Tuesday, January 29, 2008

AHA’s latest scientific statement on CPR still years out of date

You can read the full text of the document here and Medscape’s report here. Despite longstanding and mounting evidence that compression only CPR is superior, the new scientific statement persists in emphasizing traditional CPR with rescue breathing for patients with out of hospital cardiac arrest.

Dr. Gordon Ewy, chief of Cardiology at the University of Arizona Health Sciences Center and director of the Sarver Heart Center, himself a pioneer in CPR research, was not pleased. According to the Medscape report:

That seems like short shrift to Ewy, who said the report doesn't reference "any of the recent scientific data on the exciting developments in continuous-chest compression CPR" or the increasing evidence that bystander-initiated CCC resuscitation for cardiac arrest "is as good and probably better than the approach currently recommended by the AHA. In addition, encouraging continuous-chest compression CPR might be the most effective way of increasing the willingness of bystanders to perform CPR."

For some time now the Sarver Heart Center, in its public education program, has taught compression only CPR. At the same time fire department protocol changes have been introduced in Tucson.

Why is the AHA so far behind the times? As I recently stated in a Medscape Roundtable, I believe it’s a distortion of EBM:

Sometimes, EBM proponents' insistence on patient outcome-based studies slows the wheels of medical progress. The American Heart Association 2005 guidelines for emergency cardiac care provide a recent example. Investigators at the University of Arizona, Tucson, have been publishing evidence for years in support of changes in emergency cardiac care for adult victims of out-of-hospital cardiac arrest.[8,9] Despite this evidence, the guideline authors, dutifully trying to be evidence-based, failed to adopt the new methods because of a reluctance to base changes on anything other than randomized trials. However, the evidence, although based on "low-level" physiologic rationale, was compelling. More recently, the Arizona investigators were vindicated by direct evidence that the new procedures save lives. This situation represents a failure of EBM, not due to any shortcomings of EBM itself, but due to the misappropriation of its principles.

Randomized controlled trials are finally underway to address this issue. But until these trials are completed the AHA should make recommendations based on the best evidence currently available, which favors compression only CPR for out of hospital cardiac arrest. That is what the principles of EBM would have us do rather than wait, paralyzed, until RCTs are completed.

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