Stellate Ganglion Blockade to Reduce Cardiac Anxiety and PTSD Symptoms in Cardiac Arrest Survivors

Study Overview
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Brief Summary
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This is a pilot randomized controlled trial (RCT) to gain preliminary evidence regarding the acceptability, tolerability, safety, and efficacy of a combined intervention of Stellate Ganglion Blockade (SGB) and psychoeducation on trauma symptoms and health behaviors in patients exhibiting early PTSD symptoms after cardiac arrest (CA). Primary Aim 1 (Feasibility outcomes): Gain preliminary evidence regarding the acceptability, tolerability, and safety of conducting a randomized trial that evaluates a single SGB treatment in conjunction with psychoeducation among CA patients with early PTSD symptoms. Secondary Aim 1 (Treatment-related outcomes): Test, whether SGB/psychoeducation treatment in CA patients with clinically significant PTSD symptoms is associated with reduced cardiac anxiety, PTSD symptoms, and improved health behaviors (physical activity and sleep duration), assessed objectively by a wrist-worn accelerometer for 4 weeks post-discharge.

Detailed Description
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Every year in the U.S., 500,000 people experience sudden cardiac arrest (CA), caused by electrical disturbances across cardiac tissue, leading to marked arrhythmia that ultimately results in the heart ceasing to pump blood to the brain, lungs, and other organs. Due to advances in bundled post-arrest care, cardio-cerebral resuscitation, and effective cooling protocols, a substantial proportion of patients who receive guideline-based care (nearly 1 in 3 for out-of-hospital and  50% for in-hospital CA) now survive this once universally fatal condition. While most survivors retain their cognitive function and physical independence, many grapple with CA's psychological consequences in the context of learning that they were clinically dead. In particular, many describe the CA experience as traumatic, and up to 1 in 3 CA survivors subsequently develop posttraumatic stress disorder (PTSD). Not only is PTSD common in CA patients, but there is evidence that PTSD after CA may influence health behaviors and prognosis. Treatment of early PTSD and cardiac anxiety symptoms after CA requires timely intervention. Recent studies show that SGB is a safe and acceptable intervention for reducing PTSD symptoms in combat veterans. SGB treatment has never been tested to treat PTSD induced by acute medical events such as CA.

Official Title
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A Pilot Study of Stellate Ganglion Blockade + Psychoeducation to Reduce Cardiac Anxiety and PTSD Symptoms in Cardiac Arrest Survivors

Conditions
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PTSD, Cardiac Arrest, Anxiety and Fear, Sleep Disturbance, Health Behavior

Intervention / Treatment
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* Procedure: stellate ganglion block injection
* Procedure: Normal saline injection
* Behavioral: Psychoeducation


Participation Criteria
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Eligibility Criteria
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Inclusion criteria Age 18 years or older Fluent in English or Spanish A diagnosis of cardiac arrest (CA) Admitted to the New York-Presbyterian Hospital Elevated symptoms of psychological distress a. PCL-5 > 32 with a minimum of 2 weeks after cardiac arrest Exclusion criteria A prior SGB treatment Severe brain injury defined as Cerebral Performance Category Score ≥3, and/or significant aphasia, dysarthria, or cognitive impairment precluding ability to complete study questionnaires as determined by interviewer Terminal non-cardiovascular illness (life expectancy <1 year) Severe mental illness requiring urgent psychiatric hospitalization Alcohol or substance abuse that would impede ability to complete study Unavailable for telephone and in-person follow-up Allergy to amide local anesthetics (e.g., ropivacaine, bupivacaine) Pre-existing Horner's syndrome Pregnancy Current anticoagulant use History of a bleeding disorder Infection or mass at injection site

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This is a pilot RCT to gain preliminary evidence regarding the acceptability, tolerability, safety, and efficacy of a combined intervention of Stellate Ganglion Blockade and psychoeducation vs sham-procedure and psychoeducation on trauma symptoms and health behaviors in patients exhibiting early PTSD symptoms after cardiac arrest.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Stellate Ganglion Block + Psychoeducation<br>For the active SGB arm, 7 to 8 mL of ropivacaine, 0.5%, will be injected around and into the site of the ganglion once before the hospital discharge. They will also receive a 30 minutes session of psychoeducation by a health professional with experience working with CA patients. | Procedure: stellate ganglion block injection<br>* A stellate ganglion block (SGB) is an injection of local anesthetic (numbing medicine) to block the nerves located on either side of the voice box in the neck. It will be administered in an inpatient monitored setting.<br>* Other names: SGB injection;Behavioral: Psychoeducation<br>* The session will be 30 minutes in duration, to be administered by a health professional with experience working with CA patients, the goal will be to establish rapport and help patient identify anxious situations, thoughts, and bodily feelings related their recent CA that could lead to avoidant behavior. Explain how many of these feelings are common in CA survivors, and they are often unrelated to their risk of its recurrence. Explain how the body has a fight-or-flight system that is controlled in part by the stellate ganglion and explain how blocking the action of this part of the body can reduce the feelings of anxiety that commonly occur. Discuss how certain activities such as exercise can increase feelings of anxiety around bodily sensations, but continued engagement could reduce that fear and that exercise is helpful for recovering from CA<br>|
| Placebo Comparator: Normal saline injection + Psychoeducation<br>For the sham procedure, 1 to 2 mL of preservative-free normal saline will be injected into deep musculature in the neck. They will also receive a 30 minutes session of psychoeducation by a health professional with experience working with CA patients. | Procedure: Normal saline injection<br>* An injection of normal saline will be injected into muscle on either side of the voice box in the neck. It will be administered in an inpatient monitored setting.<br>* Other names: Sham procedure;Behavioral: Psychoeducation<br>* The session will be 30 minutes in duration, to be administered by a health professional with experience working with CA patients, the goal will be to establish rapport and help patient identify anxious situations, thoughts, and bodily feelings related their recent CA that could lead to avoidant behavior. Explain how many of these feelings are common in CA survivors, and they are often unrelated to their risk of its recurrence. Explain how the body has a fight-or-flight system that is controlled in part by the stellate ganglion and explain how blocking the action of this part of the body can reduce the feelings of anxiety that commonly occur. Discuss how certain activities such as exercise can increase feelings of anxiety around bodily sensations, but continued engagement could reduce that fear and that exercise is helpful for recovering from CA<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of eligible subjects who get enrolled in the trial | This is designed to measure the feasibility of successful enrollment. | Baseline (pre-procedure) | 
| Number of patients recruited per month | This is designed to measure the rate of enrollment, with <4 patients/month considered not meeting outcome | Assessed at 10 Month from the beginning of enrollment | 
| Proportion of participants who complete the 4-weeks assessments | This is designed to assess the short-term attrition and lost to follow-up up to 4 weeks post-enrollment. | Study Completion (Approximately 11 months) | 
| Proportion of participants who complete the 12-weeks assessments | This is designed to assess the long-term attrition and lost to follow-up up to 12 weeks post-enrollment. | Assessed at 12-weeks post-procedure | 
| Proportion of participants who develop one or more signs of Horner's syndrome | Horner's syndrome density grading scale will be used to assess treatment fidelity | Assessed at baseline post-procedure | 
| Treatment expectancy questionnaire | Treatment credibility will be assessed. | Assessed at baseline, post-procedure | 
| The proportion of participants completing the check-list of various components of Psychoeducation | This is designed to assess the feasibility of administering psychoeducation, with >80% of the components in the checklist as a threshold for success. | Assessed at baseline post-procedure | 
| The proportion of participants with >80% of the total actigraph wear time | It is designed to assess the acceptability of actigraphy | Assessed at 4-weeks post-procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The proportion of participants with clinically significant symptoms of Posttraumatic Stress Disorder (PCL-5) | The Effect of SGB-PsychoED intervention on PTSD symptoms will be assessed using PCL-5. | Assessed pre-procedure and then repeated at 4-weeks post-procedure | 
| The proportion of participants with clinically significant symptoms of Cardiac anxiety | The effect of SGB-PsychoED intervention on cardiac anxiety will be assessed using cardiac anxiety questionnaire (CAQ) | Assessed pre-procedure and then repeated at 4-weeks post-procedure | 
| The proportion of participants with clinically significant symptoms of Generalized anxiety disorder. | The effect of SGB-PsychoED intervention on generalized anxiety disorder will be assessed using generalized anxiety disorder scale-7 (GAD-7) | Assessed pre-procedure and then repeated at 4-weeks post-procedure | 
| The proportion of participants with clinically significant symptoms of depression. | The effect of SGB-PsychoED intervention on depression will be assessed using the eight-item Patient Health Questionnaire depression scale (PHQ-8). | Assessed pre-procedure and then repeated at 4-weeks post-procedure | 
| The proportion of participants with moderate to high levels of physical activity. | Effect of SGB-PsychoED intervention on mean minutes/day of physical activity as measured by the objective actigraphy data | Assessed at 4-weeks post-discharge | 
| The proportion of participants with reduced duration of sleep. | Effect of SGB-PsychoED intervention on mean hours/day of sleep as measured by the objective actigraphy data | Assessed at 4-weeks post-discharge |