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Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 October 21, 2025 S555

Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC

ideally above 20 mm Hg, are associated with increased rates of ROSC.43 The combination of the association of higher ETCO2 with ROSC and the findings that CPR quality can increase ETCO2 suggests that targeting compressions to a value of at least 10 mm Hg, and ideally 20 mm Hg or greater, may indicate mechanically adequate technique. Other factors known to impact ETCO2 values need to be considered, including minute ventilation, drug administration, airway management strategies, and cardiac arrest etiology. ETCO2 monitoring is most reliable when measured through an endotracheal tube, but it can also be used with a supraglottic airway or bagmask ventilation with unclear utility. When an invasive arterial line is in place, arterial diastolic pressure can approximate coronary perfusion pressure and myocardial perfusion during CPR.44 The use of diastolic blood pressure monitoring during cardiac arrest is associated with higher ROSC, but there are inadequate adult data to suggest any specific pressure in adults. 7.	 If an arterial line is in place, the development of an arterial waveform or a sudden increase in diastolic pressure during a rhythm check showing an organized rhythm may indicate ROSC.45 When a waveform is present, it is important to ensure it correlates with a palpable pulse to verify ROSC. The placement of an arterial line requires appropriate expertise and resources; however, placement during cardiac arrest may detract from the provision of high-quality CPR. 8.	 Original work evaluating head-up CPR was done

in porcine models, which demonstrated conflicting evidence of efficacy.46,47 A recent ILCOR systematic review identified no randomized controlled trials and only 3 observational studies, each with significant methodological limitations.48–50 With these and other challenges the systematic review identified, for the outcome of survival to discharge and survival to discharge with favorable neurological outcome, evidence on Head up CPR was considered very low–certainty of evidence downgraded for serious risk of bias. Taken together, current evidence regarding head-up CPR is limited in the absence of RCTs or appropriate comparisons. Furthermore, implementation of this approach requires specialized equipment (automated positioning device, mechanical CPR device, an impedance threshold device) and significant training. Based on this, there is currently insufficient evidence for its use outside of well-designed clinical trials, although future work is needed to evaluate this adjunct. REFERENCES

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