Written by Ketan Patel
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The 2025 guidelines integrate new RCTs on temperature control, blood pressure targets, coronary angiography timing, post return of spontaneous circulation (ROSC) testing, and neuroprognostic biomarkers, while also including favorable outcome prediction, myoclonus phenotyping, and structured survivorship support.
AHA 2025 post-arrest priorities
Post-arrest care determines whether survival translates to meaningful recovery, making evidence-based neuroprognostication, hemodynamic targets, and survivorship planning essential to avoid premature withdrawal and optimize long-term outcomes.
This subset of updates addresses interventions to optimize neurologic and functional outcomes after ROSC. Authors present guidelines informed by systematic reviews, RCTs (TTM2, TOMAHAWK, COACT, DOSE VF), registries, and expert consensus with class of recommendation (COR)/ level of evidence (LOE) grading.
Key Updates and Highlights (COR in parentheses):
- Finding the culprit: 12-lead ECG always post ROSC (1), with utility for CT, echocardiogram and/or point of care ultrasound (2b). Emergency coronary angiography only for STEMI/shock/instability (not routine in comatose non-STEMI), when cardiac cause suspected (1).
- Keep them cool: temperature control 32–37.5°C (1) for ≥36 hours recommended (2a). Prehospital cooling may not convey benefit (2, No Benefit).
- Road MAP for success: Simpler post-ROSC MAP target of ≥65 mmHg (1). No superior vasopressor choice when needed, but may be utilized with temporary mechanical circulatory support when refractory shock is present post-ROSC. (2b, 2b).
- Brain game: multimodal neuroprognostication ≥72 hours post-normothermia (1).
- Stop the shakes: Seizures are common post-ROSC. Identify early and intiate therapy on all seizures with early EEG (1). Have a high suspicion for myoclonus as a manifestation of seizure.
Limitations include many neuroprognostic studies suffer from self-fulfilling prophecy bias, small sample sizes, lack of blinding, heterogeneous definitions (e.g., myoclonus, EEG patterns), and reliance on hospital-discharge outcomes rather than 3–6 month maximal recovery; temperature and coronary intervention trials excluded key subgroups (e.g., non-shockable rhythms, cardiogenic shock).
How will this change my practice?
What happens after ROSC is just as important as achieving ROSC. These guidelines help me initiate the proper cascade of events when I eventually hand off to cardiology and critical care. Additionally, they build a foundation of best practices (and avoidance of pitfalls!) in post-resuscitative care that doesn’t stop with pulses. I appreciate the simplification of some target goals, which will allow my team to put the patient on a better path to a neurologically intact outcome.
Source
Part 11: Post-Cardiac Arrest Care: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 Oct 21;152(16_suppl_2):S673-S718. doi: 10.1161/CIR.0000000000001375. Epub 2025 Oct 22. PMID: 41122894.
