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Original research article
Different defibrillation strategies in survivors after out-of-hospital cardiac arrest
  1. Jolande A Zijlstra1,
  2. Rudolph W Koster1,
  3. Marieke T Blom1,
  4. Freddy K Lippert2,
  5. Leif Svensson3,
  6. Johan Herlitz4,
  7. Jo Kramer-Johansen5,
  8. Mattias Ringh3,
  9. Mårten Rosenqvist6,
  10. Thea Palsgaard Møller2,
  11. Hanno L Tan1,
  12. Stefanie G Beesems1,
  13. Michiel Hulleman1,
  14. Andreas Claesson3,
  15. Fredrik Folke2,
  16. Theresa Mariero Olasveengen5,
  17. Mads Wissenberg7,
  18. Carolina Malta Hansen7,
  19. Soren Viereck2,
  20. Jacob Hollenberg3
  21. for the COSTA study group
  1. 1 Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
  2. 2 Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
  3. 3 Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
  4. 4 Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
  5. 5 Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
  6. 6 Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
  7. 7 Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
  1. Correspondence to Professor Jacob Hollenberg, Center for Resuscitation Science, Department for Medicine, Karolinska Institutet, Stockholm 118 83, Sweden; jacob.hollenberg{at}


Background In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival.

Methods We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded.

Results A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm.

Conclusion Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm.

  • cardiac arrest
  • ventricular fibrillation

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  • Contributors All authors designed the study together. All authors contributed in the planning of intended tables and figures. JAZ, RWK and JH acquired the data. JAZ and MTB were responsible for statistical analysis. JAZ and JH drafted the work, and all authors revised it critically for intellectual content. All authors approved of the version to be published. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This work was supported by Laerdal Foundation for Acute Medicine (Denmark). the Swedish Heart–Lung Foundation and Laerdal Foundation (Stockholm), Physio-Control, Zoll Medical, Philips Medical, Cardiac Science and Defibtech, The Netherlands Organization for Scientific Research (NWO, grant ZonMW Vici 918.86.616 and ZonMW 827.11.001), Dutch Heart Foundation (2010T083), the Dutch Medicines Evaluation Board (MEB/CBG) and The Netherlands CardioVascular Research Initiative (Dutch Heart Foundation, Dutch Federation of University Medical Centers, Netherlands Organization for Health Research and Development, Royal Netherlands Academy of Sciences – (CVON2012-10 Predict) (Netherlands)).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The medical ethics review boards of all four participating academic institutes approved the study and gave a waiver for obtaining (written) informed consent. All patient identifying information was removed before transferring of data to the COSTA analysis centre.

  • Provenance and peer review Not commissioned; externally peer reviewed.