COVID-19 pandemic led to significant decline in cardiac arrest survival rates

American Heart AssociationNov 11 2024

Out-of-hospital cardiac arrest survival rates dropped significantly at the onset of the COVID-19 pandemic in 2020 and have continued to remain lower than in the pre-pandemic years of 2015-2019, according to a preliminary study to be presented at the American Heart Association's Scientific Sessions 2024. The meeting, Nov. 16-18, 2024, in Chicago, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.

The analysis of data for more than a half million adults in the U.S. who had an out-of-hospital cardiac arrest between 2015-2022 also found lower survival rates in predominantly Black and Hispanic communities.

Our results indicate that the onset of the COVID-19 pandemic largely erased gains in out-of-hospital cardiac arrest survival that had been achieved during the ten years before the pandemic, and it exacerbated disparities among Black and Hispanic communities. We need to make a concerted effort toward improving survival rates across the board, with targeted efforts to support people in communities with a majority of Black and Hispanic residents."

Eric Hall, M.D., study's lead author and cardiology fellow at UT Southwestern Medical Center in Dallas

Cardiac arrest occurs when the heart suddenly stops beating. It is often fatal if appropriate steps, such as activating emergency response starting with lay rescuer CPR, and early defibrillation, are not taken immediately. Most out-of-hospital cardiac arrests happen at home, in public settings or in nursing homes rather than at a hospital, according to the American Heart Association.

In this study, researchers compared out-of-hospital survival rates in the U.S. during the pre-pandemic years (2015-2019) to when COVID-19 spread rapidly (2020-2022), particularly in the early stages when cardiac arrest survival rates decreased sharply. The team also examined whether survival rates improved in the years since the pandemic began and if the improvements were shared equally among various racial and ethnic communities.

The analysis found:

• Before the pandemic, the rate of overall out-of-hospital survival-to-hospital discharge was nearly 10%. The cardiac arrest survival rate varied across communities: in those with mostly Black and Hispanic residents, it was about 8%; and in multi-race communities, it was close to 11%, compared to a survival rate of more than 11% in predominantly white communities.

• In 2020, out-of-hospital cardiac arrest survival decreased to 9% overall; however, in Black and Hispanic communities, survival declined to 6.6%, a relative decrease of -16.5% compared to before the pandemic. This was a larger relative decrease than was seen in multi-race integrated communities (-6.5%) or predominantly white communities (-8.1%).
• In 2021 and 2022, there was little improvement in survival overall after out-of-hospital cardiac arrest (9.1%), still significantly below pre-pandemic levels of 9.9%. There was modest improvement in survival after cardiac arrest in majority Black and Hispanic communities, such that the disparity in survival rates between these communities and white communities narrowed to 2.6% in 2022, compared to a gap of more than 3% for 2015-2019. Survival rates, however, remained lower for Black and Hispanic communities in comparison to predominantly white communities in every period studied.

The results surprised the research team. "We expected that survival after out-of-hospital cardiac arrest would have bounced back to levels before the pandemic," said Saket Girotra, M.D., S.M., the study's senior author and an associate professor of cardiology in the department of internal medicine at UT Southwestern Medical Center in Dallas. "Even in 2022, survival rates remained worse than before the pandemic."

Girotra noted that the team is conducting additional research to better understand the role of emergency medical services in providing cardiac arrest care and to identify best practices for treating patients who experience out-of-hospital cardiac arrest.

Sarah Perman, M.D., M.S.C.E., FAHA, chair of the American Heart Association's Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, said other factors are likely hindering a rebound from the COVID-19 pandemic.

"During the pandemic, we saw notable delays in people seeking health care," said Perman, an associate professor in the department of emergency medicine at Yale School of Medicine. "Now, I think we're seeing individuals who are having challenges accessing health care. So we're not in an environment where we can completely rebound.

"It's also really important that we recognize another factor," she said. "In 2019, we saw the addition of fentanyl into the illicit drug market, and that obviously coincided a little bit with the pandemic. That has continued to be a factor, and we are seeing a higher incidence of overdose-associated cardiac arrest. I think that also complicates how this data can be interpreted."

Perman urged educational initiatives and community outreach to increase cardiac arrest awareness and CPR skills: "If someone who is in our circle unfortunately succumbs to a cardiac arrest, it's important to remember that you need to push hard and fast on the chest and call 911, so that you can activate emergency medical services to assist with the resuscitative efforts."

The research has several limitations. Although the findings are based on data from the Cardiac Arrest Registry to Enhance Survival, or CARES, which covers more than half of the U.S. population, the data may not be applicable to communities that do not participate in the registry. The study's design focused on observations, limiting the ability to assess reasons or causes for the findings. The research period ended in 2022, while the declaration to end the public health emergency status for the COVID-19 pandemic was May 11, 2023.

Study details, background and design:

• The analysis included more than 506,000 adults from the CARES registry who had experienced an out-of-hospital cardiac arrest from 2015-2022. The average age was about 62 years old; 64% were men, 22% were Black adults, and 7% were Hispanic adults.
• The study compared survival after out-of-hospital cardiac arrest for 2015-2019 before the COVID-19 pandemic to each of the years 2020, 2021 and 2022 after the beginning of the pandemic.
• Researchers also examined survival rates for differences based on the racial and ethnic composition of the people in communities served by emergency medical service agencies, defined as predominantly white communities (more than 80% white residents), predominantly Black or Hispanic communities (more than 50% Black or Hispanic residents) or multi-race integrated communities.