A Cardiac Arrest Centre (CAC) is a specialised institution offering all recommended treatment options for patients with out-of-hospital cardiac arrest (OHCA), including access to a coronary angiography laboratory with 24/7 PCI capability, targeted temperature management, extracorporeal membrane oxygenation, mechanical ventilation, and neurological prognostication.

Cardiac arrest centres are expected to play a crucial role in post-resuscitation care within the Chain of Survival, which emphasises the importance of early recognition, high-quality CPR, rapid defibrillation, advanced life support, and post-resuscitation care. Research indicates that patients treated at these centres have significantly better survival rates and neurological outcomes compared to those treated at non-specialised facilities.

A meta-analysis by Yeo, Jun Wei, et al. in 2022 showed that survival with favourable neurological outcomes improved significantly with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]). Furthermore, survival also significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]).

In the 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) published by the International Liaison Committee on Resuscitation (ILCOR), it was recommended that adult patients with non-traumatic OHCA be cared for in CACs rather than in non-cardiac arrest centres, in settings where this can be implemented.

The position paper jointly published by the European Society for Emergency Medicine and the European Society of Cardiology in 2020 also recommended that OHCA patients be transported to CACs in the acute phase.

However, such recommendations are mostly based on expert opinion or observational studies. The ARREST study, published in 2023, is the first randomised trial of its kind to study the effect of cardiac arrest centres. Conducted in the UK, the study enrolled 862 patients aged 18 or older who experienced return of spontaneous circulation after cardiac arrest without ST elevation. The results did not show a significant difference in 30-day mortality between the cardiac arrest centre group (63%, 258 out of 411 participants) and the standard care group (63%, 258 out of 412) (unadjusted risk ratio for survival 1·00, 95% CI 0·90–1·11; p=0·96). The authors concluded that expedited transfer to cardiac arrest centres following out-of-hospital cardiac arrest in adult patients without ST elevation did not result in reduced mortality rates, despite the well-resourced facilities available at these centres.

However, the RCT was carried out in a very specific urban setting, making it difficult to recommend for or against transferring OHCA adults with a presumed cardiac cause presenting with non-STEMI and prehospital ROSC to a CAC.

Yet, there remain unresolved challenges to the implementation of CACs, and some knowledge gaps need to be addressed before a definitive recommendation can be made. These challenges include:

1. Resource Allocation: Establishing and maintaining a cardiac arrest centre requires significant investment in infrastructure, training, and technology.

2. Regional Disparities: Not all regions have equal access to cardiac arrest centres, leading to disparities in care and outcomes.

3. Knowledge Gaps: Further research is needed to understand the cost-effectiveness of transferring patients to these centres and to ensure that there are no negative outcomes associated with bypassing the nearest hospitals (e.g., de-skilling in post-arrest management). Additionally, more studies are needed to determine whether there is a safe distance or time for transport, and to assess the impact on families, particularly in remote areas.

While more evidence is needed regarding the effectiveness of CACs, there are still many opportunities for intervention within the Chain of Survival. For example, the establishment of a cardiac arrest registry could provide data on the efficiency of emergency healthcare systems and be used for benchmarking, surveillance, audit, and feedback, as well as for evaluating the effectiveness of survival-enhancing measures.

Secondly, survival after OHCA depends significantly on the immediate initiation of CPR, with survival rates dropping by 10% for every minute of delay in CPR and defibrillation. Rapid initiation of emergency services can add 5-10% to a community's survival rate. Enhancing public awareness, increasing the rate of high-quality bystander CPR, and implementing a territory-wide public access defibrillation programme can also improve survival rates after OHCA.

Finally, the introduction of Good Samaritan legislation is crucial. There is concern among the general public regarding potential legal liabilities if something goes wrong during the resuscitation process. Such legislation would provide reassurance and could encourage more people to intervene, promoting a culture of helping others in society.