequent risk of morbidity and mortality.
The Lived Experience of Cardiac Arrest Survivors
With the goal of gaining more nuanced and specific information regarding recovery after cardiac arrest and patient-centered perspectives on how to improve recovery, Presciutti interviewed a subset of 15 cardiac arrest survivors. In this qualitative study, 53% (n=8) were women, 93% (n=14) were White. Survivors were interviewed on average 5 years after the event (range, 1.5 – 14 years), and their average age at arrest was 51 (range, 34–71 years). The sample was relatively affluent, with 80% of the sample reporting a household income of $100,000 or greater.
The study revealed several themes reflecting the challenges facing survivors of cardiac arrest.
Feeling Unprepared: Nearly every survivor reported feeling unprepared for survivorship, attributing this to a lack of appropriate resources and education relevant to recovery. Specifically, survivors reported that they did not receive information outlining accurate expectations for recovery, how to manage challenges, and how to understand and deal with non-cardiac symptoms.
“I had no expectation it would be as difficult, that any of this stuff would be as difficult as it has been.”
Often, survivors reported feeling “lost” because of this absence of resources, education, and appropriate expectations — the sense that nobody was there to point them in the right direction, that they lacked the specific information needed to negotiate their situation.
Non-Cardiac Symptoms: Most survivors did not anticipate experiencing non-cardiac symptoms (i.e., executive function and attention deficits, memory problems, brain fog, fatigue, disorientation) and were thus surprised and often frustrated when they experienced these symptoms.
“I think it would have helped me an awful lot if I could have had more of an explanation about what was actually wrong with me.”
“I was exhausted. I think that was the other thing, like, I was really surprised at how tired I was. You know, I can remember just trying to get my daughter ready to get picked up for school, and having a shower, and I was, like, ‘Oh, my god, I need to go back to bed.’ I was really surprised. So, I think we need education about what are the things to expect when you go home.”
Many survivors experienced post-traumatic stress symptoms and noted avoiding physical exertion or external reminders of the arrest (eg, location of arrest, hospitals), emotional numbing, and persistent, threatening somatic reminders of the trauma. Anxiety was manifested as rumination, fear of experiencing a repeat arrest, and anxiety about not knowing what caused the cardiac arrest. Survivors also reported depressive symptoms, including lack of motivation, lethargy, isolation, and feelings of doom and dread.
“Everything would be going fine, and then all of a sudden, you’d have this feeling of impending doom or dread, for no reason. And, you know, it would be there for a while, 20, 30 minutes.”
“For myself, when that situation [cardiac arrest] happened to me, I lost a lot of the drive and a lot of the ambition that I had. … And I just sort of like exist.”
“I think the depression and the doom and the dread and anxiety of what I’m facing didn’t really hit me until maybe about 9 months afterwards. I was kinda numb 6 to 9 months afterwards. … I was getting my affairs in order, getting beneficiaries changed, so I had a lot going on in my mind. I was getting ready to die.”
How Can We Improve Care for Cardiac Arrest Survivors?
The qualitative study also revealed long-term survivors’ recommendations for improving survivorship at multiple levels:
Systemic Recommendations: Survivors should receive resources, education, and information outlining appropriate expectations for recovery. This will require education of providers, consistent follow‐up from providers after discharge, and inclusion of caregivers throughout the hospitalization and beyond. Efforts are now in place to standardize the provision of domain‐specific services (eg, cognitive, physical, and psychological) in post–cardiac arrest management.
Social Recommendations: At the social level, survivors noted the importance of peer support groups, spending time with family and friends, and support for family members and caregivers. While directly addressing these social challenges may be beyond the purview of medical providers, survivors, their families and caregivers should be guided toward beneficial social resources, such as the Sudden Cardiac Arrest Foundation or the Sudden Cardiac Arrest Association. Of note, peer support groups have been shown to be effective in reducing psychological distress.
Individual Coping Recommendations: Survivors noted the value of acceptance, resilient coping, regaining control in one’s life, seeking treatment for non-cardiac symptoms, and focusing on meaning and purpose. Up to this point, survivors have needed to develop their own strategies for adaptation; however, behavioral health providers can draw from these recommendations and work with survivors to identify what works best for survivors. Psychotherapeutic interventions focused on meaning and purpose may be efficacious in addressing existential concerns. Further, targeting acceptance and resilience is efficacious in terms of preventing chronic emotional distress in individuals and caregivers after experiencing a traumatic medical event.
Presciutti notes that this research points to promising pathways that may improve cardiac arrest survivorship at systemic, social, and individual coping levels. Future studies could use these findings as targets for psychosocial interventions designed to support and improve survivorship. “As more people are surviving cardiac arrest now than ever before, there is a considerable survivorship base that needs emotional support. We are now focusing our efforts in developing interventions to build resiliency and prevent chronic emotional distress in these survivors and their families.”
Read More
Presciutti A, Siry-Bove B, Newman MM, Elmer J, Grigsby J, Masters KS, Shaffer JA, Vranceanu AM, Perman SM. Qualitative Study of Long-Term Cardiac Arrest Survivors’ Challenges and Recommendations for Improving Survivorship. J Am Heart Assoc. 2022 Jul 19;11(14):e025713.
Presciutti A, Newman MM, Grigsby J, Vranceanu AM, Shaffer JA, Perman SM. Associations between posttraumatic stress symptoms and quality of life in cardiac arrest survivors and informal caregivers: a pilot survey study. Resusc Plus 2021; 5:100085.
Presciutti A, Newman MM, Vranceanu AM, Shaffer JA, Perman SM. Associations between depression and anxiety symptoms with quality of life in cardiac arrest survivors with good neurologic recovery and informal caregivers of cardiac arrest survivors. J Affect Disord Rep. 2020; 2:100046.
Presciutti A, Shaffer JA, Newman M, Perman SM. Modifiable provider-patient relationship factors and illness perceptions are associated with quality of life in survivors of cardiac arrest with good neurologic recovery. Resusc Plus. 2020 Jun 12;3:100008.
Alexander Presciutti, MA, MSCS, PhD is a clinical psychology fellow at the Mass General Center for Health Outcomes and Interdisciplinary Research (CHOIR) and Harvard Medical School. He has focused on improving the quality of life and emotional well-being of those impacted by critical illness. At CHOIR, he is working with Dr. Ana-Maria Vranceanu on the Recovering Together study (NINR R01), which aims to build resiliency and improve emotional distress in neurocritical care patients and their informal caregivers. He plans to adapt this intervention for the cardiac arrest population.
Dr. Ana-Maria Vranceanu is a clinical health psychologist, Associate Professor of Psychology at Harvard Medical School, and Founding Director of the Center for Health Outcomes and Interdisciplinary Research (CHOIR). She is also the James and Elizabeth Gamble Endowed Chair Co-Director (Psychiatry) for MassGeneral Neurosciences, and Co-director for Grants Consultation and Support within the Department of Psychiatry. She is an expert in mind-body and lifestyle intervention development and testing. Dr. Vranceanu has served as Principal Investigator for over 20 research grants and has published more than 200 peer-reviewed articles. She is currently PI on several federally funded projects including: Active Brains Digital (NIA R01); Doorstep (NCCIH 34 with Cale Jacobs); Resilient Youth with Neurofibromatosis (DoD R01); Resiliency in Adults with Neurofibromatosis (DoD Ro1); Recovering Together (NINR R01); and Toolkit for Optimal Recovery (NCCIH R01).
