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CMHC PULSE

Cardio Metabolic Health Congress – Official Blog

Updated Cardiac Arrest Care Recommendations

Emergency medical services respond to over 347,000 cardiac arrest incidents per year, while the condition remains a leading cause of mortality and morbidity in the United States and worldwide. To assist clinicians in the treatment and care of these patients, the American Heart Association (AHA) releases regularly updated resuscitation guidelines for cardiac arrest survival, which have now been made available in a supplemental Circulation article.

The latest recommendations found in the 2020 Guidelines for Cardiopulmonary Resuscitation (CPR) and Cardiovascular Care emphasize the need for extended care outside of in-hospital and out-of-hospital restoration of the heartbeat; survival after cardiac arrest requires an integrated approach of people, training, equipment, and systems of care. An additional “recovery phase”– addressing treatment, surveillance, and rehabilitation – has been added to the Chain of Survival.

“Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to address the sequelae of cardiac arrest and optimize transitions of care to independent physical, social, emotional, and role function,” the authors wrote.

Emotional Recovery 

The guidelines stress the need for a structured assessment of anxiety, depression, post-traumatic stress, and fatigue in cardiac arrest survivors as well as their caregivers. They also recommend cardiac arrest survivors are engaged in a multimodal rehabilitation assessment and receive treatment for physical, neurological, cardiopulmonary, and cognitive impairments before being discharged from the hospital. It is essential to recognize the significant emotional toll cardiac arrest has on both patients and their caregivers. As such, emotional recovery needs to be prioritized. Cardiac arrest survivors and their caregivers need to receive comprehensive, multidisciplinary long-term recovery and treatment plans upon discharge, which should include medical and rehabilitative treatment recommendations as well as mental health support.

CPR Training and Education 

Given the socioeconomic disparities in CPR prevalence, CPR training and resuscitation education should be increasingly tailored to target the layperson, specific racial populations, and barriers that limit bystander CPR for female victims. Through educational training and improved public awareness efforts the likelihood of successful resuscitation efforts will rise. Replacing the prior recommendation of checking for pulse before beginning resuscitation, the new AHA guidelines highlight the need for CPR whenever cardiac arrest is suspected, due to the low risk of harm to a victim receiving chest compressions when not in cardiac arrest.

Updated Guidelines for Pregnancy and Children

In addition, the 2020 guidelines outline new recommendation for cardiac arrest care in children and pregnant women, including the following:

  1. Children are now included in the recommendation to have CPR prioritized over naloxone administration in case of suspected respiratory or cardiac arrest related to opioid overdose.
  1. Pediatric patients in particular should receive compression ventilation CPR, in which case rescue breaths should be targeted to 20-30 breaths per minute.
  1. Fetal monitoring should not be conducted during cardiac arrest in pregnant patients due to potential interference with maternal resuscitation.
  1. Comatose pregnant women should receive targeted temperature management with continuous monitoring of the fetus for bradycardia as a potential complication.

Finally, guidelines specific to the COVID-19 era have been outlined in interim guidance to better educate healthcare professionals as well as the general population on current recommendations issued to prevent viral transmission.

How the Burden of Chronic Diseases and COVID-19 Create a Syndemic Environment 

The emergence and overlap of the novel coronavirus with a continued global rise in chronic diseases – including persistently high rates of obesity, diabetes, and cardiovascular disease – as well as those driven by deteriorating environmental conditions have drastically exacerbated the COVID-19 death toll. While we are currently living in the midst of an unprecedented global public health crisis, the COVID-19 pandemic has highlighted the many structural elements that have been consistently failing in the background.

Ranging from racial health disparities and health access inequities to gaps in education and medically siloed communities, systemic public health failures drive our continuous battle against the virus. Critical sociopolitical and public health factors that have allowed many nations to successfully contain the viral outbreak are falling short in the United States. The burden of disease is growing exponentially as the devastation of the COVID-19 pandemic meets the underlying hot bed of chronic disease, further contributing to widening preexisting health gaps. Capacity constraints in healthcare facilities, widespread shortages of personal protective equipment, and vast disparities in mortality rates by race are symptoms of a much larger problem.

Syndemic of Chronic Diseases and COVID-19 

Rising rates of chronic disease, persistent infectious diseases, and public health failures have been largely responsible for the growing number of deaths during the COVID-19 viral outbreak, resulting in what The Lancet’s medical journal editor-in-chief, Richard Horton, refers to as a “syndemic.” Defined as the aggregation of two or more concurrent or sequential disease clusters, a syndemic or synergistic epidemic, attacks populations from multiple vulnerable levels – it will not be solved with the discovery of an effective treatment or the development of a COVID-19 vaccine.

In an article recently published in The Lancet, Horton argues against treating COVID-19 as a singular viral epidemic. Instead, he urges the scientific community along with public health officials to approach the current crisis with a multi-pronged strategy taking into consideration the aggregation of diseases at hand.

In his text, Horton writes: “Two categories of disease are interacting within specific populations—infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs). These conditions are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities.”

The Global Burden of Disease

Per data from a global study of human health, consistently rising rates of chronic diseases coupled with the surging COVID-19 outbreak have resulted in a situation much graver than a pandemic. As the most comprehensive study of its kind, the Global Burden of Disease Study analyzes 286 causes of death, 369 diseases and injuries, as well as 87 risk factors in 204 countries across the world to provide an overview of global population health. Currently, it is also proving valuable in determining the impact of COVID-19 – a virus that cannot be viewed as existing in a vacuum separate from the diseases it exacerbates.

The study reports that the leading causes of poor health in individuals aged 50 and above worldwide are cardiometabolic conditions namely, ischemic heart disease stroke, and diabetes.

While in younger demographics, those aged between 10 and 49 years, the primary causes are road injuries, HIV/AIDS, lower back pain, and depressive disorders.

Cardiometabolic conditions and immunodeficiencies are particularly dangerous when coupled with the novel coronavirus. Driving the more than 1 million deaths caused by COVID-19 to date are chronic health conditions that weaken population health, such as high blood pressure, high blood sugar, obesity, and high cholesterol. These in turn, result from unhealthy diets and poor physical activity levels, which will continue to shape population health across the world even after the pandemic subsides.

Looking to the Future 

The rise in chronic disease prevalence worldwide combined with public health failures have left many populations vulnerable to health emergencies such as the COVID-19 pandemic. Thus, approaching the virus outbreak from a syndemic perspective is vital to its successful eradication; targeting biological and societal factors is essential to improving prognosis, treatment, and public health policy.

Societal factors such as the vulnerability of older and minority citizens faced with disparities in healthcare access will not be solved by the introduction of a biomedical solution. Comprehensive policies are needed to reverse the many inequities plaguing the healthcare system per the syndemic approach, which prioritizes an integrated strategy to understanding and treating diseases. This will ultimately prove more successful than any attempt at merely controlling an epidemic of disease.

Combating the novel coronavirus will require focused attention on the non-communicable diseases and socioeconomic inequality increasing susceptibility and the likelihood of poor health outcomes. Addressing the COVID-19 pandemic means addressing the array of chronic diseases burdening the U.S. population. This includes improving obesity and diabetes management, optimizing cardiovascular and cancer care, as well as targeting preventative medicine strategies toward mitigating the health risk factors abundant in the population. Any other singular approach will leave individuals just as vulnerable to future iterations of COVID-19 or the next viral outbreak; a post-pandemic future will not be possible without the solution of the multitude of problems fueling it to begin with.