2025+ERC指南：复苏的流行病学

Practice Guideline

# European Resuscitation Council Guidelines 2025 Epidemiology in Resuscitation

Enrico Baldia,b,+,1, Jan Wnent c,d,e,1, Maria Luce Caputo f,g,h, Kirstie L Haywood,Gisela Lilja,k,Siobhan Masterson 1,m,n,Ziad Nehme 0,p,Gavin D Perkins,1,4,Fernando Rosell-Ortiz S, Anneli Stromsoe, T,u, Ingvid B.M. Tjelmeland w,Jan-Thorsten Graesner c,d,e

Abstract

These European Resuscitation Council Guidelines 2025 on epidemiology of resuscitation provides key information about incidence, patients' char-acteristics, system organisation and outcomes for both out-of-hospital and in-hospital cardiac arrest in Europe and beyond. Information regarding patients' post survival experience and causes of cardiac arrest, including genetic factors, are also reported. Recommendations are provided to sup-port the development of cardiac arrest registries, and improve out-of-hospital cardiac arrest(OHCA) follow-up with an emphasis on quality of life, and perform autopsy including genetic analysis in young individuals.

Keywords: Cardiac arrest, Epidemiology, Incidence of cardiac arrest, Genetics, OHCA, IHCA, Registries

Introduction

Cardiac arrest is one of the leading causes of death worldwide.1,2 Whether cardiac arrest occurs outside the hospital(i.e. out-of-hospital cardiac arrest- OHCA) or inside the hospital(in-hospital cardiac arrest-IHCA), differences in incidence and outcome have been reported over the years across countries.3-5 These differences are due to several reasons, including variations in population charac-teristics(e.g. age, socio-economic status, co-morbidities), in system organisation(e.g. different emergency medical services(EMS) sys-tems or differences in teams responding to IHCA; geographical vari-ation; implementation of first responders network), and treatment provided by the system of care(e.g. quality of CPR, interventions,decisions on when initiate or terminate resuscitation, post-resuscitation care).6 Differences also arise from variation in data col-lection practices(e.g. case definition, ascertainment methods and outcome verification).

For these reasons, since the early 1990s, the Utstein recommen-dations on outcome reports for OHCA and IHCA have been published and periodically updated to provide researchers with a single tem-plate to facilitate and harmonise data collection.7-9 This enables inter-system and intra-system comparisons to identify gaps in knowl-edge, and to support clinical research.8.9 Understanding the epidemi-ology of cardiac arrest as accurately as possible is a step towards understanding its causes, improving treatments and patients' out-comes.10 This chapter provides an overview of incidence, patient characteristics, system organisation and outcomes of OHCA and IHCA. It also focuses on post-survival recovery and underlying causes of cardiac arrest(SCA), including genetic factors(Fig.1).

The chapter focuses mainly on epidemiology in European coun-tries; however, reference is also made to non-European countries.A section on epidemiology in lower resourced countries and remote areas is also included.

Individual search strategies were constructed for each section of these Guidelines. Searches were conducted using PubMed,

* Corresponding author.

E-mail address: enrico.baldi@unipv.it(E.Baldi).

1 Joint first co-authorship.

https://doi.org/10.1016/j.resuscitation.2025.110733

0300-9572/© 2025 European Resuscitation Council. Published by Elsevier B.V.

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# EPIDEMIOLOGY OF RESUSCITATION KEY MESSAGES

# Establish national registries

All European countries should have comprehensive national registries for Out-of-Hospital Cardiac Arrest (OHCA) and In-Hospital Cardiac Arrest (IHCA) according to the Utstein template

# Use multidisciplinary teams for counseling

Autopsy and genetic results should be managed by multidisciplinary teams in specialised circuits to provide family counseling and eventual screening

# Conduct comprehensive autopsies

All victims of unexpected sudden death under age 50 should receive a full autopsy, including genetic analysis using 5-10 ml of blood in EDTA

Measure long-term patient outcomes

Routine measurement of physical and non-physical outcomes for all cardiac arrest survivors is essential

Enhance post-resuscitation care

More research and expanded access to post-resuscitation rehabilitation services are needed

Improved emergency response systems developed in remote areas

Use registry data for system planning

Data from OHCA and IHCA registries should be used to inform healthcare system planning and cardiac arrest responses

EPIDEMIOLOGY OF RESUSCITATION


Support low-resource settings

Epemiological registries must be developed in low-resource settings to allow improvement of treatment and outcomes

Improve response systems in remote areas

Improved emergency response systems must be developed in remote areas to improve outcomes

Implement 2222 for IHCA

The telephone number 2222 should be standardised for IHCA response across Europe

Expand IHCA research

There is a need for increased research efforts focused on in-hospital cardiac arrest in Europe

Fig.1-Epidemiology of resuscitation-key messages.

Embase and Cochrane. Only publications in English from the last 10 years were included, unless there was limited literature avail-able or in the case of particularly relevant articles (i.e. articles with key information not included in subsequent studies). Abstracts were reviewed by at least two authors and relevant articles were read in full-text.

These Guidelines were drafted, discussed and agreed upon by the European Resuscitation Council(ERC) Epidemiology in Resuscitation Writing and the ERC Guidelines 2025 Steering Commit-tee.This Guideline was posted for public comment between 5 and 30. May 2025. A total of 21 individuals submitted 22 comments, lead-ing to 10 changes in the final version. Subsequently, the feedback was reviewed by the writing group, and the Guideline was then updated where relevant. The Guideline was presented to and approved by the ERC Board and the ERC General Assembly in June 2025. The methodology used for guideline development is presented in the executive summary. ${ }^{11}$

Summary of facts on epidemiology in resuscitation

Out-of-hospital cardiac arrest

● The annual incidence of EMS-treated OHCA in Europe is 55 per 100,000 inhabitants.

● The mean age of patients is of 67.2±17.3 years.

● Male subjects account for 65% .

● Seventy percent occur in private locations.

● A shockable rhythm is the initial presentation in 20% of cardiac arrests; 91% have a medical aetiology.

● Nine European countries have an OHCA registry with full popula-tion coverage and 17 countries have a first responder system at least at a local level.

● The bystander CPR rate in Europe is 58% with significant regio-nal variations(from 13% to 82%).

● The use of an AED before EMS arrival varies from 2.6% to 59%in different European countries.

● Survival after OHCA in Europe is 7.5% with a range in European countries from 3.1% to 35%.

In-hospital cardiac arrest

● The annual incidence of IHCA in Europe is 1.5 to 2.8 per 1000 hospital admissions.

●The proposed standard internal telephone number to alert the emergency team(2222) for IHCA in Europe is implemented in 2% of countries only.

Long term survival and return to societal participation

● In European countries where withdrawal of life sustaining treat-ment is practised, poor neurological outcomes occur in less than 10% of cardiac arrest survivors, whilst in situations where with-drawal of life sustaining treatment is not practised survival with poor neurological outcome is more common.

●The majority of OHCA survivors indicate the need for post-discharge follow-up with access to a multi-disciplinary team.

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● One out of three OHCA survivors receive cardiac rehabilitation and only one out of ten receive brain injury rehabilitation.

Genetic variants and autopsy in cardiac arrest patients

● A clinically actionable pathogenic or likely pathogenic variant in a gene potentially related to the cause of sudden cardiac arrest is identified in up to 25% of OHCA cases younger than 50 years.

● Autopsy in young sudden cardiac arrest victims is currently not routinely performed in many European countries.

Low-resource settings and remote areas

● The rate of bystander CPR and AED use is lower in low-resource settings compared to high-resource settings.

● Lower resourced countries tend to lack OHCA registries accord-ing to the Utstein template and based on a reference territory

● Early BLS and rapid response by an EMS are crucial and deter-mines the prognosis of an OHCA patient also in remote areas.

Evidence informed guideline

Out-of-hospital cardiac arrest

Incidence

The incidence of OHCA has been reported in multiple studies includ-ing the three major EuReCa studies.2,12 5 Across all EuReCa stud-ies, the incidence of cardiac arrest per 100,000 inhabitants demonstrated significant inter-country variation. In the 2022 three-month EuReCa-3 study, the annualised incidence ranged from 31 to 243 per 100,000 inhabitants, with an overall average of 82 per 100,000. Similarly, the incidence of EMS-treated OHCAs varied sig-nificantly with an overall incidence of 55 per 100,000 (range from 17 per 100,000 to 104 per 100,000).5 The mean incidence of cardiac arrest remained consistent throughout the 8 years of the EuReCa studies.(Table 1).2,5,12

Accurately estimating the true incidence of OHCA remains chal-lenging because of reporting limitations-most notably, the restric-tion to cases treated by emergency medical services (EMS), which likely underestimates the overall burden of disease. The proportion of patients with cardiac arrest where no resuscitation was started may differ systematically because of cultural norms or religious beliefs, bystanders' willingness to start CPR and variations in how and when the EMS are alerted. ${ }^{13}$ As highlighted by the EuReCa THREE study, only EMS-treated OHCAs are reported in many Euro-

<EndOfPara>pean countries, meaning the reasons for not initiating CPR are miss-ing from a significant portion of the population. ${}^{5}$ Given that dispatch centres serve a gatekeeping role for ambulance services and that most use a standardised dispatch protocol, ${ }^{14}$ it should be feasible in the future to systematically collect data on true incidence of car-diac arrest. This aligns with the recent Utstein update on data collec-tion from dispatch centres. ${ }^{8}$

The number of reported OHCAs in Europe has increased in recent years when compared with one or two decades ago.$^{5,12,15}$ Whether these differences reflect an increased number of OHCAs or simply a more comprehensive reporting is unclear. It is unknown if this can be partly explained by improved case ascertainment meth-ods and increased coverage by regional and national registries or by an increase in intervention initiated before EMS arrival.

European OHCA incidence appears consistent with non-European settings. EMS-treated OHCA rates range from 44 to 56 per 100,000 population in Australia, New Zealand,Singapore, and South Korea, to 62-76 in the United States, and up to 97-100 in Japan-Illustrating a similar degree of international variation. ${}^{16-18}$

The incidence of OHCA was impacted by the COVID-19 pan-demic. During the early stages of the outbreak, regions severely affected by the virus, such as Northern Italy and the Paris region in France, reported an increase in OHCA incidence of up to 187%compared with the same period in the previous year.19,20 Further analysis confirmed that OHCA incidence increased significantly in regions with high weekly COVID-19 incidence, returning to previous values after the end of the outbreak.21,22

Patients' characteristics and presenting rhythms

Patient characteristics, ${}^{23-26}$ event circumstances, ${}^{27-30}$ underlying etiology and presenting rhythms significantly influence survival out-comes.${}^{31}$ Therefore, differences in these characteristics across European countries must be considered to understand regional vari-ation in outcomes and opportunities for improvement.

The mean age of EMS-treated OHCA was reported as 67.6 ±17.5 year.2 This aligns with findings from the third ILCOR report on OHCA, where the mean age ranged from 62 to 76 years, across different countries.18 These patterns mirror the mean age of the gen-eral population in Europe 32 with similar trend in the United States,Australia and New Zealand.17.33 Global comparisons reveal wider variability, patients from the middle east and Asia tend to be younger with a mean age of 50 years in United Arab Emirates and 57 years in

Table 1 - The mean incidence of OHCAs in the three EuReCa surveys.

||Overall OHCAs|Overall OHCAs|EMS-treated OHCAs|EMS-treated OHCAs| |---|---|---|---|---| ||Mean incidence per 100,000|Range of incidence per 100,000 across countries|Mean incidence per 100,000 countries|Range of incidence per 100,000 across countries| |EuReCa $ONE^{12}$|84|28-160|49|19-104| |EuReCa TWO $^{2}$|89|53-166|56|27-91| |EuReCa THREE $^{5}$|82|31-243|55|17-104|

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 Fig.2-Coverage of OHCA registries in European countries in 2019(2A) and in 2025(2B). Countries not participating are left white.

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 Fig.3- Availability of data in out-of-hospital cardiac arrest registries in Europe. Fig.3A is ambulance data, Fig. 3B is hospital data and Fig. 3C is patient-reported quality of life data. Countries not participating are left white.

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(C)

GUIDELINES 245

Availability less than 50%

No data collected

Non-participating countries

Fig 3.(continued)

Thailand. Conversely older ages have been reported in Japan(75 years) and Taiwan(76 years). ${}^{34}$ Interestingly, the mean age of the OHCA patients in whom the resuscitation was not started was higher than in patients in whom CPR was started $(71.5\pm 17.4$ years versus $67.6\pm 17.5$ year). ${}^{2}$

Sex distribution among OHCA patients is similar across Europe,with males representing about 65% of patients overall.2 e.g. 68% in Norway and France, and just under 60%, in Italy. 17,18 This pattern is largely in line with international data,33,35 although lower in some countries, e.g. 57% in Japan 17,18,34 and higher in others, e.g.82.7% in the United Arab Emirates.34

Approximately one-third of OHCA cases in Europe are unwit-nessed OHCA, ranging from 17.3% in France to 46% in Denmark.17 Bostands represent the largest group of witnesses, ranging from 44% in Germany and Denmark to 69% in France. EMS personnel are present at the time of arrest less frequently, ranging from 8%in Ireland to 16% in Switzerland.17 Outside Europe, unwitnessed OHCA exceed 50% in the United States, Canada, Japan, South Korea, Singapore, Taiwan and United Arab Emirates,17,18,34 whilst EMS-witnesses events seem to be similar globally. ${}^{17,33,34}$

In Europe, the majority (70%) of OHCAs occur in private resi-dences such as the patient's home with reported rates ranging from 61.5% in Switzerland to 76.3% in Italy. ${ }^{2}$ The proportion of cardiac arrests which occurred in a private residence increased during the COVID-19 pandemic. ${ }^{21,36}$ Around 10 % of OHCAs occur in public places or in nursing homes, with fewer cases occurring in schools,\end{align*}

with data reported from United States, Australia and Japan, ${}^{16}$ although OHCAs in nursing homes are less common in some Asian countries(about 2-5%). ${}^{16,18,34}$

The initial rhythm of arrest is one of the most important prognostic factors for short- and long-term survival. In Europe, approximately one in five patients with an EMS-attempted resuscitation experience a‘shockable rhythm’(ventricular fibrillation(VF) or pulseless ventricular tachycardia) as the first monitored rhythm of cardiac arrest.2 However,the rate of first monitored shockable rhythms varies three-fold across European countries from 11.4% to 36.8%. This may partly explain regional differences in outcomes.2 Similar variability has been reported in other continents, such as Asia(from 4.1% to 19.8% in dif-ferent regional areas) and Australia(22.9-44.0%).33.34 Emerging data suggest that the proportion of first monitored shockable rhythms may be declining over time, giving rise to a higher proportion of OHCA with initial asystole and pulseless electrical activity.37-41 For example, in Sweden, the proportion of OHCA with an initial shockable rhythm declined from 39.5% in 1990 to 17.4% in 2020, with a larger differ-ence in women(35.9% in 1990 to 11.4% in 2020).38 Similar findings have been reported in other regions.39-41

An important consideration is that the initial rhythm reported depends on the time interval between the cardiac arrest and the first rhythm analysis. Large population studies highlighted that the odds of a shockable first monitored rhythm declined with each additional minute of no-flow time as VF degenerates into a non-shockable rhythm, and that bystander CPR significantly mitigates the degrada-tion of shockable rhythms over time. ${}^{42-44}$

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Arrest aetiology strongly correlates with the initial rhythm and patient age. Medical causes precipitated 91.1% of OHCA, while trauma, asphyxia, drug overdose, drawing and electrocution made up the remaining cases.2 The leading cause of medical-related OHCAs include underlying cardiac aetologies. In Sweden, the proportion of cardiac arrests caused by heart disease have declined for both men and women, from 80.5% in 1990 to 58.7% in 2020,38 with similar declines observed in other high resource countries.41 The German Resuscitation Registry reported increasing OHCA of presumed cardiac aetiology between 2006 and 2020, but with values that have risen from just below to just over 60%.39 Most OHCAs in adults $\geq 40$ years are from cardiac cause.38 Drug overdose and suicide represents the lead-ing cause in young adults and adolescents, and this is an increasing trend in some parts of Europe (e.g. in Sweden).45

EMS organisation

A 2025 survey of EMS system characteristics gathered data from 27 European countries about EMS dispatch, on scene management,and coverage by cardiac arrest registries. ${}^{14}$ Compared with a previ-ous survey in 2019, ${}^{46}$ there were changes in the countries reporting a median EMS response interval of less than ten minutes in urban areas. Austria, Cyprus, the Netherlands, Slovakia and Slovenia reported improvement, whilst Belgium, Italy, Luxembourg, Norway,Poland and Switzerland reported a deterioration. ${ }^{14}$ Variation was noted in how response intervals are calculated according to start(e.g. starting of the call, ambulance alerting) and end points.

Early recognition and early initiation of CPR is crucial to improve survival. 47 To achieve that, several first responder systems have been established. 48,49 Only 17 countries reported having estab-lished first responder system without changes over time. 14,46

Several countries established a new OHCA registry or expanded an already existing OHCA registry in the last five years (Fig. 2). 14,46 Currently, nine countries report having an OHCA registry with national coverage (Cyprus, Denmark, Greece, Hungary, Ireland,Luxembourg, Norway, Sweden, Switzerland). ${ }^{14}$

Case ascertainment and data completeness are key drivers of how representative a registry is of the population it covers.50,51 As can be seen in Fig.3, data completeness levels are high for EMS treatments and survival to hospital(>80 % data completeness). By contrast, data are less complete for hospital treatments. For health-related quality of life only one registry manages to capture information from more than 50 % of the survivors (Norway). Health-care systems need reliable and accurate information if they are to be used for quality improvement purposes.8 This highlights that there is still much room for improvement across Europe.14

Community response

Dispatching community first responders to cardiac arrest A systematic review identified that eight mobile phone systems from seven countries in Europe are used to alert community first responders for OHCA.48 This includes text messages or spe-cially designed smartphone applications.52 Activation radii (i.e.the distance from the scene that first responders are activated),prioritising volunteers to reach the scene, exclusion criteria(e.g.unsafe environment, patient's age) and methods for retrieval of AEDs tend to vary between systems. A recent survey of EMS systems suggests there are more systems being used across Europe than have been published in recent literature.46

<BeginOfPara>A meta-analysis on the impact of dispatching community first responders to cardiac arrest including six European countries,

reported higher CPR and AED use with community first responders compared with the conventional emergency response. ${ }^{49}$ The activa-tion of community first responders also improved the rate of defibril-lation before EMS arrival, particularly in private homes. ${ }^{53}$

Risks for dispatched community first responders are rarely reported. ${}^{54}$ In Denmark, the rate of injury was only 26/7334(0.35%), with one ankle fracture reported. ${}^{55}$ The psychological impact of a volunteer responding to cardiac arrest was also investi-gated; 24.7%, 5.5% and 1.2% of 5395 respondents reported low,moderate, or severe impact, respectively. ${}^{56}$ More severe impact was associated with lack of CPR training, younger age and female sex. Dispatching first responders seems to be equally safe in both public and private locations. ${}^{57}$ Taking care in terms of psychological safety, continuing motivation and standardised debriefing needs to be included in first responder systems. ${}^{58}$

Bystander CPR and defibrillation rates

Bystander CPR rates vary across Europe with a mean bystander CPR rate of 58%, but with a very wide range (13 % to 82 %). 2,59 A common barrier to starting bystander CPR is a lack of knowledge $(29.9 \%)$ . In a survey, even among those who reported that they knew what to do during an OHCA and how an AED works, few were able to mention specific actions required. ${ }^{60}$ A meta-analysis including 23 studies (10 from European countries) reported advanced age,lower socioeconomic and educational status, and marginalisation groups (due to race or language differences) were barriers to lay per-sons participating in resuscitation training. ${ }^{61}$ Enablers identified were having previously witnessed a collapse, awareness of AEDs loca-tions, certain occupations, and legal requirements for training. ${ }^{61}$ The rate of bystander CPR appears to be influenced by the popula-tion awareness about OHCA. Community interventions such as 'Restart a Heart' may contribute to improved bystander CPR rates. ${ }^{62}$

Talance awareness about OHCA. Community interventions such as 'Restart a Heart' may contribute to improved bystander CPR rates. ${ }^{62}$

Database analyses suggests that bystanders are more likely to perform chest compression-only CPR than standard CPR, but with a wide variability across European countries. ${}^{15,63}$ Socioeconomic status affects the probability of receiving bystander CPR and socially deprived areas in a country have a lower probability of bystander CPR. ${}^{64}$ A review of 29 studies across 35 countries (in-cluding 9 studies from Europe) also reported higher rates of bystander CPR in countries with a higher Gross Domestic Product per capita. ${}^{65,66}$

Unwitnessed OHCA at home and among older people are less often resuscitated by bystanders. ${}^{67}$ In contrast, in the case of exercise-related cardiac arrest, although representing a minority of all OHCAs, there is a much higher rate of bystander CPR reported than for other OHCAs(95% vs 77.4% in Denmark). ${}^{68}$ Similarly,bystander AED use was higher for exercise-related OHCA compared with the general OHCA population. ${}^{68}$

The rate of AED use remains variable in European countries,ranging from 2.6% to 59% of cases, although an increase has been observed in some countries in the last decade. ${ }^{69}$ Bystander defibril-lation is reported as less likely in urban settings, at home, and in women. ${ }^{70}$

Community response during COVID-19 pandemic

According to a meta-analysis including approximately 50,000 OHCAs from around the world, the reduction in bystander CPR rate was directly related to the weekly COVID-19 incidence in each area. ${ }^{21}$ Bystander CPR and bystander AED use rates fell during

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the COVID-19 period, particularly in public places, and particularly during the first COVID-19 wave in different European areas. ${}^{71,72}$ European first responder systems reacted differently to the COVID-19 pandemic and this led to different results in different coun-tries.73 Community first responder engagement and bystander defib-rillation rates did not differ significantly during lockdown and non-lockdown periods in two Danish regions. However, compression-only CPR was more often performed during the lockdown period then previously (79 % versus 59 %). ${}^{74}$ Similar findings were observed in a worldwide registry-based study that included data from several Euro-pean countries ${}^{75,76}$ and in a large study in the UK. ${}^{77}$ There was a reduction in CPR initiated by first responders during the pandemic in Switzerland (45.3 % during pandemic vs 62.2 % before pan-demic), but no difference in defibration rates by first responders (15.9 % during pandemic vs 23.9 % after pandemic), probably because alerting for community first responders was deactivated, but maintained for on-duty first responders. ${}^{78}$

Outcome

The ERC recommends registries report outcomes according to the Utstein template to improve comparability between health systems. Registries should prioritise collecting information about survived event, ROSC, transport, survival and neurological out-come at discharge or at 30 days. ${}^{8}$

There is substantial international variation in survival rates and neurological outcomes. ILCOR reported survival to hospital dis-charge or 30-day survival ranged from 3.4% to 15.6%.18 Some areas reported even lower values (e.g. China 2.8%).79.80 Unfortu-nately, resuscitation outcome is unknown in many countries particu-larly among those with developing emergency systems.81,82

<BeginOfPara>Prognostic factors for cardiac arrest outcome are age, $23,24$ gen-der, $83,84$ aetiology, initial arrest rhythm, $27,85-87$ previous and existing comorbidities, $88,89$ location of the cardiac arrest, $90,91$ whether the arrest was witnessed, $27,28$ socioeconomic status, $92,93$ and ethnic-ity. $94$ Also the way health systems are organised, $95$ available post-resuscitation care facilities (e.g. percutaneous coronary inter-

<EndOfPara>vention,96-99 temperature control,98,100-102 cardiac arrest centres103,104) are contributing factors on the variability in patient survival.Furthermore, a significant variability in OHCA outcome may be observed in the same region or country, despite the same health system organisation, because of differences in demographics and the community response,105-108 which can change over time.Differences in decisions on when to terminate resuscitation in the field will influence the denominator, which will affect outcome rate.110

Unfortunately, these aspects are not always captured by current data collection systems. ${}^{111}$ However, despite their inaccuracies and limitations, data from registries constitute the standard for knowing the outcomes from OHCA. These registries should enable annual updates that describe trends in outcomes and compare different areas of the world. For example, in 2024 the US Cardiac Arrest Reg-istry to Enhance Survival (CARES) documented a survival to hospital discharge rate of 10.2% for all EMS-treated non-traumatic adult OHCA cardiac arrests and 8.1% for survival with good neurological function. ${}^{1}$ The Australian Aus-ROC Epistry captures data from Aus-tralia and New Zealand and reported survival to hospital discharge/30-days as 13% with a range across different EMS from 9.9% to 20.7%. ${}^{33}$ The Swedish OHCA Registry has reported on the evolution in the treatment of OHCA during more than 30 years.${}^{38}$ In Europe, the European Registry of Cardiac Arrest (EuReCa)has performed 3-monthly cross-sectional studies including about 30 countries, providing the data source on OHCA for the Atlas of Cardiovascular Diseases in Europe. ${}^{112}$ Over the years of these stud-ies the average survival has changed from 10.3% [range 1.1-30.8%] in 2014 to 8% [0-18%] in 2017, and 7.5% [3.1-35%] in 2022. ${}^{5}$ These results correlate well with annual reports from national registries. ${}^{113-119}$ (Table 2).

In Europe, the European Registry of Cardiac Arrest (EuReCa)has performed 3-monthly cross-sectional studies including about 30 countries, providing the data source on OHCA for the Atlas of Cardiovascular Diseases in Europe.112 Over the years of these stud-ies the average survival has changed from 10.3% [range 1.1-30.8%] in 2014 to 8% [0-18%] in 2017, and 7.5% [3.1-35%] in 2022.5 These results correlate well with annual reports from national registries. 113-119 (Table 2).

The Utstein comparator group (bystander witnessed OHCA with a first monitored shockable rhythm) represents the recommended sub-group for system comparison on survival. Reported survival rates are higher than the general population of OHCA patients: 20% in Eng-land, ${}^{113}$ 27.1% in Spain, ${}^{115}$ and 30% in Europe in 2022.5 Several European countries (Denmark, the Netherlands, Sweden, Czech

Table 2 - Outcome reported for OHCAs in different European countries.

|Country|Type of outcome|Rate| |---|---|---| |England|Survival at hospital discharge|7.9%| |France|Survival at hospital discharge|4.9%| |Spain|Survival at hospital discharge|11.5%| |Ireland|Survival at hospital discharge|6%| |Spain|Survival at hospital discharge with CPC 1 or 2|9.8%| |Germany|Survival at hospital discharge with CPC 1 or 2|10.5% (males) -7.1% (females)| |Sweden|Survival at 30 days|12.3%| |Denmark|Survival at 30 days|14.4%| |Norway|Survival at 30 days|15%|

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Republic and Norway) exceeded 40% survival for this benchmark in 2022.5

A peculiar sub-group of patients are those with a traumatic cardiac arrest, for whom resuscitation was considered futile in the past. ${}^{120}$ How-ever, recent data suggest that a good outcome can also be achieved in these patients, as the reported good neurological status at discharge ranged between 2.0% in Germany 121 and 6.6% in Spain.122

During the first wave of the COVID-19 pandemic, the outcome of OHCA patients was worse regardless of known predictors of out-come and regardless of the incidence of COVID-19 in a region.21 This highlights how the pandemic profoundly affected the manage-ment and survival of cardiac arrest patients worldwide.

Scientific consensus and policies from the European Parlia-ment123 have highlighted the importance of knowing local outcome data about OHCA in each country to issues guidance how to improve the response system and to enhance survival. The ERC recom-mends that maintenance of registries with high-quality data and adhering to the Uststein template should be an integrated part of each EMS service. This will help to improve their services and their patients' outcome.

Diversity, equity, equality & inclusion (DEEI) discrepancies on outcome

Studies show that racial, gender, and socioeconomic disparities influ-ence cardiac arrest outcomes. Women receive 27% less bystander CPR than men and survival is lower for women compared with men.124-127 Black and Hispanic patients in the USA tend to have lower survival rates and to receive fewer interventions before EMS arrival.128,129 Hispanic patients in the USA had poorer survival out-comes, even after accounting for medical history.130,131 Lower-income and rural areas have longer EMS response times, fewer pub-lic AEDs and lower survival rates. 108,132-134 These disparities among these groups are reflected by their under-representation in resuscita-tion science.124,135 Ethnicity, gender, socioeconomic status, geo-graphic location, sexual orientation, and disability are all characteristics that contribute to differences in healthcare out-comes.136 Equitable resuscitation science requires mitigating barri-ers that contribute to survival rates, training accessibility, and clinical decision-making. This includes ensuring diverse representa-tion among authors and researchers who can then create culturally competent approaches to guideline development. Recently, the Women's International Group to Inspire, Support, and Empower Women in Resuscitation(WISER) was founded to promote gender equality within resuscitation research community.137

Epidemiology of paediatric resuscitation

Resuscitation in children is rare and most challenging presentation in OHCA. Most of the data on paediatric OHCA comes from North America and Asia.138 While age-definitions and eligibility criteria dif-fer across reports, data from Italy,Spain,Sweden,Norway,Ger-many,Denmark and the Netherlands indicates that the incidence of EMS-treated paediatric OHCA varies between 3.1 and 9.0 cases per 100,000 person-years.139-145 The incidence of paediatric OHCA has a U-shaped relationship with age, with the highest incidence observed in infancy and adolescence.139,141,142,144 The aetiology of OHCA also correlates with age: sudden infant death syndrome(SIDS) is the leading cause of death in children under 12 months of age, while hypoxia,trauma and cardiac causes are more prevalent in adolescent children.45,140,142,145,146 Recent data from Sweden

indicate that overdose and suicide are common in adolescent chil-dren and may be increasing.45 The vast majority of cases, particu-larly in young children, are witnessed, occur in the home and have an initial non-shockable rhythm.140-143,147 In adolescents, initial shockable rhythms are common and a third of all events are precipitated by physical activity.144 Bystander CPR occurs in 41 % to 88 %of cases, although the provision of defibrillation before EMS arrival remains infrequent (<10%).140-142,144,147,148 Rates of survival and neurologically favourable survival are low in paediatric OHCA, but these outcomes may also be influenced by age, aetiology and initial rhythm.141,143,146 Overall survival to hospital discharge or 30-day survival varies between 7% and 40%, while neurologically favour-able survival varies between 4% and 15%. 141,142,144,145,147,148

Treatment by bystanders using public access defibrillation can result in survival rates exceeding 80%.141 Data from Sweden and Netherlands also indicates that both short-term survival outcomes and neurologically favourable survival are increasing over time.45,143,148 Despite limited reports from Europe examining the long-term quality-of-life and functional recovery of children sur-vivors of OHCA, the available data suggests survivors maintain good neurological outcomes at longer-term follow-up.145,149

Although synthesised data on the incidence and outcomes of paediatric OHCA are lacking, existing reports indicate some differ-ences and similarities across regions. In Australia, the incidence of EMS-treated paediatric OHCA was 4.9 cases per 100,000 person-years(6.7 per 100,000 in EMS-treated cases) and 8.1% of patients survived to hospital discharge.150 In North American regions con-tributing to the Resuscitation Outcomes Consortium, the incidence of EMS-treated paediatric cases was 6.8 cases per 100,000 person-years(8.3 per 100,000 in EMS attended cases) with 10.2% surviving to hospital discharge.151 In comparison, Asian regions contributing to the Pan Asian Resuscitation Outcomes Study reported a pooled survival to hospital discharge rate of 8.6%,although the incidence was not reported.152 A recent systematic review exploring the influence of sociodemographic factors on paedi-atri or OHCA indicates that the incidence of paediatric OHCA and the presence of bystander CPR were strongly associated with race and ethnicity, with minority populations being disproportionately impacted.153 These factors may contribute to global differences in the outcome of paediatric OHCA.

In-hospital cardiac arrest (IHCA)

Incidence

There is wide variation in the incidence of treated IHCA in Europe. 154,155 The ERC continues to recommend the adoption across Europe of the Utstein recommendations for reporting in-hospital cardiac arrest.9 The Utstein recommendations advocate reporting incidence as the number of treated in-hospital cardiac arrests per 1000 hospital admissions(excluding cardiac arrests which occur in the emergency department). A few studies on this topic have been published recently(Table 3 and Supplementary Table 1).3,4,91,156-161 They confirm previous European studies, which showed an incidence of 1.5 to 2.8 per 1000 admissions. 162-166 Patients are aged 67 to 75 years and most are male(60%-69%),which is very consistent across different studies and countries.3,4,156-158,160,161 However, outcome data show significant variations

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Table 3- IHCA incidence, characteristics and outcome in published studies from 2020 to 2024.

|Reviewed published studies (2020-2024) focusing on ICHA Core Elements' reported|IHCA Utstein's Core Elements' reported|Age (Mean)|Sex (Male)|Number of treated IHCA per year|Incidence of HICHA per year|Location of IHCA per1000admission per year|Monitored (M) nonmonitored (NM) area|MyROSC% (M) nonmonitored (NM) area|Survival to discharge%|30-day survival%|Neurological outcome CPC 1-2%|DNAR reported|| |---|---|---|---|---|---|---|---|---|---|---|---|---|---| |Adielsson-2020-Sweden 156|Yes|72.6|6.4|23,950|N/A|All|N/M|N/A|N/A|32.5%|N/A|No|| |Albert-2023-Sweden 156|Yes|74|63.1|4,324°|N/A|All|N/M|N/M|65.3/49.9%|N/A|48.4/18.7%|89.8/72.8%|No| |Andersson-2022-Sweden 157|No|N/A|N/A|245|N/A|All|N/M|N/A|N/A|N/A|49.8%|40%|Yes| |Bruchfeld-2024-Sweden 157|No|75|60|5,788°|N/A|All|N/M|N/M|45%|21%|N/A|16%|No| |Creutzburg-2021-Denmark|Yes|67|69|444/4940|1.133.1/11|General ward|N/A|N/A|N/A|N/A|N/A|N/A|No| |Flam-2024-Sweden 159|No|N/A|N/A|3,737|16.1E|ICU|M|N/A|N/A|N/A|N/A|N/A|No| |Silverplats-2024-Sweden 160|Yes|73|65|745/254°|2.9/12.4°|All|N/M|63/72°|N/A|N/A|40/39%|92/91%|Yes| |Yoris-2020-Denmark|No|74|65|1,892|N/A|All|N/M|N/A|N/A|N/A|27.3%|N/A|No| |Yoris-2022-Denmark|161|74|63.1|8,727|N/A|All|N/M|N/M|N/A|N/A|62%|N/A|No|

DNAR: Do Not Attempt Resuscitation.

* Hospital/Patient/Pre-event/Cardiac Arrest Process/Postresuscitation Process/Outcome.

Non-Utstein Core Elements.

A Cardiac/non-cardiac cause.

B Cardiac/non-cardiac group.

C Non-shockable IHC.

D Pre-Implementation Early Warning Score/Post-Implementation Early Warning Score group.

E Intensive Care Unit(ICU) cardiac arrest events.

F Prospectivally retrospectively registered.

G Total/CIU admissions

H< min resuscitation duration.

between the different studies, also depending on differences in the denominator, but ranging between 27.3% and 62%.3,4,91,156,160,161(Table 3).3,4,91,156-161

Response organization

The ERC was a key stakeholder in the development of the 10 steps toward improving IHCA quality of care and outcomes recommenda-

on behalf of the International Liaison Committee on Resuscitation

Plan and prepare

 Build and support governance and infrastructure for a resuscitation program

 resuscitation processes and outcomes

 Implement effective education and training for resuscitation

 Establish patient and family goals of treatment early and reassess often

 Stop preventable in-hospital cardiac arrests

       Fig.4-10 Steps to improve in-hospital cardiac arrest quality of care and outcomes.

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Table 4- Summary of use of 2222 emergency call number for IHCA in European Countries.

|Country|Survey date|Hospitals|Use of 2222 (%)| |---|---|---|---| |Belgium|2021|Flemish Hospitals|2/19(11%)| |Denmark|2017|Hospitals|9/40(29%)| |France|2019|Military Hospitals|2/8(25%)| |Ireland|2019|Public and Private Hospitals|52/67 (78%)| |ERC guideline survey|2025|14 countries|2/14 (13%)|

tions from ILCOR.167 The programme highlights the importance of planning and preparation, systems to prevent IHCA and inappropri-ate resuscitation, optimal organisation of the emergency response to IHCA including delivery of guideline-based care and principles of person-centred culture(Fig. 4).

Develop and deploy an effective resuscitation response system

Step 6 of the ILCOR initiative on improving IHCA describes the importance of a hospital-wide resuscitation response system that is easily and rapidly activated. It highlights the importance of a high-quality resuscitation team that includes preassigned, experienced,and interdisciplinary health care professionals.167 A survey amongst guideline writing group authors(n=14, 100% response) covering 14 countries(Austria, Croatia, Denmark, France, Germany, Greece,Italy, Netherlands, Norway, Serbia, Spain, Sweden, Switzerland,United Kingdom) explored the characteristics of the response to IHCA. Most countries used a designated cardiac arrest team(78%). Team roles were pre-assigned before cardiac arrest in nine countries(60%), at the time of the cardiac arrest in two(20%),and there was no consistent approach in two(20%). The use of multi-professional teams was almost universal(93%)- just one country included physicians only. Some form of standardised advanced life support training was provided in all but one country.The ERC Advanced Life Support Course was used in 6 countries(40%), local advanced life support courses in 6 countries(40%)or no consistent approach in 2 countries(13%). Use of a defibrillator was permitted by physicians(all countries) and nurses in ten coun-tries(73%).

The ERC continues to recommend the use of a standard internal telephone number(2222) for IHCA in Europe.168 Despite these rec-ommendations being made in 2016, penetration across Europe is limited.(Table 4) Forward citation tracking of the publications recom-mending implementation of 2222 as the standard number to alert the in-hospital resuscitation team demonstrates variable penetration across Europe.169-172

Outcome

Outcome data should be reported consistently to enable compar-isons. Core outcome data should include reasons for CPR termina-tion, ROSC, survival and neurological outcome at discharge and/or at 30-days.

There are far fewer studies reporting outcomes from IHCA com-pared with those reporting outcomes from OHCA. Data identified by the ERC writing group are summarised in Table 3 and show that vary-ing rates of ROSC(range 45-72%), survival(range 27.3-62%) and neurological outcome(range 16-92%). There is also evidence that IHCAs in monitored areas, younger age, shockable rhythm, with less comorbidity are associated with best outcomes, whilst IHCAs occur-ring early in the morning are associated with worse outcomes. ${}^{173}$ The ERC therefore strongly advocates for the roll out of IHCA registries in accordance with Utstein recommendations.

Long term survival and return to societal participation

Measurement of outcome and recovery

Long term survival and outcome

Severe hypoxic-ischaemic brain injury is a devastating outcome for cardiac arrest survivors. In most European countries where with-drawal of life sustaining treatment is routinely practiced, a poor neu-rological outcome is seen in less than 10% of cardiac arrest survivors.174 In situations where withdrawal of life sustaining treat-ment is not applied, survivors with severe hypoxic-ischaemic brain injury are substantially more common. Even among survivors classi-fied with a good outcome, the effects of hypoxic-ischaemic brain injury may impact everyday life. The most frequently reported neuro-logical sequela is neurocognitive impairment, affecting most sur-vivors in the early phase and up to 50% over the longer term,where it is mostly mild-to-moderate.174,175

When assessed at group level, the use of generic measures of health-related quality-of-life suggests comparable levels of health with the general population. ${}^{175,176}$ However, more nuanced analyses reveal that several health-related quality-of-life sub-domains are poorer in cardiac arrest survivors, and that cognitive, physical,emo-tional problems and fatigue are common. ${}^{174,177-180}$

Families of cardiac arrest patients(also known as 'co-survivors')are also at significant risk of emotional problems including anxiety,increased care-giver burden, and post-traumatic stress.181-183 Being a witness to a relation's cardiac arrest increased the risk for emo-tional problems,181 and cognitive impairment in the survivor was associated with increased caregiver strain.183,184 Logistical and eth-ical challenges with collecting detailed information beyond hospital

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discharge remains a critical issue for long-term recovery reporting. ${ }^{8,175}$

A recent review of recovery and survivorship following paediatric cardiac arrest describes the commonality of cognitive impairment,including difficulties with memory, language, attention, communica-tion, and executive functioning, impaired physical functioning, and activities of daily living. ${ }^{185}$ Emotional problems, such as anxiety,depression, or behavioural problems, may manifest as somatic com-plaints or attention difficulties. Changes in family social functioning are also described. Few studies capture long-term outcomes beyond 2-3 years post hospital discharge. ${ }^{185}$

Registries

The Utstein template defines core and supplementary outcome vari-ables and recoding methodologies to be collected in the event of OHCA. ${ }^{8}$ Since its introduction, patient survival and neurological sta-tus have received increasing focus. Utstein guidance directs that neurological outcome is reported using the Cerebral Performance Category (CPC) and/or modified Rankin Scale (mRS) for adults and the Paediatric Cerebral Performance Category for children at hospital discharge or at 30 days. ${ }^{8}$ Because the collection of post-discharge survival status and health-related quality-of-life data requires extensive resources they are identified as supplementary outcomes. Recommended health-related quality-of-life assessments are in line with the Core Outcome Set for Cardiac Arrest (COSCA)outcome reporting recommendations: that is, the Short-Form 36-item Health Status Survey (SF-36), EuroQoL EQ-5D-5L, or the Health Utility Index version 3 (HUI3) for adult survivors at 90-days ${ }^{186}$ and the Pediatric Quality of Life Scale (PEdSQL) for children at 6-months. ${ }^{187}$ However, a recent review of studies citing Utstein guidance found that the supplementary outcomes were rarely used,with fewer than 3.3% assessing health-related quality-of-life. ${ }^{8}$

Research

The introduction of the COSCA guidance has contributed to an improvement in outcome reporting: ${ }^{188} 82 \%(45 / 55)$ of recent trials reported neurological function, of which 19 of 45 adopted the modified Rankin Scale as a measure of functional outcome;33 % (18/55) of trials reported health-related quality-of-life, with most (16 of 18) including recommended assessments. The EuroQoL EQ-5D-5L was most frequently used. However, continued heterogeneity in the reporting of health-related quality-of-life is hindering data synthesis. ${ }^{176,179}$

Recognising the limitation of generic assessments, COSCA high-lights the complementarity of domain-specific assessment, for exam-ple, of cognition, fatigue, anxiety, and participation. However, without specific assessment guidance, further heterogeneity in domain-based outcome reporting has been described. For example, a review of 43 studies described more than 50 measures and a range of different cut-points used to assess neurocognitive function follow-ing OHCA. ${}^{177}$ Similarly, 16 different measures of anxiety or depres-sion across 32 studies of cardiac arrest survivors were reported in another review. ${}^{180}$ Variation in measurement choice and cut points impacts prevalence reporting; standardisation is urgently required to support greater transparency in the assessment of symptom incidence.

<BeginOfPara>Recent evidence suggests that the Montreal Cognitive Assess-ment (MoCA) is an acceptable measure of cognitive screening fol-lowing cardiac arrest, $^{189,190}$ further underpinning recommendations for its use in this population. $^{191}$ The measure is usually administered

<EndOfPara>face-to-face or via a digital meeting. Whilst a telephone version is available, the psychometric properties are less known, and hence this version should be applied with caution. ${}^{192}$

Despite the Hospital Anxiety and Depression Scale (HADS) being widely used as a measure of anxiety and depression in cardiac arrest survivors, ${}^{180}$ there are few psychometric evaluations of its use with this population. ${}^{193}$ However, there is strong evidence supporting its use in the general population and in patients with cardiac disease.For example, evidence from a large Danish population of cardiac patients suggests acceptable evidence of essential measurement properties, in keeping with earlier studies. ${}^{194}$

Fatigue assessment guidance following cardiac arrest is not available. Whilst the most widely used measures in cardiac arrest are the Fatigue Severity Scale(FSS)195-197 and the Modified Fatigue Impact Scale(MFIS),197-199 information of psychometric properties is limited in this population. Evidence from other patient groups(e.g. multiple sclerosis) suggest they are comparable when measur-ing physical aspects of fatigue in populations with mild to moderate fatigue.200 However, where both physical and cognitive aspects are important, and where higher levels of fatigue might be antici-pated, the somewhat longer Modified Fatigue Impact Scale is preferable.200

Guidance for the assessment of activities and participation follow-ing cardiac arrest does not exist. However, functional outcome scales and health-related quality-of-life assessments, such as the modified Rankin Scale and Short-Form 36-item Health Status Sur-very, commonly include these domains; the value of reporting health-related quality-of-life outcomes at a domain-level has been demonstrated. ${ }^{201}$ Whilst overall physical and mental component summary scores on the Short-Form 36-item Health Status Survey suggested health status comparable to the general population, at the domain level impairment was substantial. This was particularly noted where people experienced difficulties engaging in roles related to work and other activities due to physical (50 % impaired) and emo-tional (35%) limitations. ${ }^{201}$

Variation in outcome assessment following paediaciatric cardiac arrest (what is assessed, when, and by whom) is described, which may further contribute to the reported heterogeneity in post-arrest problems described and our understanding of long-term out-comes. ${ }^{185}$ Moreover, the widespread use of blunt global assess-ments such as the Paediatric Cerebral Performance Category(PCPC) may inadequately capture change in patient and family important outcomes such as ability to engage with friends, school,and society. Introduction of the Paediatric-COSCA guidance in 2020187 is expected to contribute to improvements in outcome reporting and our understanding of the long-term recovery and sur-vival of children. ${ }^{185}$

Routine practice

Measures to use during follow-up in clinical practice are detailed in the ERC Guidelines 2025 Post-resuscitation care, and includes guid-ance for screening of cognitive, emotional challenges, and fatigue and exploring limitations in physical activity and physical function. ${}^{202}$

Rehabilitation and return to societal participation

Follow-up and screening

The 2021 ERC Post-resuscitation Guidelines recommended the assessment of physical and non-physical impairments both before and within 3-months of hospital discharge to identify rehabilitation needs and the provision of timely and targeted care through appro-

13

priate referrals.191 An early follow-up assessment, including screen-ing for cognitive and emotional challenges, is supported by an RCT from the Netherlands.203-205 This cost-effective intervention con-tributed to a positive impact on mental health and an earlier return to work at one year.205,206 Several European national guidelines and quality standards now recommend early follow-up following car-diac arrest- for example, Sweden, 207 France, 208 United King-dom,209,210 Scotland,211 and the Netherlands.212 To what extent cardiac arrest survivors in Europe are assessed before discharge and/or at follow-up is unknown.

Most cardiac arrest survivors who responded to a UK survey (95 of 123 (77 %); median 2 yrs since cardiac arrest) reported being followed-up, typically by a cardiologist (62%). The majority (99%)indicated the need for post-discharge follow-up with access to a multi-disciplinary team; more than half (61 %) preferring early follow-up within one month of discharge. Prioritised topics included:medical issues (as the cause of the cardiac arrest and heart dis-ease), mental fatigue/sleep and screening for emotional and cogni-tive challenges.213

Almost all respondents to a survey of French ICUs reported pro-viding oral information to cardiac arrest survivors prior to discharge(136/145, 94%).208 However, just half noted the OHCA survivors'neurological and functional outcome in medical records or organized a post ICU follow-up which included cognitive and emotional screen-ing. Described barriers to provision of follow-up appointments included: lack of awareness and knowledge; limited resources,including limited interdisciplinary collaboration; limited evidence to justify the cost; and an absence of practical recommendations. ${}^{208,212}$

Informed by previous experiences203-206 and European deli-nes214 the Essex Cardiothoracic centre started the UK's first dedi-cated follow-up clinic for cardiac arrest.215 Cardiac arrest survivors(approximately 70 per year) are assessed by an ICU nurse and car-diologist before discharge and provided with multiple information sources, ranging from contact details to a peer support group. A post-discharge telephone call is organized within 48-hours, with follow-ups at 2-, 6- and 12-months for survivors and their carers.215 A hub-and-spoke sub-regional model with a single lead cardiac arrest centre performing patients' assessment both in-person and remotely is being implemented in Italy. Such an approach may reduce disparities in care allowing this type of follow-up even in hos-pitals with limited resources.216

The 'Copenhagen Framework217 provides a further example of guideline translation 191,214 into clinical practice. A stepwise multidis-ciplinary approach to organise and manage follow-up and rehabilita-tion, implemented through two high-volume cardiac arrest centres(approximately 200 survivors a year), it includes: in-patient assess-ments; early follow-up 1-2 weeks post-discharge; and a more exten-sive follow-up at 2-months for both survivors and their family members.

Rehabilitation

The 2021 guidelines recommend that, where indicated, cardiac arrest survivors should be referred for specialist rehabilitation. ${ }^{191}$ However, there remains a lack evidence for rehabilitation after car-diac arrest.2018 Current evidence based clinical practice recommen-dations for rehabilitation after cardiac arrest are discussed in the ERC Guidelines 2025 Post-resuscitation care.202 Here we explore and describe available European rehabilitation pathways for cardiac arrest survivors. Participants in a large trial including mainly Euro-pean OHCA survivors described their experience of rehabilitation

within the first six-months post-arrest.192 Just 29 out of 836 patients participated in cardiac rehabilitation, with fewer than 12%receiving brain injury rehabilitation(in-hospital: 12%; outpatient:5%).192 In a smaller Danish study of OHCA survivors who had been in employment before their arrest(n= 38), 100% had a rehabilitation plan at time of discharge.219 The most frequently accessed rehabilita-tation interventions involved psychologists addressing psychological issues(78%) and physiotherapists supporting exercise capacity(68%). Although rehabilitation participation was high, almost half of survivors reported unmet rehabilitation needs at 6-months, includ-ing support for existential issues, speech problems, return to work,fatigue and energy management.219

Whilst many cardiac arrest survivors are eligible for cardiac reha-bilitation, engaging in these programmes alongside other patients who have experienced an acute cardiac/coronary event, those sur-vivors whose cardiac arrest was idiopathic or due to non-ischaemic causes are generally excluded.174,175,215 A survey of Danish cardiac rehabilitation facilities suggests that cardiac arrest survivors received less specialised cardiac rehabilitation than myocardial infarction patients. This included less patient education, exercise training,screening for anxiety and depression and nutritional counselling.220

Commencing at three-months post-arrest for survivors who had been discharged to home, a small Danish pilot study tested a combina-tion of residential and home-based rehabilitation including education,physical activity training, and psychosocial support.198 Carers were invited to attend the residential group sessions. Whilst this small pilot study is unable to provide sufficient evidence to support a change in practice, patient and clinician satisfaction was high. However, the spe-cialised residential component may not be feasible in many settings.

Due to the prevalence of cognitive impairment in cardiac arrest survivors, a potential knowledge gap in care delivery by cardiology-based healthcare professionals has been described,212,221 with a greater need for interdisciplinary collaboration proposed.215,221,222 By example, a combined cardiac and cognitive rehabilitation pro-gramme is provided to cardiac arrest survivors at a single centre in the Netherlands.223 More specifically, whilst those without cognitive impairment follow a traditional cardiac rehabilitation programme,those with impairment participate in smaller cardiac rehabilitation groups with the addition of a cognitive rehabilitation programme. This pathway has not been evaluated, but 23% of cardiac arrest survivors referred for cardiac rehabilitation had cognitive problems.224

Brain injury rehabilitation is often provided to cardiac arrest sur-vivors with severe hypoxic-ischaemic brain injury, with care provided alongside other patients with acquired brain injury - e.g., traumatic brain injury. 225 Whilst guidance on brain injury rehabilitation following cardiac arrest is not available in the European context, insight can be gained from several retrospective studies (e.g., patient records)from the last decade. A retrospective review of patients admitted to a Turkish brain injury in-patient rehabilitation facility between 2011 and 2015, reported anoxic brain injury following cardiac arrest in 5% of patients. 225 Patients with anoxic brain injury received the same intense rehabilitation programme as patients with traumatic brain injury, including physiotherapy, occupational therapy, cognitive reha-bilitation and speech-language therapy for 5 h a day, for 20 days. In a small Dutch study of patients hospitalised and institutionalised because of unresponsive wakefulness syndrome (most due to cardiac arrest), more than half (54%) had not received any rehabilitation.226 By contrast, a larger German study on 93 patients describes early,daily interdisciplinary neurological rehabilitation for patients with sev-ere hypoxic-ischaemic brain injury (34% of cardiac causation), which

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continued until improvement ceased or complications were observed(including death).227 Following a mean duration of 109 days, 41%were discharged to a nursing facility, 23% were referred for additional rehabilitation, 18% returned home, 10% needed further acute-care and 8% died. Of those comatose at admission, 82% remained coma-tose at discharge. A single French centre describes a six-month ther-apetic intervention for institutionalised patients with anoxic brain injury(n= 11/20 caused by cardiac arrest; mean 8-years post-event).228 Consisting of medication, psychotherapy, support group,and physical, cultural and/or artistic therapeutic activities, it positively impacted quality of life and social participation.

Genetic variants and autopsy in cardiac arrest patients

The cause of cardiac arrest is known to be different according to the age of the victim. Coronary artery disease indeed represents the cause of cardiac arrest in most people over 50 years, but it explains only a minority of cases in young people. In young victims, most of the sud-den cardiac deaths are attributable to other diseases, of which the majority are genetically determined structural or arrhythmogenic myocardial pathologies.229,230 Differences in the cause of cardiac arrest become more pronounced at younger ages.231,232 In young vic-tims of sudden cardiac disease, the most common causes are hyper-trophic cardiomyopathy-which is particularly prevalent in athletes-and arrhythmogenic cardiomyopathy. Other significant contributors include dilated cardiomyopathy and primary arrhythmogenic disorders,such as familial long-QT syndrome, catecholaminergic polymorphic ventricular tachycardia, and Brugada syndrome.231,232 The identifica-tion of such an aetiology in the deceased may have important implica-tions for families, allowing their arrhythmic risk to be defined and potentially preventing further sudden death events. In concordance with other European Societies the ERC recommends that a full post-mortem examination, including heart dissection, sampling for genetic and toxicological analysis, should be done in all the young sudden car-diac disease victims. However, although this recommendation is endorsed by numerous scientific societies in Europe and beyond,the post-mortem examination of young sudden cardiac disease victims is currently not routinely performed in many European countries.233,234

Genetic post-mortem analysis(so-called lolecular autopsy) is important because about one third of the sudden cardiac disease remains unexplained after autopsy.235-237 For this reason, the collec-tion of 5-10 mL of blood in Ethylenediaminetetraacetic acid(EDTA) is recommended during post-mortem examination or whenever possible,even on the OHCA scene.235,238,239 Modern techniques of DNA eval-uation(e.g. multi-gene panels using next-generation sequencing)enable identification of a clinically actionable pathogenic or likely pathogenic variant in a gene potentially related to the cause of sudden cardiac death in up to 25% of cases, with significant implications for the care of their families.231,240-247 Considering genetic data together with the phenotype provides much more informative data at a clinical level than using genetic data alone. Molecular and familial analysis together enable increased diagnostic yield.248 The clinical data, includ-ing information about the deceased, the context and the triggers of the event, and the families, are all important.249-251 Modern DNA analysis techniques enable the identification of a considerable percentage of

variants of uncertain significance(VUS) on genes of interest. How-ever, unlike pathogenic or likely pathogenic variants, these types of variants present significant challenges when explaining their signifi-cance to family members of the deceased and, if still alive, to the patients themselves.250 The ERC recommends that genetic and clini-cal testing should be undertaken only by multidisciplinary teams including professionals with skills to counsel on the implications and the uncertainty of results and to decide about the appropriateness of extending the screening to the first-degree relatives of the victims,and experienced cardiologists able to direct testing to the correct phe-notype.252 These teams should ideally be based in tertiary centres that offer comprehensive professional expertise and can receive patient referrals from a wide region. These centres should also be capable of periodically reanalysing and reclassifying variants as new data on pathogenicity become available. 247,253 There has been consensus that the autopsy and genetic testing should be performed in those under the age of 40 years;250,254 however, other studies suggest that the age range should be extended up to 50 years.255,236,251,256 This wider age range is supported by two recent expert consensus state-ments on genetic evaluation of patients with unexplained sudden car-diac arrest.252,257 These statements represent the official views of the European Society of Cardiology(ESC) and numerous arrhythmia sci-entific societies worldwide(European Heart Rhythm Association,Heart Rhythm Society, Asia Pacific Heart Rhythm Society and Latin American Heart Rhythm Society). Therefore, the ERC strongly recom-mends performing a comprehensive post-mortem examination(includ-ing heart dissection and toxicological analysis) and a molecular autopsy on all victims of unexpected sudden death under 50 years old.

Low-resource settings and remote areas

Out-of-hospital cardiac arrest and IHCA occur worldwide, regardless of a country's available resources, population density, or remote-ness. Although responding to cardiac arrest may not be a primary focus of emergency services in lower-resourced countries, the fun-damental principles of resuscitation still apply. However, the epi-demiology, organisation of response and treatment, and both short- and long-term outcomes differ significantly in these settings and in remote areas. Therefore, it is important to consider the treat-ment of OHCA and IHCA in less-resourced countries and remote regions separately. The response to OHCA in remote areas of high-resourced countries involves entirely different strategies and resource allocation compared to those in lower-resourced settings.

Low-resource settings

The only available data on OHCA in low-resourced countries in Eur-ope concern Serbia and Bosnia and Herzegovina,258,259 two of the most low-resourced countries in Europe, where an incidence of OHCA of 85.6 per 100,000 and 54 per 100,000 inhabitants/year respectively is reported, which aligns with the median reported inci-dence of 55 per 100,000 inhabitants/year in Europe.5 Some charac-teristics of OHCAs in those countries are similar to other European countries, such as the majority of events occurring at home, but other aspects are significantly different. In particular, the rate of first mon-itored shockable rhythm reported in Bosnia and Herzegovina is con-sistently higher than in other European countries, representing

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$45.6\%$ of OHCAs. ${ }^{258,259}$ The rate of bystander CPR $(15.3\%$ among bystander witnessed in Serbia and 3.3 % among all OHCAs in Bos-nia and Herzegovina) and AED use (0 % in Bosnia and Herzegovina) is lower compared with the European average value. ${ }^{258,259}$ This reflects on the outcome, as the ROSC and survival rates in both countries are lower than the median value in Europe. ${ }^{2,5}$

The differences between low- and high-resourced countries become even more apparent outside Europe, where there is a reporting bias because of a lack of OHCA registries adapted to the Utah template set and based on a reference territory, 260 both of which are essential for reliably understanding the phenomenon. Most reports are derived from hospital-based registries that do not follow the Utstein template, and often describe cases where patients in car-diac arrest are transported to the Emergency Department without EMS activation, 261-265 leading to clear delays in treatment, compro-mised care, and poorer outcomes.

Estimating the incidence of OHCA is only feasible in a few countries with functioning registries, such as South Africa and Argentina-both classified as 'upper-middle income' countries. Reported incidence rates are 23.2 per 100,000 inhabitants per year in Cape Town and 53 per 100,000 inhabitants per year in the city of Bariloche, although the latter figure includes all OHCAs, not just those treated by EMS. 266,267 No inci-dence data are available from other countries.

The available data suggest that the mean age of OHCA patients in low-resourced countries is lower than in high-resourced settings,ranging from 55 years in Pakistan265 to 63 years in South Africa.266 This likely reflects both a younger general population and differing attitudes toward resuscitation in elderly individuals. The location of OHCA, though difficult to interpret because of reporting limitations,varies considerably. The proportion of OHCAs occurring at home ranges from 56.1% in China80 to 79.7% in South Africa.266

A first monitored shockable rhythm is found in only a small fraction of patients-approximately 1% in both Pakistan263 and South Africa.266 Bystander intervention is also rare, with CPR rates ranging from 2.3%in Pakistan and 5.1% in Iran,263,268 to 18.7% in China and 22% in Viet-nam,80,269 underscoring the strong correlation between bystander CPR and gross domestic product.65 Outcomes for OHCA patients in these settings are generally poor: in cohorts with presumed lower reporting bias, ROSC is about 1%, 266 and survival to hospital discharge ranges from 0% to 4%.263,265,266.268 There are no data on ICHA in low-resourced countries in Europe. Existing data from non-European coun-tries are limited and typically based on small patient cohorts. The reported incidence in Egypt is 1.77 per 1000 patients discharged,while the median age in Uganda is 40 years.271 ROSC rates range from 49.3%272 to 62.2%,271 and survival rates from 14.9%271 to 35.5%,272 with improved outcomes reported following the implementation of in-hospital Rapid Response Teams.270,273 In summary, for both OHCA and IHCA in low-resourced countries, the establishment of robust reg-istries is of paramount importance to accurately define the epidemiology and to monitor progress in treatment and patient outcomes.

Remote areas

Regarding OHCAs in remote areas, available European data are lim-ited to mountain regions, which represent the most remote settings within the European context. Studies from the French, ${}^{274}$ Polish, ${}^{275}$ and Austrian Alps ${}^{276}$ reveal some common features-such as a mean age of OHCA victims around 60 years and a predominance of male patients-but also highlight significant differences in bystan-

der intervention and outcomes. French data suggest a key reason for this variation: OHCAs that occur on ski slopes are more likely to receive bystander CPR and AED use, leading to better survival rates,compared with those that occur off the slopes or in other mountain settings, including typical Utstein-defined locations such as homes public spaces, or workplaces. ${}^{274}$ This emphasises that the response to the arrest, rather than the location itself, is the critical factor in determining patient outcomes. Remote areas are more widespread outside Europe, and informative data on OHCA in these contexts come from Canada, ${}^{277}$ the United States, ${}^{278}$ and Australia. ${}^{279,280}$ In these countries, OHCA patients in rural and remote settings tend to be younger, and bystander CPR and AED use are more common than in urban areas. However, significantly longer EMS response times in remote regions consistently reduce the likelihood of ROSC and survival in all three countries, underlining the particular chal-lenges of managing OHCA in geographically isolated areas.

Declarations of competing interest

Declarations of competing interests for all ERC Guidelines authors are displayed in a COI table which can be found online at https://doi.org/10.1016/j.resuscitation.2025.110733.

Acknowledgement

The ERC would like to thank Tommaso Scquizzato for creating the photographic on the 10 Steps to improve in-hospital cardiac arrest quality of care and outcomes-Fig.4.

Appendix A. Supplementary material

Supplementary data to this article can be found online at https://doi.org/10.1016/j.resuscitation.2025.110733.

Author details

${}^{a}$ Division of Cardiology, Fondazione IRCCS Policlinico San Matteo,pavia, Italy $\quad b$ Cardiac Arrest and Resuscitation Research Team(RESTART), Fondazione IRCCS Policlinico San Matteo, Pavia,Italy $\quad c$ Cardiac Calcase Medicine, University Hospital Schles-wig-Holstein, Kiel, Germany dDepartment for Anaesthesiology and Intensive Medicine, University Hospital Schleswig-Holstein, Kiel,Germany"German Resuscitation Registry, Nuernberg, Germa-ny fDepartment of Cardiology, Cardiocentro Ticino Institute, Ente Ospedalierio Cantonale, Lugano, Switzerland 9Fondazione Ticino Cuore, Lugano, Switzerland hFaculty of Biomedical Sciences, Uni-versita della Sivizzera Italiana, Lugano, Switzerland Warwick Medical School, University of Warwick, Coventry, United Kingdom/Neurology,Department of Clinical Sciences Lund, Lund University, Lund,Sweden $\quad$ Neurology, Skane University Hospital, Lund, Swe-den'Clinical Directorate, HSE National Ambulance Service, Dublin,Ireland $\quad$ "Discipline of General Practice, University of Galway,Ireland "School of Medicine, University College Cork, Cork, Irelan-d'Centre for Research and Evaluation, Ambulance Victoria, Victoria,Australia's School of Public Health and Preventive Medicine, Monash University, Victoria, Australia $\quad$ University Hospital, University of University Birmingham, United Kingdom $\quad$ 'University Hospitals Coventry and Birmingham, United Kingdom

16

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Warwickshire, Coventry, United Kingdom Servio de Emergencias Sanitarias 061, Lo Rioja, Spain 10.School of Health and Welfare,Dalama University, Falun, Sweden"Centre for Clinical Research Dalama, Uppsala University, Falun, Sweden"Department of Pre-hospital Care, Region of Dalana, Falun, Sweden"Division of Prehospital Services, Oslo University Hospital, Oslo, Norway

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