ERC Guidelines 2025: a new system-level view on Cardiac Arrest
The 2025 ERC Guidelines introduce significant evidence-based updates in cardiac arrest epidemiology and management. Dr Enrico Baldi outlines the most relevant changes for clinical practice.
An interview with Enrico Baldi, MD, PhD
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esanum: If you had to summarise the overall spirit of the 2025 Guidelines in one or two ideas, what would you say?
I would say that the new guidelines push us to look at cardiac arrest not only as an isolated emergency event, but as part of a system that begins long before the arrest and continues long after the return of circulation. On the one hand, the epidemiology chapter calls for better data through OHCA and IHCA registries, for more attention to long-term outcomes and rehabilitation, and for systematic autopsy and genetics in young sudden deaths. On the other hand, the ethics chapter reminds us that resuscitation decisions must be rooted in respect for the patient, in transparent communication and in the avoidance of futile or discriminatory treatments. If we combine these elements, we have a much stronger basis to improve not just survival, but meaningful survival, in patients with cardiac arrest.
esanum: Let us talk about out-of-hospital cardiac arrest. What are the key numbers and messages from the new guidelines?
If we look at OHCA, the annual incidence of EMS-treated OHCA in Europe is about 55 per 100.000 inhabitants, and the overall survival rate is roughly 7,5%. These figures show that cardiac arrest remains a major public health issue. One of the problems we highlight is that only nine European countries have an OHCA registry with full population coverage. However, having such a registry is crucial if we want to understand the epidemiology in a specific setting and identify where the system is performing well or poorly. For this reason, we recommend that European countries implement national, population-based OHCA registries that adhere to the Utstein template. This is the only way to correctly inform healthcare system planning and the organisation of cardiac arrest responses with the goal of improving survival.
esanum: What about in-hospital cardiac arrest? Is the situation similar in terms of data availability?
The situation is even more challenging for IHCA. The estimated annual incidence in Europe is about 1,5 to 2,8 IHCAs per 1.000 hospital admissions, but very little evidence is available compared with OHCA. Data are sparse, and systems to capture them are less developed. Another important point concerns how the alarm is raised in case of IHCA. A standard internal telephone number, 2222 [Ed. Note: this is the standardized internal emergency call number proposed by the European Resuscitation Council], has been proposed to alert the emergency team inside hospitals across Europe, but this number is currently implemented in only 2% of countries. From an epidemiological and organisational perspective this is a missed opportunity, because standardising the way we call for help is a fundamental step in ensuring a timely and coordinated response. In the chapter we therefore stress that it is crucial to establish IHCA registries, as we recommend for OHCA, and also to standardise the IHCA response in European hospitals by adopting the 2222 number.
esanum: The chapter also dedicates a section to post-resuscitation care. What are the main concerns there?
Post-resuscitation care is a key area because survival after cardiac arrest is not just a matter of being discharged alive from hospital. We highlight that the rate of poor neurological outcome varies across different countries and that one important factor is whether withdrawal of life-sustaining treatment is practised or not. This means that outcome data need to be interpreted in the context of local end-of-life practices. We also point out that both physical and non-physical limitations affect a significant proportion of survivors. Many patients experience fatigue, cognitive problems, and psychological symptoms that may seriously affect quality of life.
The majority of OHCA survivors report the need for post-discharge follow-up with access to a multidisciplinary team, but in reality this need is often not met. Only around one out of three OHCA survivors receives cardiac rehabilitation and only one out of ten receives brain injury rehabilitation. For these reasons, we recommend routine measurement of physical and non-physical outcomes for all cardiac arrest survivors and we suggest more research and, very importantly, expanded access to post-resuscitation rehabilitation services.
esanum: One of the most striking parts of the chapter you and your colleagues wrote is the section on autopsy and genetics. What do the new guidelines say in this area?
Autopsy plays a crucial role in identifying genetic cardiac diseases in young victims of sudden cardiac arrest, with the potential not only to explain the cause of death but also to protect their families. Despite this, autopsy is not routinely performed in many European countries for young victims of sudden cardiac arrest. We also underline the importance of genetic post-mortem analysis. Studies show that a clinically actionable pathogenic or likely pathogenic variant in a gene potentially related to the cause of sudden cardiac arrest can be identified in up to 25% of OHCA cases younger than 50 years. This is a very significant proportion. Based on these data, we recommend for the first time in ERC Guidelines that all victims of unexpected sudden death under the age of 50 should receive a full autopsy, including genetic analysis. Furthermore, we suggest that the results of autopsy and genetic testing should be managed by multidisciplinary teams in specialised clinics, so that appropriate family counselling and screening of relatives can be offered.
esanum: You also looked at low-resource and remote settings. What are the key issues there?
In low-resource settings the rate of bystander CPR and AED use is lower compared to high-resource settings, and these countries usually do not have OHCA registries based on the Utstein template and on a defined reference territory. This means that the burden of cardiac arrest and the effectiveness of interventions are often invisible. We therefore highlight the importance of developing epidemiological registries in low-resource settings to allow improvement in treatment and outcomes over time. As for remote areas, there is evidence that early basic life support and a rapid response by an EMS are crucial and determine the prognosis of an OHCA patient even in remote locations. On this basis, we suggest that emergency response systems in remote areas should be strengthened and optimised to improve outcomes, for example by reducing response times and ensuring that basic resuscitation can be started as early as possible.
esanum: Speaking of ethics, what do the guidelines say about starting, continuing, and ending CPR?
When it comes to ethics, the guidelines try to give a very pragmatic framework rather than rigid rules. On starting CPR, the basic message is that resuscitation should generally be initiated in cases of unexpected cardiac arrest, unless there are clear reasons not to do so. These reasons include obvious signs of irreversible death, such as decomposition or injuries incompatible with life, or the presence of a valid do-not-attempt-resuscitation order or advance directive that is known and applicable in that situation. The guidelines make an important point here: age, frailty or chronic illness alone are not sufficient reasons to withhold CPR at the scene of an arrest. The decision should not be driven by stereotypes about “poor quality of life”, but by clinical information, prognosis and the patient’s previously expressed values.
Once CPR has been started, the guidelines describe continuing and stopping resuscitation as part of the same decision process. Continuing is appropriate for as long as there is a realistic chance of meaningful benefit, for example when potentially reversible causes are still being treated or when the prognosis remains uncertain. Stopping CPR becomes appropriate when, after adequate efforts, there is no sign of recovery, no reversible factors left to address, or when it is clear that further attempts would be inconsistent with the patient’s wishes or goals of care. The emphasis is on avoiding futile treatment and on making these decisions in a transparent, team-based way, with proper documentation and careful communication with relatives.
Overall, the ethics chapter underlines that CPR should remain the default response to cardiac arrest, not at any cost and not in a discriminatory way. Decisions to start, continue or end resuscitation should be grounded in evidence and clinical judgement, but also in respect for autonomy and in a fair, non-ageist approach to care.
esanum: Do you personally agree with this approach? Modern medicine in high-income countries allows people to live to very advanced ages, and several studies have highlighted the issue of medical futility, showing extremely low rates of neurologically intact survival in patients with advanced frailty, end-stage disease, or severely impaired pre-arrest functional status. Some argue that clinicians have become reluctant to acknowledge the possibility of dying. In this context, do you think it is appropriate that the guidelines do not provide more explicit criteria for when CPR should not be initiated, especially in cases where a patient’s expected quality of life would likely be severely compromised?”
This is a very complex issue. As you suggest, it is true that modern medicine has made both clinicians and patients increasingly reluctant to accept the possibility of death. Expectations have risen on both sides, and many people assume that resuscitation should always succeed.
From the perspective of guideline development, however, it is extremely difficult to propose clear exclusion criteria beyond those already stated, such as obvious signs of irreversible death or the presence of a valid advance directive. Several studies, meta-analyses and reviews have examined whether specific clinical characteristics could reliably identify patients in whom CPR would be futile. The problem is that any such criteria would need extremely high sensitivity and specificity - essentially, they would need to identify with near-absolute certainty those who will not survive, without ever denying a chance of survival to someone who might benefit. At the moment, no criteria meet that standard.
For this reason, I am broadly aligned with the approach taken in the ERC Guidelines. I believe the right direction is to continue working toward better tools that help us stratify the likelihood of survival. These will almost certainly have to be multiparametric rather than based on a single variable. When combined thoughtfully, such factors may help guide decisions on whether it makes sense to continue resuscitation - the basis of what we call Termination of Resuscitation, or TOR, rules.
So my view is that while the guidelines cannot yet provide rigid criteria for when not to start CPR, we should keep refining prognostic models that support clinicians in making these difficult, ethically sensitive decisions.
esanum: You were part of the writing group that drafted the new 2025 ERC Guidelines. Could you describe what it was like to work on this document - the collaboration within the team, the challenges you encountered, and what it felt like to contribute to such a pivotal European standard?
It was truly an honor and a privilege to be part of - and actually leading - the writing group for the epidemiology chapter of the 2025 ERC Guidelines. It gave me the opportunity to collaborate with a truly international group of professionals from diverse backgrounds - cardiologists, intensivists, psychologists focused on post-resuscitation care, and epidemiologists. It was a very enriching experience both professionally and personally.
Of course, it was also a challenge to condense all the evidence into a single chapter and to bring together the many perspectives that form the heart of the epidemiology section. But I think the strongest feeling was one of being very happy and proud to contribute to something that represents not just my field of work but also a personal passion.
It has been a journey of more than two years, and seeing the final document come together was truly rewarding. I also want to extend my thanks to the ERC office for their constant support and problem-solving. It really felt like being part of a big family working toward a common goal.