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Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 October 21, 2025 S539

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

modern equivalents with better efficacy (eg, administration of intra-arrest medications via an in-place endotracheal tube) have been removed. 7.	 Use of point of care ultrasonography (POCUS) by experienced professionals during cardiac arrest may be considered to diagnose reversible causes if it can be done without interrupting resuscitative efforts (ie, CPR). 8.	 Polymorphic ventricular tachycardia is always unstable and should be treated immediately with defibrillation, because delays in shock delivery worsen outcomes. 9.	 Intravenous (IV) access remains the first-line choice for drug administration during cardiac arrest; however, intraosseous (IO) access is a reasonable alternative if IV access is not feasible or delayed. 10.	 Arrythmias can be both the cause of and a manifestation of clinical instability. Evaluating the proximal cause of that instability will direct professionals to the most judicious use of these guidelines.

PREAMBLE

In the United States, cardiac arrest remains a significant public health challenge. The incidence of EMS-treated OHCA is 83.4 individuals per 100 000 population annually.1 Despite advancements in resuscitation science, training, and systems of care, survival to hospital discharge after EMS-treated OHCA remains low, at approximately 10%. Immediate interventions, such as high-quality CPR and timely defibrillation, are crucial for improving outcomes. In-hospital cardiac arrest (IHCA) occurs in approximately 1 in 100 hospitalized adults. Data indicates that about 72.2% of these patients achieve return of spontaneous circulation (ROSC), with survival to hospital discharge rates around 24.2%. Among those who survive to discharge, approximately 85% have favorable neurological outcomes. These statistics underscore the importance of ALS interventions, including advanced airway management, pharmacologic therapies, and coordinated postresuscitation care, in both prehospital and inhospital settings. The International Liaison Committee on Resuscitation (ILCOR) emphasizes the “Formula for Survival,” which identifies 3 critical components for improved outcomes: guidelines based on sound science, effective education of resuscitation professionals, and well-functioning systems of care..2 The 2025 ALS guidelines build upon these principles by incorporating the latest evidence, promoting high-quality education for ALS professionals, and describing the critical decisions required to provide lifesaving emergency cardiovascular care. This document outlines the American Heart Association (AHA) recommendations for ALS interventions, drawing from rigorous evidence evaluation and expert consensus. Recommendations are tailored to the scope and practice of ALS professionals, focusing on enhancing survival and functional recovery. The 2025 ALS guidelines aim to provide a framework for continued advancements in resuscitation science while highlighting areas for future research and innovation.1

REFERENCES

1 Martin SS, Aday AW, Allen NB, Almarzooq ZI, Anderson CAM, Arora P, Avery

CL, Baker-Smith CM, Bansal N, Beaton AZ, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Committee. 2025 Heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation. 2025;151:e41–e660. doi: 10.1161/CIR.0000000000001303 2.	 Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D,

Eisenberg M, Sterz F, Nadkarni VM, Soar J, et al; Utstein Formula for Survival Collaborators. The formula for survival in resuscitation. Resuscitation. 2013;84:1487–1493. doi: 10.1016/j.resuscitation.2013.07.020

INTRODUCTION TO THE 2025 ALS GUIDELINES

Scope of the Guidelines The 2025 ALS guidelines provide evidence-based recommendations for health care professionals managing adult cardiac arrest and life-threatening cardiovascular emergencies. These guidelines are tailored to professionals with advanced training in resuscitation techniques, incorporating a wide range of pharmacologic and device-based therapies and critical interventions to optimize survival and neurological outcomes. This document complements the separately published 2025 BLS guidelines, which address foundational resuscitation practices for lay rescuers and BLS- and ALS-trained health care professionals. Importantly, the ALS guidelines address prehospital resuscitation, in-hospital resuscitation, and TOR recommendations when resuscitation has been unsuccessful. There is a recognition that in the literature there is differential use of the terms return of spontaneous circulation (ROSC) versus return of circulation. For the purposes of these guidelines, after CPR, when return of circulation is achieved by mechanical means (eg, extracorporeal membrane oxygenation), we use return of circulation; when due to cardiac function, we use ROSC. Specific recommendations about the training of ALS resuscitation professionals are provided in Part 12: Resuscitation Education Science,1 recommendations about incorporating ALS professionals or procedures into systems of care are provided in Part 4: Systems of Care,2 recommendations about caring for the adult patient following ROSC are provided in Part 11: Post– Cardiac Arrest Care,3 and recommendations about ethical considerations in delivering or withholding ALS care are provided in Part 3: Ethical Considerations of Resuscitation.4

Organization of the Writing Group The ALS Writing Group included experts in emergency medicine, EMS, cardiology, critical care, public health, nurs-

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