Public health crisisThe American Heart Association has released Heart and Stroke Statistics - 2022 Update. According to the report, cardiac arrest remains a public health crisis. There are more than 356,000 out-of-hospital cardiac arrests (OHCA) annually in the U.S., nearly 90% of them fatal. The incidence of EMS-assessed non-traumatic OHCA in people of any age is estimated to be 356,461, or nearly 1,000 people each day. Survival to hospital discharge after EMS-treated cardiac arrest languishes at about 10%.

There are several ongoing challenges to understanding the epidemiology of cardiac arrest in the U.S. Despite being a leading cause of death there are currently no nationwide standards for surveillance to monitor the incidence and outcomes of cardiac arrest. Thus, registries and clinical trials are used to provide best estimates. These sources include the Resuscitation Outcomes Consortium (ROC), 2005-2015, and the ongoing Cardiac Arrest Registry to Enhance Survival (CARES).

OHCA incidence: Adults

  • The incidence of EMS-assessed OHCA in 2015 was 347,322 based on extrapolation of ROC data.
  • Based on CARES data, in 2020 the location of OHCA in adults was most often a home or residence (73.9%), followed by public settings (15.1%), and nursing homes (10.9%). 
  • OHCA was witnessed by a layperson in 37.1% of cases or by a 911-responder in 12.8% of cases. For 50.1% of cases, collapse was not witnessed.

OHCA incidence: Children 

  • Based on ROC data, the incidence of EMS-assessed OHCA in children in 2015 was 7,037.[1]
  • Based on CARES data, in 2020, the location of OHCA in children was most often home (87.5%), followed by a public place (12.2%).

Sports-related SCA/SCD

  • Sports-related SCA accounted for 39% of SCAs among those ­<18 years of age, 13% for those 19-25 years of age, and 7% for those 25-34 in a prospective registry of 3,775 SCAs in Portland, OR between 2002-2015.
  • The incidence of SCD from Lexis Nexis and public media reports during youth sport participation, estimated by the Sport and Fitness Industry Association from 2007-2015, was 1.83 deaths per 10-million athlete years.
  • Pre-participation screening of 5,169 middle and high school students (mean age 13 years) from 2010-2017 revealed high-risk cardiovascular conditions in 1.47%.

COVID effects

The COVID pandemic had multiple effects on the incidence of OHCA. 

  • In New York City, the incidence of OHCA attended by EMS (March 1-April 25, 2020) increased 3-fold, compared with the same period a year earlier. 
  • Data from the CARES registry showed increased delays to initiation of CPR for OHCA and reduced survival after OHCA coinciding with timing of the pandemic. There was a reduction in the frequency of shockable rhythms, OHCA in public locations, and bystander AED use. Despite this, there was no significant alteration in frequency of bystander CPR.

Awareness and treatment

  • The prevalance of reported CPR training was 18% and having CPR training at some point was 65% in a survey of 9,022 people in the U.S. in 2015. The prevalence of CPR training was lower in Hispanic/Latino people, older people, people with less formal education, and lower-income groups.
  • Laypeople initiated CPR in 40.8% of OCHAs (CARES 2020 data). States with higher bystander CPR rates include Alaska (72%), California (41.8%), Hawaii (45.2%), Mississippi (42.4%), Montana (49.6%), Nebraska (49.1%), North Carolina (42.9%), Oregon (56%), Vermont (53.8%), and Washington (56.3%).
  • Laypeople were less likely to initiate CPR for people with OHCA in low-income Black neighborhoods or in predominately Hispanic neighborhoods than in high-income White neighborhoods.
  • Laypeople used AEDs in 5.8% of OHCAs and provided a shock in 1.3% of OHCAs (CARES 2011-2020 data). 
  • Laypeople used AEDs in 9% of OCHA cases in 2020. States with higher rates of bystander AED use include Alaska (9.7%), Minnesota (9.4%), Nebraska (16.3%), North Carolina (9.5%), Oregon (13.5%), Pennsylvania (10.3%), Utah (9.5%), and Washington (10.9%).

OHCA outcomes: Adults

  • Survival to hospital discharge after EMS-treated OHCA was 9% and survival to hospital discharge with good functional status was 7%, based on 124,088 cases (CARES 2020). Note: the AHA previously reported that unadjusted survival to hospital discharge after EMS-treated OHCA increased from 10.2% in 2006 to 12.4% in 2015 in the ROC epistry.
  • Survival to hospital discharge after EMS-treated OHCA was higher in the Midwest and South, relative to the Northeast.
  • Survival and neurologic recovery after OHCA are worse in White Hispanic, Black, and Asian patients, compared with White patients. Disparities were explained only in part by delays in onset of medical care, suggesting there may be other underlying vulnerabilities.

OHCA outcomes: Children

  • Survival to hospital discharge after EMS-treated nontraumatic OHCA in 2015 was 13.2% for children in the ROC epistry.
  • Survival to hospital discharge was 6.5% for 1,366 children < 1 year of age, 14.4% for 880 children 1-12 years of age, and 21.2% for 736 children 13-18 years of age (CARES 2020). 

OHCA outcomes: Sports-related SCA-SCD

  • In a population-based registry of all paramedic responses for SCA from 2009-2014, 43.8% of athletes with SCA during competitive sports survived to hospital discharge.

Complications

  • Survivors of cardiac arrest experience multiple medical problems including impaired consciousness and cognitive deficits.
  • Functional impairments are associated with reduced function, reduced quality of life, and shortened life span.
  • Functional recovery continues over at least the first 12 months after OHCA in children and over 6 to 12 months after OHCA in adults.
  • Serial testing in a cohort of 141 people who survived hospitalization after SCA revealed severe cognitive deficits (13%), anxiety and depression (15%), post traumatic stress symptoms (28%), and severe fatigue (52%). Subjective symptoms declined over time after SCA, although 10-22% had cognitive impairments at 12 months, with executive functioning being most affected. Of 141 individuals who survived hospitalization after SCA, 72% returned to work after 12 months.
  • Of 287 people who survived hospitalization after OHCA, 47% had reduced participation in pre-OHCA activities and 27% of those who were working before OHCA were on sick leave at 6 months.
  • Among 195 caregivers of cardiac arrest survivors, 25% experienced anxiety and 14% experienced depression at 12 months.

Compiled by Mary M. Newman, MS, Sudden Cardiac Arrest Foundation

[1] More recent research not reported in the AHA statistics indicates the incidence of OHCA in children is 23,514.