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Circulation October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 Circulation is available at www.ahajournals.org/journal/circ © 2025 American Heart Association, Inc. Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Jane G. Wigginton, MD, MSCS, Vice Chair; Sachin Agarwal, MD, MPH; Jason A Bartos, MD, PhD; Ryan A. Coute, DO; Ian R. Drennan, ACP, PhD; Ameera Haamid, MD; Peter J. Kudenchuk, MD; Mark S. Link, MD; Ashish R. Panchal, MD, PhD; Michele M. Pelter, RN, PhD; Marina Del Rios, MD, MS; Amber J Rodriguez, PhD; Sarah M. Perman, MD, MSCE; Stephen Sanko, MD; Pavitra Kotini-Shah, MD; Michael C. Kurz, MD, MS, Chair ABSTRACT: In these 2025 Advanced Life Support Guidelines, the American Heart Association provides comprehensive recommendations for the resuscitation and management of adults experiencing cardiac arrest, respiratory arrest, and life-threatening cardiovascular emergencies. Based on structured evidence reviews and the latest clinical research, these guidelines offer evidence-based strategies to optimize survival and patient outcomes. The 2025 guidelines provide guidance for the treatment of cardiac arrest, including ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity, as well as peri-arrest conditions such as atrial fibrillation and flutter with rapid ventricular response. Recommendations are made for defibrillation, electrical cardioversion, advanced airway management, drug therapies, and intravenous access. Additionally, guidelines are provided for the use of double sequential defibrillation, head-up cardiopulmonary resuscitation, and point-of-care ultrasound in the advanced life support setting. Termination of resuscitation rules have been refined to guide decision-making based on the emergency medical services professional’s scope of practice. Finally, these guidelines also underscore the importance of identifying causative versus secondary arrhythmias to inform the appropriate timing of therapeutic strategies. Key Words: AHA Scientific Statements ◼ advanced cardiac life support ◼ airway management ◼ arrhythmias, cardiac ◼ cardiopulmonary resuscitation ◼ drug therapy ◼ electric countershock ◼ emergency medical services TOP 10 TAKE-HOME MESSAGES FOR ADULT ADVANCED LIFE SUPPORT 1. A rapid assessment of clinical stability is essential to direct the appropriate advanced life support (ALS) treatment, and these guidelines go into greater depth to describe how poor organ perfusion manifests as instability. 2. Higher first-shock energy settings (≥200 J) are preferable to lower settings for cardioversion of atrial fibrillation and atrial flutter. 3. Updated termination of resuscitation (TOR) guide- lines emphasize rule application based on emergency medical services (EMS) scope of practice (basic life support [BLS], ALS, or universal TOR rule [UTOR]), and that end-tidal carbon dioxide (ETCO2) should not be used in isolation to end resuscitative efforts. 4. The usefulness of vector change (VC) and double sequential defibrillation (DSD) has not been established as therapies for shock-refractory ventricular fibrillation (VF); however, further investigation of these techniques, patient candidacy, and the development of new technology to optimize shock delivery are necessary. 5. Head-up cardiopulmonary resuscitation (CPR) use is discouraged outside of the setting of rigorous clinical trials with appropriate subject protections. 6. Recommendations regarding outdated or extraor- dinary procedures that have been replaced by Downloaded from http://ahajournals.org by on October 7, 2026