The following are key perspectives from the 2018 American Heart Association (AHA) Focused Update on Advanced Cardiovascular Life Support (ACLS) Use of Antiarrhythmic Drugs During and Immediately After Cardiac Arrest: An Update to the AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care:

1. Antiarrhythmic medications are commonly administered during and immediately after a ventricular fibrillation (VF)/pulseless ventricular tachycardia (pVT) cardiac arrest. However, it is unclear whether these medications improve patient outcomes.
2. The 2018 AHA Focused Update on ACLS guidelines summarize the most recent published evidence for and recommendations on the use of antiarrhythmic drugs during and immediately after shock-refractory VF/pVT cardiac arrest.
3. The updated guidelines state that amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. These drugs may be particularly useful for patients with witnessed arrest, for whom time to drug administration may be shorter.
4. Although available studies do not demonstrate an improvement in survival to hospital discharge (or neurologically intact survival to discharge) associated with either amiodarone or lidocaine, return of spontaneous circulation (ROSC) was higher in patients receiving lidocaine compared with placebo, and survival to hospital admission was higher with either drug compared with placebo. As a result, lidocaine is now recommended as an alternative to amiodarone and has now been added to the ACLS Cardiac Arrest Algorithm for treatment of shock-refractory VF/pVT.
5. The routine use of magnesium for cardiac arrest is not recommended in adult patients. However, magnesium may be considered for torsades de pointes (i.e., polymorphic VT associated with long QT interval).
6. There is insufficient evidence to support or refute the routine use of a beta-blocker early (within the first hour) after ROSC. Similarly, there is insufficient evidence to support or refute the routine use of lidocaine early (within the first hour) after ROSC.
7. The revised guidelines state that in the absence of contraindications, the prophylactic use of lidocaine may be considered in specific circumstances (such as during emergency medical services transport) when treatment of recurrent VF/pVT might prove to be challenging.
8. As noted in earlier guidelines, CPR and defibrillation are the only therapies associated with improved survival in patients with VF/pVT.
9. Clinicians should note that the optimal sequence of ACLS interventions for VF/pVT cardiac arrest, including administration of a vasopressor or antiarrhythmic drug, and the timing of medication administration in relation to shock delivery is not fully known.
10. The sequence and timing of interventions recommended in the current ACLS Adult Cardiac Arrest Algorithms will be affected by the number of providers participating in the resuscitation, their skill levels, and the ability to secure intravenous/intraosseous access in a timely manner.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Acute Coronary Syndrome, Advanced Cardiac Life Support, Arrhythmias, Cardiac, Amiodarone, Anti-Arrhythmia Agents, Cardiopulmonary Resuscitation, Defibrillators, Electric Countershock, Emergency Medical Services, Heart Arrest, Lidocaine, Magnesium, Pharmaceutical Preparations, Tachycardia, Ventricular, Torsades de Pointes, Ventricular Fibrillation

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