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cardio.post-arrest.shockable-rhythm.v1PRODUCTION
cardio.post-arrest.shockable-rhythm.v1

Post-cardiac-arrest care — initial shockable rhythm (VF/pVT)

cardiologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

Initial shockable-rhythm (VF/pVT) OHCA cohort: cardiac etiology >80% probability; favourable survival + neurologic outcome compared with non-shockable; route immediately to parent cardio.post-arrest.core.v1 for TTM + neuroprog arc

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shockable rhythm confirmed at first analysis

Patient inputs (15)

ICD eligibility framing + ECPR window (ARREST: 18-75); MADIT-II horizon if EF ≤30 + ischemic CMP

Witnessed + bystander CPR + low-flow time → favourable neuro prognosis; CAHP/OHCA score inputs (AHA 2020)

VF/pVT confirmed at first analysis — cardiac etiology presumption; differentiates from PEA/asystole pathway

CPR duration → ECPR eligibility per ARREST (PMID 33308475 — <60 min low-flow); neuro prognosis weighting

Contrast nephropathy + drug renal-adjustment (AHA 2020)

Arrhythmogenic — replete to 4-4.5 mmol/L (AHA 2020 Class I)

STEMI → emergent cath within 90 min (AHA 2020 Class I); non-STEMI → routine cath strategy per COACT/TOMAHAWK

Cardiac etiology workup; serial trending; STEMI/NSTEMI distinction (4th UDMI 2018)

Tissue hypoperfusion + clearance (SCAI 2022 PMID 35718438)

Hemodynamic stability post-ROSC; SCAI staging if shock develops

TTM target 33-37.5 °C × 24h (TTM2 PMID 34133859)

Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa)

STEMI emergent (Class I); shockable non-STEMI routine timing per COACT (Lemkes NEJM 2019 PMID 30883045) + TOMAHAWK (Desch NEJM 2021 PMID 34587023)

Prior MI / EF / ICD / channelopathy — drives ICD upgrade decision + secondary-prevention pathway (AVID; HRS 2017)

LV/RV function, valvular cause, structural disease — drives ICD strategy + advanced HF eval

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Severity triggers (5)

5 need judgement
  • informationallife_threateningstemi_on_post_rosc_ecg_shockable
    ST elevation meeting STEMI criteria on first post-ROSC ECG following shockable-rhythm arrest — emergent cath (AHA 2020 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrecurrent_vf_pvt_post_rosc
    Recurrent VF/pVT episodes post-ROSC despite ACLS pharmacotherapy (AHA 2020 ACLS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_vf_arrest_arrest_criteria
    Persistent VF/pVT despite ≥3 defib + amiodarone + epinephrine; meets ARREST criteria (age 18-75, witnessed, bystander CPR, low-flow <60 min)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiogenic_shock_post_rosc_shockable
    Post-ROSC SBP <90 + lactate ≥2 + cool extremities — SCAI 2022 stage C+
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereicd_secondary_prevention_indication_window
    VF/VT-driven arrest unrelated to reversible cause + meaningful neurologic recovery → secondary-prevention ICD indication during admission (AVID PMID 9411221)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Shockable-rhythm OHCA phenotype — STEMI vs non-STEMI cath strategy + secondary-prevention ICD pathway (AHA 2020 + COACT + TOMAHAWK + AVID)
axis: shockable_rhythm_post_arrest_phenotype
Selected axis "Shockable-rhythm OHCA phenotype — STEMI vs non-STEMI cath strategy + secondary-prevention ICD pathway (AHA 2020 + COACT + TOMAHAWK + AVID)" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed (or PR if intubated) • PO/PR • load + 81 mg daily
    triggers: stemi_post_rosc, known_or_suspected_cad
    ACC/AHA 2025 ACS Class I; ISIS-2 PMID 2899772
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO/NG • BID × 12 mo
    triggers: stemi_pci_planned
    PLATO Wallentin NEJM 2009 PMID 19717846
    rxcui 1116632
  • unfractionated heparin
    first line
    anticoagulant_indirect_xa
    70-100 U/kg IV bolus → infusion to ACT 250-300 • IV • bolus + continuous
    triggers: pci_planned
    AHA 2025 ACS Class I
    rxcui 5224
  • atorvastatin
    first line
    statin_high_intensity
    80 mg • PO/NG • daily
    triggers: stemi_post_rosc, known_cad
    PROVE-IT TIMI-22 PMID 15007110
    rxcui 83367
  • amiodarone
    first line
    class_iii_antiarrhythmic
    150 mg IV bolus → 1 mg/min × 6h → 0.5 mg/min × 18h • IV • continuous taper
    triggers: recurrent_vf_pvt_post_rosc
    AHA 2020 ACLS Class IIb; ALIVE PMID 11136442
    rxcui 703
  • lidocaine
    second line
    class_ib_antiarrhythmic
    1-1.5 mg/kg IV bolus → 1-4 mg/min infusion • IV • bolus + continuous
    triggers: amiodarone_unavailable_or_contraindicated
    AHA 2020 ACLS
    rxcui 142440
  • magnesium sulfate
    add on
    electrolyte_anti_arrhythmic
    1-2 g IV • IV • one-time + repeat for TdP
    triggers: torsades_de_pointes, long_qt_with_arrest
    AHA 2020 ACLS Class IIa for TdP
    rxcui 6585
  • metoprolol succinate
    first line
    beta1_selective_blocker
    25 mg PO daily — defer if shock • PO/NG • daily; titrate
    triggers: lvef_below_40, no_cardiogenic_shock, no_high_grade_av_block
    CAPRICORN PMID 11356436 post-MI BB
    rxcui 6918

outpatient playbook — drug actions (3)

  1. 1. antiplatelet maintenance
    rxcui 243670
    ASA 81 mg daily ± P2Y12 per DAPT duration • PO • daily
    trigger: post-ACS
    AHA 2025 ACS; MASTER DAPT PMID 34516952
  2. 2. high-intensity statin maintenance
    rxcui 83367
    atorvastatin 80 mg daily; LDL <55 • PO • daily
    trigger: post-ACS
    IMPROVE-IT; FOURIER PMID 28304224
  3. 3. GDMT maintenance for HFrEF
    rxcui 1656328
    ARNI + BB + MRA + SGLT2i max tolerated • PO • as scheduled
    trigger: HFrEF post-arrest
    ACC/AHA 2022 HF 4-pillar

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after VF/pVT cardiac arrest — cardiac etiology >80% probability (AHA 2020); STEMI on first post-ROSC ECG following shockable-rhythm arrest → emergent cath (AHA 2020 Class I); VF/VT-driven arrest unrelated to reversible cause → ICD secondary-prevention indication (AVID PMID 9411221).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care — initial shockable rhythm (VF/pVT)** (cardio.post-arrest.shockable-rhythm.v1).
Phenotype framing: ACS / structural CAD / ischemic CMP / non-ischemic CMP / channelopathy (LQT, Brugada, CPVT) / WPW / commotio cordis (HRS 2017 PMID 28219760)
Scope: Initial shockable-rhythm (VF/pVT) OHCA cohort: cardiac etiology >80% probability; favourable survival + neurologic outcome compared with non-shockable; route immediately to parent cardio.post-arrest.core.v1 for TTM + neuroprog arc

No severity triggers fired against current inputs.

Plan

Regimen axis: **Shockable-rhythm OHCA phenotype — STEMI vs non-STEMI cath strategy + secondary-prevention ICD pathway (AHA 2020 + COACT + TOMAHAWK + AVID)**.
1. aspirin 162-325 mg chewed (or PR if intubated) PO/PR load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; ISIS-2 PMID 2899772
2. ticagrelor 180 mg load → 90 mg BID PO/NG BID × 12 mo (p2y12_inhibitor, first line) — PLATO Wallentin NEJM 2009 PMID 19717846
3. unfractionated heparin 70-100 U/kg IV bolus → infusion to ACT 250-300 IV bolus + continuous (anticoagulant_indirect_xa, first line) — AHA 2025 ACS Class I
4. atorvastatin 80 mg PO/NG daily (statin_high_intensity, first line) — PROVE-IT TIMI-22 PMID 15007110
5. amiodarone 150 mg IV bolus → 1 mg/min × 6h → 0.5 mg/min × 18h IV continuous taper (class_iii_antiarrhythmic, first line) — AHA 2020 ACLS Class IIb; ALIVE PMID 11136442
6. lidocaine 1-1.5 mg/kg IV bolus → 1-4 mg/min infusion IV bolus + continuous (class_ib_antiarrhythmic, second line) — AHA 2020 ACLS
7. magnesium sulfate 1-2 g IV IV one-time + repeat for TdP (electrolyte_anti_arrhythmic, add on) — AHA 2020 ACLS Class IIa for TdP
8. metoprolol succinate 25 mg PO daily — defer if shock PO/NG daily; titrate (beta1_selective_blocker, first line) — CAPRICORN PMID 11356436 post-MI BB

Setting playbook (outpatient) — Long-term cardiology + EP surveillance; ICD/WCD management; GDMT maintenance; secondary prevention; cardiac rehab; mental health
9. antiplatelet maintenance ASA 81 mg daily ± P2Y12 per DAPT duration PO daily — post-ACS (AHA 2025 ACS; MASTER DAPT PMID 34516952)
10. high-intensity statin maintenance atorvastatin 80 mg daily; LDL <55 PO daily — post-ACS (IMPROVE-IT; FOURIER PMID 28304224)
11. GDMT maintenance for HFrEF ARNI + BB + MRA + SGLT2i max tolerated PO as scheduled — HFrEF post-arrest (ACC/AHA 2022 HF 4-pillar)

Non-pharmacologic actions:
- ICD/WCD adherence + battery monitoring
- Cardiac rehab completion (12-week program); maintenance phase
- Family CPR/AED training
- Driving restriction per state law

AVOID / contraindication checks:
- Beta_blocker_avoid_acute_cardiogenic_shock (AHA 2020)
- Flecainide_avoid_structural_cad (CAST trial; HRS 2017)
- Amiodarone_avoid_thyroid_disease_relative (FDA label)
- Hypothermia_avoid_pre_ROSC_cooling (ARCTIC)

Monitoring

Regimen monitoring:
- continuous ecg telemetry (AHA 2020 Class I)
- serial troponin q2-3h x 3 then q6h (4th UDMI 2018)
- BMP q6-12h + Mg + K (AHA 2020; arrhythmia prevention)
- core temperature continuous via bladder or esophageal probe (TTM2)
- continuous EEG for 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- echo at 5-7d for lv function trajectory (AHA 2020)
- EF re echo at 40-90d for ICD eligibility (MADIT-II)

Setting (outpatient) monitoring:
- Quarterly BP + weight + symptom score
- Annual ECG ± Holter if structural disease
- Annual echo if HFrEF

Follow-up plan: EP follow-up at 1-2 weeks for ICD planning; LVEF reassessment at 40-90 d if MADIT-II eligible; secondary-prevention ICD per AVID if VF/VT unrelated to reversible cause; cardiac rehab
- Close-out criterion: EP + ICD + rehab + family screening (if channelopathy) booked

Monitoring phase: Continuous telemetry + arterial line + central line + Foley; lactate q2-4h; BMP q6-12h; serial troponin until peak; multimodal neuroprog ≥72h post-rewarm (Sandroni ERC-ESICM 2021 PMID 33745427)

Disposition

Current setting: outpatient — Long-term cardiology + EP surveillance; ICD/WCD management; GDMT maintenance; secondary prevention; cardiac rehab; mental health

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 for chronic HFrEF; cardio.ascvd.chronic.v1 for secondary prevention

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP; consider antiarrhythmic + ablation per VANISH (PMID 27149033)
- EF declining despite GDMT → advanced HF eval
- New depression / PTSD → mental health referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] ST elevation meeting STEMI criteria on first post-ROSC ECG following shockable-rhythm arrest — emergent cath (AHA 2020 Class I)
- [LIFE_THREATENING] Recurrent VF/pVT episodes post-ROSC despite ACLS pharmacotherapy (AHA 2020 ACLS)
- [LIFE_THREATENING] Persistent VF/pVT despite ≥3 defib + amiodarone + epinephrine; meets ARREST criteria (age 18-75, witnessed, bystander CPR, low-flow <60 min)

Citations

- 2020 AHA ACLS / Post-Cardiac-Arrest Care + 2025 ACC/AHA ACS + 2017 HRS expert consensus on inherited arrhythmia syndromes [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 30883045) [PMID:30883045](https://pubmed.ncbi.nlm.nih.gov/30883045/)
- Cited evidence (PMID 34587023) [PMID:34587023](https://pubmed.ncbi.nlm.nih.gov/34587023/)
- Cited evidence (PMID 9411221) [PMID:9411221](https://pubmed.ncbi.nlm.nih.gov/9411221/)
- Cited evidence (PMID 33308475) [PMID:33308475](https://pubmed.ncbi.nlm.nih.gov/33308475/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2020 AHA ACLS / Post-Cardiac-Arrest Care + 2025 ACC/AHA ACS + 2017 HRS expert consensus on inherited arrhythmia syndromes — PMID:33081530
  • Cited evidence (PMID 30883045) — PMID:30883045
  • Cited evidence (PMID 34587023) — PMID:34587023
  • Cited evidence (PMID 9411221) — PMID:9411221
  • Cited evidence (PMID 33308475) — PMID:33308475