Top Things to Know: 2023 AHA Focused Update on Adult Advanced CV Life Support
Published: December 18, 2023
- Periodic evaluations of the primary literature are necessary for ensuring the most accurate and timely recommendations are presented to the clinical community to advance the care provided to patients and strive for the best patient-centered outcomes.
- This focused update highlights areas in Advanced Cardiovascular Life Support where novel literature was published since the last formal Guidelines publication in 2020. The expert writing group evaluated the novel literature and presents here a focused update on relevant areas in ACLS where there are changes in recommended treatment.
- Of 14 major randomized trials published between 2016-2022 addressing temperature management and coronary angiography in cardiac arrest, sex or gender was reported in all studies however, the terms were used interchangeably while only 2 studies included data on race/ethnicity. Researchers are charged to develop and implement methods to promote recruitment and representation of participants from diverse backgrounds into trials in this arena.
- To address disparities in cardiac arrest and post‒cardiac arrest care, researchers studying cardiac arrest will benefit from complete demographic data for patients across the Chain of Survival.
- Use of extracorporeal CPR for patients with cardiac arrest refractory to standard advanced cardiovascular life support (ACLS) is reasonable in select patients when provided within an appropriately trained and equipped system of care. Two RCTs showed improved outcomes for groups randomized to the extracorporeal CPR arm.
- Emergent coronary angiography is not recommended over a delayed or selective strategy in patients with return of spontaneous circulation (ROSC) after cardiac arrest in the absence of ST-segment elevation, shock, electrical instability, signs of significant myocardial damage, and ongoing ischemia. Based on 4 RCTs and an ILCOR statement, this recommendation differs from the 2020 Guidelines statement.
- We recommend that all adults who do not follow commands after ROSC, irrespective of arrest location or presenting rhythm, receive treatment that includes a deliberate strategy for temperature control. We recommend selecting and maintaining a constant temperature between 33°C and 37.5°C during postarrest temperature control based on findings from the recent TTM2 study which found no differences between patients with cardiac etiology cooled to 33°C versus normothermia. There is insufficient evidence to recommend which subgroups may benefit from a particular target temperature. Patients with spontaneous hypothermia after ROSC who do not follow commands should not be routinely actively or passively rewarmed faster than 0.5°C\hour.
- A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult survivors of cardiac arrest with electroencephalography (EEG) patterns on the ictal-interictal continuum. Included in this recommendation are criteria for electrographic seizures, status epilepticus and ictal-interictal continuum.
- Organ donation is an important outcome that should be considered in the development and included in the evaluation of systems of care given 1) the disparity between organ availability and need and 2) similar organ outcomes between cardiac arrest donors and other deceased donors.
- The 2023 Focused Update provides updated recommendations that compliment or refine the last formal Guidelines in 2020. Via a thorough review of the literature, recommendations on temperature control, seizure management, organ donation and diversity/equity were formally addressed by the working group.
Citation
Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, Rittenberger JC; on behalf of the American Heart Association. 2023 American Heart Association focused update on adult advanced cardiovascular life support: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Published online December 18, 2023. doi: 10.1161/CIR.0000000000001194