Out-of-hospital cardiac arrest during the COVID-19 pandemic

COVID-19 may be responsible also for undirect death. Lockdown, movement restrictions, and fear of contamination in hospitals could have led to a reluctance to call EMS or present to EDs and may have detrimental effects on population health.
Resuscitation of patients in out-of-hospital cardiac arrest (OHCA) may be adversely affected by COVID-19 concerns, for example by fear of contracting the infection through the delivery of CPR, and by an overwhelmed health system.

Mechanisms by which COVID-19 might cause cardiac arrest include

  • vascular inflammation
  • myocarditis
  • cardiac arrhythmias
  • thromboembolism
  • indirect effects
    • fear and anxiety
    • reduced or delayed presentation for non-COVID-19 related conditions (e.g. acute coronary syndromes)
    • self-harm and substance use precipitating in cardiac arrest due to worsened mental health during social isolation

1) Lombardy, Italy (Baldi et al. NEJM 2020)

  • Authors compared OHCA that occurred in 4 provinces of Lombardy region (Lodi, Cremona, Pavia, Mantua) during the first 40 days of the COVID-19 outbreak (February 21 through March 31, 2020) with those that occurred during the same period in 2019 (February 21 through April 1)
  • 58% increase in OHCA incidence during this period (362 vs. 229)
  • cumulative incidence of OHCA in 2020 was strongly associated with the cumulative incidence of COVID-19 (Spearman rank correlation coefficient, 0.87; 95% confidence interval, 0.83 to 0.91; P<0.001)
    • the increase in the number of cases of OHCA over the number in 2019 (133 additional cases) followed the time course of the COVID-19 outbreak
    • 103 patients who had OHCA were suspected to have or had received a diagnosis of COVID-19
    • 77.4% of the increase in OHCA cases were directly attributable to COVID-19
  • Similar patient characteristics (sex and age)
  • Differences in event characteristics during COVID-19 pandemic:
    • The medical cause of OHCA was 6.5% higher (346 [95.6%] vs 204 [89.1%])
    • OHCA at home was 7.3% higher (333 [92%] vs 194 [84.7%])
    • unwitnessed OHCA was 11.3% higher (199 [55%] vs 100 [43.7%])
    • median EMS arrival time was 3 minutes longer (15 min [12-20] vs 12 min [9-15])
    • bystander-CPR rate was 15.6% lower (59 [31.4%] vs 63 [47%])
  • 14.9% higher mortality in the field among patients with attempted resuscitation (189 [82.2%] vs 107 [67.3%])

2) Paris, France (Marijon et al. Lancet Public Health 2020)

  • Authors used the Paris-Sudden Death Expertise Center registry to compare OHCA incidence and patient characteristics from a 6-week period during the COVID-19 pandemic in Paris and its suburbs (6·8 million inhabitants, March 16 to April 26, 2020) with corresponding periods over the preceding 8 years
  • Two-times increase in OHCA incidence from a baseline of 13.42 (95% CI 12.77–14.07) to 26·64 (25.72–27.53) per million inhabitants
  • The incidence of OHCA rose in parallel with the incidence of COVID-19 hospital admissions
  • OHCA incidence decreased towards baseline near the end of the 6-week period in line with a decrease in COVID-19 incidence
  • Similar patient characteristics
  • Differences in event characteristics during COVID-19 pandemic:
    • around 13% (460 [90.2%] vs 2336 [76.8%]) more cases occurred inside the home
    • fewer patients presented with shockable rhythm (46 [9.2%] vs 472 [19.1%])
    • fewer patients received bystander-CPR (239 [47.8%] vs 1165 [63.9%])
    • fewer patients received public access defibrillation (2 [0.4%] vs 33 [3.0%])
    • ambulance response times were longer
    • the proportion of OHCAs where the ambulance crew started/continued resuscitation was lower (53.1% vs 66.2%)
      • irreversible death? DNR? fear of infection? overwhelmed health system?
  • Poorer survival during COVID-19 pandemic
    • fewer patients survived to hospital admission (67 [12.9%] of 521 vs 695 [22.8%] of 3052)
    • fewer survived to hospital discharge (16 [3.1%] of 517 vs 164 [5.4%] of 3052)
  • < 10% of all patients who had an OHCA had known or suspected COVID-19
  • 33% of the increase in OHCA cases were directly attributable to COVID-19

3) Greater Paris, France (Lapostolle et al, Resuscitation 2020)

The authors compared the management of OHCA during the COVID-period (February 24th, 2020, March 24th, 2020) and the reference period (2019).

During the COVID-19 period, compared to the reference 2019 period, they found:

  • similar age (69 years (52-82) vs 66 years (55-85), p=0.6)
  • more male (84% vs 60%, p = 0.02)
  • similar bystander-CPR rates (53% vs. 49%, p = 0.6) and AED use (7% vs 3%)
  • similar time between OHCA and mobile intensive care unit (MICU) departure (13 minutes [9-17] vs 15 minutes [7-30], p=0.7)
  • similar duration of no-flow (7 minutes [2-11] vs 9 [2-15], p = 0.8) and low-flow (35 minutes [20-48] vs 29 minutes [15-45], p = 0.8)
  • similar ROSC (18% vs 21%)
  • same mortality on day 1 (7% vs 7%)

4) California, USA (Wong et al. NEJM Catalyst 2020)

  • 45% more OHCA incidence on March 2020 than February 2020
  • all of these EMS heart patients tested negative for Covid-19
  • most of these patients declared dead at scene

5) Seattle and King County, WA (Sayre et al. Circulation 2020)

  • cohort investigation of OHCA attended by emergency medical services (EMS) in Seattle and King County, WA from January 1 to April 15, 2020
  • Included patients treated by EMS already dead on EMS arrival
  • The authors investigated the prevalence of COVID-19 in out-of-hospital cardiac arrests
  • hierarchical COVID-19 classification strategy that prioritized polymerase chain reaction (PCR) testing obtained pre or post mortem and clinical classification of a COVID-like illness if PCR testing was not performed
  • For EMS OHCA patients without PCR results, two authors classified COVID-like illness status using EMS records (febrile or respiratory illness or COVID-19 exposure) (kappa agreement 0.81)
  • During the active period of COVID-19 (February 26-April 15), EMS responded to 537 (50.3%) OHCAs of which 230 (48.1%) were EMS treated
    • COVID-19 was diagnosed by PCR or COVID-like illness in less than 10% of OHCA
      • 3.7% of dead on EMS arrival
      • 6.5% of EMS treated cases
    • 5% of OHCAs in homes and 11% of OHCAs in nursing homes involved COVID-19 patients, compared to none in public places
    • Bystander CPR was provided in 57%
  • The incidence of OHCA in 2020 was compared to prior years
    • The count of total cases year to date was similar for 2020 compared to 2019 and 2018 (incidence rate ratio 0.997 [95% CI 0.989-1.016, p=.72])
    • bystander CPR by location before and after the first COVID-19 death on February 26 were unchanged (p=0.46, Fisher’s Exact test).


  1. Baldi E, Sechi GM, Mare C, Canevari F, Brancaglione A, Primi R, et al. Out-of-Hospital Cardiac Arrest during the Covid-19 Outbreak in Italy. N Engl J Med 2020:NEJMc2010418.
  2. Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C, et al. Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. The Lancet Public Health 2020:S2468266720301171.
  3. Lapostolle F, Agostinucci JM, Alhéritière A, Petrovic T, Adnet F. Collateral consequences of COVID-19 epidemic in Greater Paris. Resuscitation 2020;151:6–7.
  4. Wong LE, Hawkins JE, Langness S, et al. Where are all the patients? Addressing Covid-19 fear to encourage sick patients to seek emergency care. NEJM Catalyst Innovations in Care Delivery 2020; 1: 3.
  5. Sayre MR, Barnard LM, Counts CR, et al. Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR [published online ahead of print, 2020 Jun 4]. Circulation. 2020;10.1161/CIRCULATIONAHA.120.048951.