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October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 S544 Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC 12 Rea TD, Helbock M, Perry S, Garcia M, Cloyd D, Becker L, Eisenberg M. In- creasing use of cardiopulmonary resuscitation during out-of-hospital ventricular fibrillation arrest: survival implications of guideline changes. Circulation. 2006;114:2760–2765. doi: 10.1161/CIRCULATIONAHA.106.654715 13. Jost D, Degrange H, Verret C, Hersan O, Banville IL, Chapman FW, Lank P, Petit JL, Fuilla C, Migliani R, et al; DEFI 2005 Work Group. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circulation. 2010;121:1614–1622. doi: 10.1161/CIRCULATIONAHA.109.878389 14. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299:1158– 1165. doi: 10.1001/jama.299.10.1158 15. Cao D, Arens AM, Chow SL, Easter SR, Hoffman RS, Lagina AT, Lavonas EJ, Patil KD, Sutherland LD, Tijssen JA, et al. Part 10: adult and pediatric special circumstances of resuscitation: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(suppl 2):S578–S672. doi: 10.1161/CIR.0000000000001378 16. Hess EP, Russell JK, Liu PY, White RD. A high peak current 150-J fixed-energy defibrillation protocol treats recurrent ventricular fibrillation (VF) as effectively as initial VF. Resuscitation. 2008;79:28–33. doi: 10.1016/j.resuscitation.2008.04.028 17. Stiell IG, Walker RG, Nesbitt LP, Chapman FW, Cousineau D, Christenson J, Bradford P, Sookram S, Berringer R, Lank P, et al. BIPHASIC Trial: a randomized comparison of fixed lower versus escalating higher energy levels for defibrillation in out-of-hospital cardiac arrest. Circulation. 2007;115:1511– 1517. doi: 10.1161/CIRCULATIONAHA.106.648204 18. Tang H, Wu R, Lin L, Hao W, Shi J, Zhu H, Shengyong X, Xu J. Escalating vs fixed energy defibrillation in out-of-hospital cardiac arrest ventricular fibrillation. JAMA Netw Open. 2025;8:E257411. doi: 10.1001/jamanetworkopen.2025.7411 19. Deakin CD, Sado DM, Petley GW, Clewlow F. Determining the optimal paddle force for external defibrillation. Am J Cardiol. 2002;90:812–813. doi: 10.1016/s0002-9149(02)02623-1 20. Morrison LJ, Henry RM, Ku V, Nolan JP, Morley P, Deakin CD. Single-shock defibrillation success in adult cardiac arrest: a systematic review. Resuscitation. 2013;84:1480–1486. doi: 10.1016/j.resuscitation.2013.07.008 ANCILLARY WAVEFORM TECHNOLOGY Recommendations for Ancillary Waveform Technology COR LOE Recommendations 2b C-LD 1. The effectiveness of artifact-filtering algorithms for analysis of electrocardiogram rhythms during chest compressions for adults in cardiac arrest has not been established. 2b C-LD 2. The effectiveness of VF waveform analysis to guide the acute management of adults with cardiac arrest has not been established. Synopsis CPR obscures interpretation of the underlying rhythm because of the artifact created by chest compressions on the electrocardiogram. This makes it difficult to plan the next step of care and can potentially delay or even misdirect drug therapies if given empirically (blindly) on the basis of the patient’s presumed, but not actual, underlying rhythm. Time taken for rhythm analysis also disrupts CPR. Artifact-filtering and other innovative techniques to identify the underlying rhythm beneath ongoing CPR can surmount these challenges and minimize interruptions in chest compressions while offering a diagnostic advantage to better direct therapies.1–6 These still require further testing and validation before routine use. Recommendation-Specific Supportive Text 1 Despite the theoretical advantages, no study has evaluated artifact-filtering technologies in a real-time clinical setting or validated their clinical effectiveness compared to current resuscitation strategies. At present, filtering algorithms are strictly used for visual (manual) rhythm interpretation and not for automated VF/VT rhythm detection in automated external defibrillators during ongoing CPR. Further investigation and clinical validation are necessary before these technologies are adopted into routine clinical practice.7 2 The electric characteristics of the VF waveform are known to change over time.8 VF waveform analysis may be of value in predicting the success of defibrillation or other therapies during the course of resuscitation.9–11 The prospect of basing therapies on a prognostic analysis of the VF waveform in real time is an exciting and developing avenue of new research. However, the validity, reliability, and clinical effectiveness of an approach that prompts or withholds shock or other therapies on the basis of predictive analyses is currently uncertain. The only prospective clinical trial comparing a standard shock-first protocol with a waveform analysis–guided shock algorithm was underpowered, however, observed no difference in ROSC.12 The consensus of the writing group is that there is currently insufficient evidence to support the routine use of waveform analysis to guide resuscitation care, but it is an area in which further research with clinical validation is needed and encouraged. REFERENCES 1 Tan Q, Freeman GA, Geheb F, Bisera J. Electrocardiographic analy- sis during uninterrupted cardiopulmonary resuscitation. Crit Care Med. 2008;36:S409–S412. doi: 10.1097/ccm.0b013e31818a7fbf 2. Li Y, Bisera J, Weil MH, Tang W. An algorithm used for ventricular fibrillation detection without interrupting chest compression. IEEE Trans Biomed Eng. 2012;59:78–86. doi: 10.1109/TBME.2011.2118755 3. Li Y, Bisera J, Tang W, Weil MH. Automated detection of ventricular fibrillation to guide cardiopulmonary resuscitation. Crit Pathw Cardiol. 2007;6:131– 134. doi: 10.1097/HPC.0b013e31813429b0 4. Hu Y, Tang H, Liu C, Jing D, Zhu H, Zhang Y, Yu X, Zhang G, Xu J. The performance of a new shock advisory algorithm to reduce interruptions during CPR. Resuscitation. 2019;143:1–9. doi: 10.1016/j.resuscitation.2019.07.026 5. Fumagalli F, Silver AE, Tan Q, Zaidi N, Ristagno G. Cardiac rhythm analysis during ongoing cardiopulmonary resuscitation using the Analysis During Compressions with Fast Reconfirmation technology. Heart Rhythm. 2018;15:248–255. doi: 10.1016/j.hrthm.2017.09.003 6. Babaeizadeh S, Firoozabadi R, Han C, Helfenbein ED. Analyzing cardiac rhythm in the presence of chest compression artifact for automated shock advisory. J Electrocardiol. 2014;47:798–803. doi: 10.1016/j.jelectrocard.2014.07.021 7. Berg KM, Soar J, Andersen LW, Bottiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, et al; Adult Advanced Life Support Collaborators. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142:S92–S139. doi: 10.1161/CIR.0000000000000893 8. Asano Y, Davidenko JM, Baxter WT, Gray RA, Jalife J. Optical map- ping of drug-induced polymorphic arrhythmias and torsade de pointes Downloaded from http://ahajournals.org by on October 7, 2026