Introduction
The American Heart Association (AHA) releases updated Advanced Cardiovascular Life Support (ACLS) guidelines on a regular basis to include the most current evidence-based changes in practice and clinical advancements. This latest update, called the 2023 ACLS Focused Update, includes multiple key changes from the previous edition, enhanced to optimize health care quality and efficacy for patient management during cardiac arrest. These updates reflect growing evidence, clarifications, and changes in previous recommendations arising from the evolving resuscitation science.
Extracorporeal Cardiopulmonary Resuscitation (ECPR)
The 2023 guidelines represent a radical departure from routine use of Extracorporeal Cardiopulmonary Resuscitation (ECPR). An appropriately equipped system can safely and feasibly provide ECPR for refractory cardiac arrest in selected patients. This update reinforces the findings of randomized controlled trials such as OOH cardiac arrest and Return of Spontaneous Circulation after Emergency Cardiac Bypass Versus standard resuscitation (ARREST) and PRAGMATIC study group Hyperinvasive approach to Post-ROSC Care, which showed increased survival rates with favorable neurologic outcomes by using ECPR in patients presenting with shockable rhythms. This is in marked contrast to the 2020 recommendations, which reserved ECPR for extremely select instances.
The AHA notes the benefits come from expert centers, but says facilities and staff should be adequately trained prior to including ECPR in standard ACLS methods.
Post Cardiac Arrest Coronary Angiography
The classes of recommendation for routine emergent coronary angiography upon return of spontaneous circulation (ROSC) were later downgraded to lower class options and should only be considered as a specific indication when treating patients with STEMI, significant electrical instability, or ongoing ischemia. The increased number of patients in whom early angiography is not recommended compared with the 2020 guidelines — which suggested emergent angiography for eligible patients, based on evidence from small clinical trials showing no major benefit to immediate catheterization over a broader population – points to “a great effort by AHA/ACC writing committee trying maximally strict apply RCT findings,” Lakhdar Hammali Mohamed (German Heart Center Munich) tweeted. Instead, a more nuanced approach is encouraged; one that emphasizes patient-specific clinical indications and less of a broad application.
Hypothermia after Cardiac Arrest
The new guidelines now explicitly call for a constant temperature ranging from 32°C to 37.5°C during post-arrest care. The new recommendation is based on pooled analyses from the Targeted Temperature Management 2 trial and replaces a tighter range of 32°C to 36°C set forth in the guidelines published last year. The trial identified no difference in neurological outcomes between hypothermia and normothermia. The 2023 update replaces ‘targeted temperature management’ with the term’ temperature control’, to better capture this broader scope of temperatures and underscores that care must be individualized.
Seizure Management
The guidelines include a new recommendation on post-cardiac arrest seizure management in 2023. If the electroencephalography (EEG) phenotype lies on the ictal-interictal continuum, particularly in adults, an empirical trial of non-sedating antiseizure medications directed at survivors may be justifiable. This update recognizes that uncontrolled seizures are associated with poor neurological outcomes, and this is consistent with other brain injury populations where seizure management has become a priority to enhance recovery.
Although data are limited for this scenario, the AHA concludes that standardizing seizure definitions and treatment protocols may allow for the best care during post-arrest management.
Organ Donation Considerations
One of the major new focuses in the 2023 ACLS update is the concept of viewing organ donation as a critical care goal following cardiac arrest. These recommendations emphasize the need to incorporate organ donation into designing and assessing resuscitation programs. Several observational trials have shown neutral clinical outcomes associated with cardiac arrest donors’ transplanted kidneys and other deceased donor organs. The AHA hopes to increase the potential for saving lives, which may be realized via organ donation in situations where resuscitation efforts do not prove successful, by way of including this as a measure.
DEI — Diversity, Equity and Inclusion
New in the 2023 guidelines is a focus on improving the inclusion of diverse populations into cardiac arrest research and clinical trials. For instance, the AHA notes that there are racial and sex-based differences in cardiac arrest incidence and outcomes. This data is not a commonly reported outcome in the literature and, therefore, frequently ignored as to what results the interventional trials are seeking. Dealing with these issues is a must for developing sustainable and successful interventions. The AHA further calls on investigators to precisely describe the demographics of their study enrollees and design studies in a manner that accounts for these differences so we can better understand, and overcome inequalities in cardiac arrest care across outcomes.
Conclusion
The 2023 AHA ACLS guidelines are a testament to the AHA’s commitment to patient-centered, precise care that provides the most positive outcomes for patients, families, and healthcare providers. Updates such as the expanded recommendation for ECPR, revised strategies for coronary angiography, broader temperature control measures, and a focus on seizure management all reflect this commitment. Additionally, the incorporation of organ donation, emphasis on saving the brain as well as the heart, and emphasis on diversity highlight a holistic view of outcomes beyond immediate survival. These updates demonstrate the AHA’s dedication to adapting guidelines based on evolving evidence, aiming for optimal survival rates and neurological outcomes for cardiac arrest patients. This commitment should instill confidence in the reliability and effectiveness of the guidelines.
References
American Heart Association. (2023). Highlights of the 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. Retrieved from https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2023-ACLS-Focused-Updates/Hghlghts_2023GLFU_ALS.pdf?sc_lang=en.
