Cardiac arrest, stony heart, and cardiopulmonary resuscitation: An updated revisit

Abstract

The post-resuscitation period is recognized as the main predictor of cardiopulmonary resuscitation (CPR) outcomes. The first description of post-resuscitation syndrome and stony heart was published over 50 years ago. Major manifestations may include but are not limited to, persistent precipitating pathology, systemic ischemia/reperfusion response, post-cardiac arrest brain injury, and finally, post-cardiac arrest myocardial dysfunction (PAMD) after successful resuscitation. Why do some patients initially survive successful resuscitation, and others do not? Also, why does the myocardium response vary after resuscitation? These questions have kept scientists busy for several decades since the first successful resuscitation was described. By modifying the conventional modalities of resuscitation together with new promising agents, rescuers will be able to salvage the jeopardized post-resuscitation myocardium and prevent its progression to a dismal, stony heart. Community awareness and staff education are crucial for shortening the resuscitation time and improving short- and long-term outcomes. Awareness of these components before and early after the restoration of circulation will enhance the resuscitation outcomes. This review extensively addresses the underlying pathophysiology, management, and outcomes of post-resuscitation syndrome. The pattern, management, and outcome of PAMD and post-cardiac arrest shock are different based on many factors, including in-hospital cardiac arrest vs out-of-hospital cardiac arrest (OHCA), witnessed vs unwitnessed cardiac arrest, the underlying cause of arrest, the duration, and protocol used for CPR. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for better understanding and aggressive multi-disciplinary interventions and care. The development of stony heart post-CPR and OHCA remain the main challenges in emergency and critical care medicine.

Keywords: Cardiac arrest, Out-of-hospital cardiac arrest, In-hospital cardiac arrest, Post-resuscitation, Myocardial dysfunction, Cardiopulmonary resuscitation, Stony heart

Core Tip: Despite the advances in emergency and critical care management, the outcomes post-cardiac arrest (in-hospital or out-of-hospital) remain challenging. Post-cardiac arrest myocardial dysfunction and circulatory failure are the main predictors of cardiopulmonary resuscitation outcomes. The pattern, management, and outcome of these predictors differ between subjects based on many factors. A better understanding of the pathophysiology of these two predictors is of utmost importance to achieve better post-cardiac arrest outcomes. Although restoring spontaneous circulation is a vital sign, it should not be the end of the game or lone primary outcome; it calls for aggressive multi-disciplinary interventions and care.