PulmCrit - 2025 AHA & ESICM guidelines on post-arrest care

The ESICM and AHA both just released new guidelines on post-arrest care. It's always interesting when two professionals produce “evidence-based” guidelines on the same topic, based on the same evidence. If these guidelines were truly evidence-based, they should be identical. But of course, they're not.

Having conflicting guidelines can be frustrating, but I actually find it pedagogically useful. First of all, it illustrates that guidelines are merely guidelines—they aren't legally binding. Secondly, we must always be adapting guidelines to our specific practice (both in terms of the individual patient and circumstances at our local hospitals). The presence of two guidelines underscores the wide range of reasonable practices we may consider.

Without further ado, let's get to it.

who needs an emergent left heart catheterization?

ESICM and AHA guidelines are basically consistent on this. According to the AHA guidelines, there are four indications for emergent catheterization:
- [1] STEMI or STEMI-equivalent (guidelines aren't using the term OMI yet). The immediate post-arrest ECG often shows ischemic changes, so PCI is indicated if these persist on a repeat ECG. (ESICM 2025)
- [2] Cardiogenic shock attributable to coronary artery disease. (AHA 2025 2A)
- [3] Recurrent ventricular arrhythmias. (AHA 2025 2A)
- [4] Evidence of significant ongoing myocardial ischemia. (AHA 2025 2A) This is a little vague, but it leaves room to exercise clinical judgement.
For comatose patients who don't meet one of the above criteria, emergency coronary angiography isn't recommended. (AHA 2025 class III recommendation). This makes sense, especially if you pay attention to the word comatose. Catheterizing these patients isn't an emergency. Waiting a few days allows some basic neuroprognostication to occur before catheterization. For patients who clearly have a poor neurological prognosis, cardiac catheterization is nonbeneficial.
Coronary angiography is recommended prior to discharge in adult survivors with suspected cardiac etiology, especially in the presence of an initial shockable rhythm, unexplained left ventricular systolic dysfunction, or evidence of severe myocardial ischemia (AHA 2025 Class I). The guidelines don't specify a timeline; this will be determined by patient-specific factors and local cardiology services.

BP targets

ESICM recommends targeting MAP >60-65 mm, whereas AHA recommends targeting MAP >65.
In practice, these guidelines are pretty similar.
Start with a MAP goal of >65 mm initially. Once the dust has settled, this may be individualized based on hemodynamic assessment, perfusion indices, and patient history.
The concept of targeting a higher MAP (e.g., >75 or >80 mm) wasn't supported by evidence. This is probably because patients with mild-moderate anoxic brain injury don't generally have substantially elevated intracranial pressure. Patients with profound anoxic injury absolutely do have elevated intracranial pressure, but in that situation, there is minimal likelihood of clinical recovery regardless.

oxygenation targets

ESICM recommends targeting 94-98% saturation, whereas AHA recommends targeting 90-98%.
Patients with darker skin may have artificially elevated saturation readings. In that situation, using the ESICM target of 94-98% is sensible to avoid occult hypoxemia.
Patients with lighter skin can probably be managed with usual oxygenation targets (e.g., 92-98% sat goal).
ESICM recommends targeting pO2 of 75-100 mm, whereas AHA recommends targeting pO2 of 60-105 mm. The ESICM target seems more reasonable to me here, to avoid dipping into a hypoxemic range. However, the AHA target provides some flexibility to accept lower pO2 values in certain patients (e.g., those with ARDS).

pan-CT scans

Both guidelines support the use of pan-CT scans for post-arrest patients.
The role of these scans is multiple:
- Evaluate for an underlying cause of arrest.
- Evaluate for CPR complications (e.g., splenic laceration).
- Neuroprognostication (low yield initially, but yield increases over several hours).
These scans don't usually need to happen immediately. A good time to obtain a scan is often following resuscitation and stabilization in the emergency department, while the patient is en route to the ICU.
🙏 Please stop road-tripping post-arrest patients to the scanner and solely getting a head CT scan. If you're going to go through the effort of transporting a critically ill patient to radiology, get the whole scan.

temperature control

ESICM recommends actively preventing fever by targeting a temperature <37.5
AHA guidelines recommend maintaining a temperature between 32-37.5C. Honestly, I get the feeling that the AHA is still partying like it's 2009. The AHA continues to make references to therapeutic hypothermia, whereas the ESICM seems to have moved on.
I'm really tired of talking about this topic. I've discussed this previously in the blog in 2015, 2016, 2019, and 2021 (posts that have aged well, if I may say so).
Despite Herculean efforts to demonstrate benefits from hypothermia over several decades, RCTs simply haven't borne out a benefit from hypothermia.
Prevention of fever is still probably beneficial and should be undertaken. This can be achieved by setting the temperature control to 36 °C or 37.5 °C. Either of these is fine and much easier and safer to do than 33C. My general preference is 37.5 °C, as this avoids fevers (demonstrated to be safe in TTM2) and causes less shivering than 36 °C.
It might be time to ask some tough questions about temperature control in anoxic brain injury. Why is temperature control considered so essential in anoxic brain injury, but less important in every other neurocritical illness (stroke, intracranial hemorrhage, meningitis, traumatic brain injury, etc.)? Is it because there is a fundamental difference in the biology of these disorders, or because two simultaneously published RCTs in the NEJM in 2002 about post-arrest management got insanely overhyped?

neuroprognostication

The ESICM is very simply head and shoulders above the AHA in terms of neuroprognostication.
The ESICM created a concrete algorithm for neuroprognostication in 2021 and subsequently prospectively validated it in three trials involving 1791 patients (with a zero false-positive rate of predicting poor neurological outcome). (35399085, 38059722, 39151721) One of these studies was performed in Korea, where withdrawal of life-sustaining therapy is extremely rare (thereby avoiding a self-fulfilling prophecy bias). This is a truly monumental accomplishment: producing an evidence-based protocol that was validated to perform flawlessly across three peer-reviewed publications at numerous centers on different continents.
The AHA guideline produces no concrete approach to neuroprognostication. The AHA guidelines also barely even mention the ESICM algorithm. Failure to meaningfully discuss the ESICM algorithm is arguably guideline malpractice, if such a thing exists. The AHA guidelines provide some information on individual prognostic tests but no coherent strategy for neuroprognostication.
I would recommend following the ESICM guidelines and algorithm on neuroprognostication. I don't think the AHA guidelines add anything to the ESICM guidelines in this regard.

That's it for now. I've updated the IBCC chapter on post-cardiac arrest, so there are more details over there.

Links to the guidelines:

41122894 Hirsch KG, Amorim E, Coppler PJ, Drennan IR, Elliott A, Gordon AJ, Jentzer JC, Johnson NJ, Moskowitz A, Mumma BE, Presciutti AM, Rodriguez AJ, Yen AF, Rittenberger JC. 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 [PubMed]
41123621 Nolan JP, Sandroni C, Cariou A, Cronberg T, D'Arrigo S, Haywood K, Hoedemaekers A, Lilja G, Nikolaou N, Olasveengen TM, Robba C, Skrifvars MB, Swindell P, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2025: post-resuscitation care. Intensive Care Med. 2025 Oct 22. doi: 10.1007/s00134-025-08117-3 [PubMed]