A critic's assessment of our approach to cardiac arrest.

In this issue of the Journal, Weisfeldt et al.1 report that ventricular fibrillation is identified less frequently during sudden cardiac arrest in the home than in public places, even when the arrest is witnessed. The authors surmise that age and coexisting illnesses are responsible and that the location of sudden cardiac arrest may be a surrogate for underlying disease severity. In addition, poorer outcomes were observed with use of the automated external defibrillator (AED) in the home, as compared with public AED use. The authors conclude that perhaps AEDs should be reserved for public locations and cardiopulmonary resuscitation (CPR) should be taught more broadly, as the better path to improving survival from sudden cardiac arrest. This research is controversial in several respects. Does this study really show that ventricular fibrillation in sudden cardiac arrest occurs less often in the home than in public? Without electrocardiographic (ECG) data regarding the onset of the event, we cannot know for certain. What we do know is that untreated ventricular fibrillation will deteriorate to asystole over a period of minutes, and probably more rapidly in patients with more advanced cardiac disease; after 25 minutes, nearly all patients are in asystole.2 Although primary bradyarrhythmias as the cause of sudden cardiac arrest are becoming more common, most instances of bradycardia — specifically asystole — follow ventricular fibrillation. These considerations alter the interpretation of the findings that Weisfeldt et al. report. If the home rescuer takes just 60 seconds longer to call 911, as compared with the public witness, then the findings could be explained simply as a matter of response speed. The Home Use of Automated External Defibrillators for Sudden Cardiac Arrest trial (NCT00047411) showed that spouses confronted with the sudden collapse of a loved one commonly exhibit emotional distress and confusion, thus delaying an effective response.3 How much time actually elapses between witnessing and assessing the collapse and dialing 911? Does this interval differ between the home and the public setting? Does it differ between those who have CPR training and those who do not? Knowing the answers to these questions has broad implications. The greater number of bystanders who witness sudden cardiac arrest in public makes calling 911 more likely to occur closer to the time of collapse. Moreover, those who have completed CPR courses know that they should call 911 promptly. Because seconds matter, even a modest delay in the 911 call could lead to differences in outcome. Consequently, the lone rescuer at home, who is probably less aware of the critical importance of speed, would lose the race to a public bystander. What about AED use in the home? Certainly, at present, no grounds exist to broadly promote publicly financed home AEDs. However, this policy assessment should not dissuade persons from purchasing their own AEDs. The dismissal of home AEDs is premature, and other than the personal expense, there is no known downside to such a purchase. Moreover, some home rescuers do indeed act quickly and can save a life.3 Perhaps the presence of ECG monitoring technologies in the home would prompt a more rapid response and shave off valuable seconds to minutes, improving outcomes of arrests at home. As an alternative to a home AED, the increased use of CPR does not make sense to me. At best, CPR represents a placeholder. Overall survival rates remain poor, and 300,000 sudden cardiac deaths still occur annually in spite of national CPR awareness. One simple reason for such gloomy results may be the logistic impossibility of responding to a broadly disseminated, quasirandom event that causes death within minutes. Yet there may be another, more subtle reason for this bleak lack of progress. If CPR were a drug or a surgical procedure, its value would be tested prospectively, but it has not