Resuscitation Group / ACLSpdx

12/08/2025

Is Heads-Up CPR evidence indicate we should be using it now?
– Michael Christie

https://www.resuscitationgroup.com/blog/68/is-heads-up-cpr-evidence-indicate-we-should-be-using-it-now/

Heads-Up CPR (HUP-CPR) has emerged as an innovative approach to cardiopulmonary resuscitation (CPR), showcasing potential benefits in patient outcomes, particularly regarding neurological viability following cardiac arrests. The premise of heads-up positioning during CPR is based on the physiological advantages it offers, including improved cerebral perfusion and reduced intracranial pressure (ICP). Studies suggest that HUP-CPR, when combined with adjunctive resuscitation techniques, can enhance survival rates and neurological outcomes in both animal models and clinical settings (Moore et al., 2017; Moore, 2023; Pepe et al., 2019; Bachista et al., 2024)

Research indicates that elevating the head and thorax during CPR not only contributes to better hemodynamics but also bolsters critical perfusion to the brain. For instance, animals receiving active compression-decompression CPR in a heads-up position demonstrated improved cerebral perfusion pressure (CerPP) and earlier spontaneous gasps, indicative of preserved brain function post-arrest (Moore et al., 2017; (Pourzand et al., 2023; Arango et al., 2022; Pourzand et al., 2024).

These findings suggest that HUP-CPR could be superior to traditional CPR methods, particularly in long-duration resuscitations experienced during emergency responses. This advantage is poignant in high-rise building scenarios where response times are extended, thereby increasing the low-flow time before CPR initiation (Park et al., 2019; Damjanović et al., 2023).

However, outcomes associated with HUP-CPR are not universally established. A study involving porcine models indicated that prolonged head-up positioning could potentially worsen survival outcomes under certain circumstances, emphasizing the need for further investigation to delineate optimal positioning strategies during resuscitation (Park et al., 2019; Damjanović et al., 2023). While other investigations have reported improved neurological survival rates with automated heads-up positioning compared to conventional CPR techniques, discrepancies remain evident, highlighting the necessity for large-scale randomized controlled trials to confirm these benefits in human subjects (Moore, 2023; Pepe et al., 2019; Huang et al., 2021).

The critical role of adjunctive techniques, such as impedance threshold devices and active compression-decompression methods, further augments the efficacy of HUP-CPR. Combining these methods often results in enhanced cerebral blood flow and cardiac performance, driving better clinical outcomes when applied effectively (Pourzand et al., 2023; Arango et al., 2022; Moore, 2025). Observational studies support a time-sensitive association between HUP-CPR application and improved survival with favorable neurological status in out-of-hospital cardiac arrest scenarios (Bachista et al., 2024; Moore, 2025).

Moreover, the reduction in intracranial pressure observed during elevated positioning indicates a critical pathway through which HUP-CPR may mitigate secondary brain injuries that often accompany cardiac arrest events Levy et al., 2022). This aligns with broader goals of improving resuscitative techniques that focus not only on restoring circulation but also preserving neurological integrity (Chen et al., 2018; Levy et al., 2022). The implementation of head-up strategies in cardiac resuscitation protocols could potentially redefine critical care practices in both prehospital and hospital settings.

In conclusion, while preliminary animal studies and observational research suggest promising outcomes for heads-up CPR regarding cerebral perfusion and neurological recovery, further longitudinal studies are imperative to fully establish its clinical applicability and safety among diverse patient populations. Continued exploration into the interaction of CPR positioning with adjuncts will help refine cardiac arrest management strategies, ultimately aiming to enhance survivorship and functional recovery in victims of cardiac arrest.

References:
Arango, S., Kshatriya, S., Metzger, A., Salverda, B., Lick, M., Moore, J., … & Lurie, K. (2022). Abstract 11244: active decompression during device assisted elevation of the head and thorax, an impedance threshold device, and active compression decompression cardiopulmonary resuscitation is needed for sustained hemodynamic benefit in a porcine model of prolonged cardiac arrest. Circulation, 146(Suppl_1).
https://doi.org/10.1161/circ.146.suppl_1.11244
Bachista, K., Moore, J., Labarère, J., Crowe, R., Emanuelson, L., Lick, C., … & Pepe, P. (2024). Survival for nonshockable cardiac arrests treated with noninvasive circulatory adjuncts and head/thorax elevation*. Critical Care Medicine, 52(2), 170-181.
https://doi.org/10.1097/ccm.0000000000006055
Chen, G., Qiao, Y., Ma, J., Wang, J., Hei, F., & Yu, J. (2018). Extracorporeal cardiopulmonary resuscitation in children of asia pacific. Chinese Medical Journal, 131(12), 1436-1443.
https://doi.org/10.4103/0366-6999.233946
Damjanović, D., Pooth, J., Liu, Y., Frensch, F., Wolkewitz, M., Haberstroh, J., … & Trummer, G. (2023). The impact of head position on neurological and histopathological outcome following controlled automated reperfusion of the whole body (carl) in a pig model. Journal of Clinical Medicine, 12(22), 7054.
https://doi.org/10.3390/jcm12227054
Huang, C., Chen, K., Lin, Z., Chou, Y., Chen, W., Lee, T., … & Lin, Y. (2021). The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis. Critical Care, 25(1).
https://doi.org/10.1186/s13054-021-03797-x
Levy, Y., Hutin, A., Polge, N., Lidouren, F., Fernández, R., Kohlhauer, M., … & Tissier, R. (2022). Head and thorax elevation prevents the rise of intracranial pressure during extracorporeal resuscitation in swine. Shock, 58(3), 236-240.
https://doi.org/10.1097/shk.0000000000001971
Moore, J. (2023). Head-up cardiopulmonary resuscitation. Current Opinion in Critical Care, 29(3), 155-161.
https://doi.org/10.1097/mcc.0000000000001037
Moore, J. (2025). Abstract sun705: comparison of 5-year neurologically intact survival between an automated head up cardiopulmonaryresuscitation registry and a national cardiac arrest registry. Circulation, 152(Suppl_3).
https://doi.org/10.1161/circ.152.suppl_3.sun705
Moore, J., Segal, N., Lick, M., Dodd, K., Salverda, B., Hinke, M., … & Lurie, K. (2017). Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitation, 121, 195-200.
https://doi.org/10.1016/j.resuscitation.2017.07.033
Park, Y., Hong, K., Shin, S., Kim, T., Ro, Y., Song, K., … & Ryu, H. (2019). Worsened survival in the head-up tilt position cardiopulmonary resuscitation in a porcine cardiac arrest model. Clinical and Experimental Emergency Medicine, 6(3), 250-256.
https://doi.org/10.15441/ceem.18.060
Pepe, P., Scheppke, K., Antevy, P., Crowe, R., Millstone, D., Coyle, C., … & Moore, J. (2019). Confirming the clinical safety and feasibility of a bundled methodology to improve cardiopulmonary resuscitation involving a head-up/torso-up chest compression technique. Critical Care Medicine, 47(3), 449-455.
https://doi.org/10.1097/ccm.0000000000003608
Pourzand, P., Moore, J., Metzger, A., Salverda, B., Suresh, M., Arango, S., … & Lurie, K. (2023). Abstract 320: survival and neurological function with rapid versus delayed automated head-up cpr in a porcine model of prolonged cardiac arrest. Circulation, 148(Suppl_1).
https://doi.org/10.1161/circ.148.suppl_1.320
Pourzand, P., Moore, J., Metzger, A., Suresh, M., Salverda, B., Hai, H., … & Lurie, K. (2024). Abstract sa308: augmentation of intraventricular stroke volume during head up position cpr: implications for clinical outcomes. Circulation, 150(Suppl_1).
https://doi.org/10.1161/circ.150.suppl_1.sa308

resentations have always faced unlikely chances of survival. The primary objective was to determine if, in addition to conventional CPR (C-CPR), expeditious application of noninvasive circulation-enhancing adjuncts, and then gradual elevation of head and thorax, would be associated with higher likel...

11/08/2025

Ketamine as a dissociative agent in medical procedures – Michael Christie

https://www.resuscitationgroup.com/blog/67/ketamine-as-a-dissociative-agent-in-medical-procedures/

Ketamine has established itself as a valuable dissociative agent for procedural sedation in medical settings, offering advantages due to its anesthetic and analgesic properties. Originally developed as an anesthetic in the 1960s, it effectively provides sedation while preserving airway reflexes and cardiorespiratory function, making it particularly suitable for various clinical procedures in both adults and pediatric patients (Zaki et al., 2023; Afify et al., 2023).

In emergency medicine, ketamine is often used to facilitate painful procedures without necessitating complete anesthesia. This is achieved through its ability to induce a dissociative state, which is characterized by a sense of detachment from the environment and a reduction in pain perception (Zaki et al., 2023; (Javid et al., 2015; (Goddard et al., 2021; . The dosages for procedural sedation typically range from 0.25 mg/kg to 1 mg/kg, with the flexibility to adjust based on the specific clinical context or the concurrent use of other sedation agents (Goddard et al., 2021; . This level of dosing allows for a rapid onset of dissociation, which is particularly beneficial in emergency scenarios where time is crucial (Zaki et al., 2023; Scheppke et al., 2014).

Dissociative conscious sedation (DCS) has been utilized as an effective alternative to general anesthesia during procedures such as fiberoptic bronchoscopy and laryngeal surgeries (Javid et al., 2015; (Javid & Shaabani, 2015; . This technique often employs subcutaneous administration of ketamine alongside narcotics, achieving satisfactory sedation while minimizing respiratory depression (Javid & Shaabani, 2015; Shabani et al., 2014). This is crucial in scenarios where patient cooperation or airway protection must be maintained, particularly in pediatric procedures (Suryaprakash & Tham, 2017).

Furthermore, the safety profile of ketamine during procedural sedation has been closely examined. Studies indicate that, unlike many other sedatives, ketamine maintains protective airway reflexes and adequate respiratory function, which is critical for ensuring patient safety during sedation (Goddard et al., 2021; Lee & Tham, 2022). Despite its advantageous properties, ketamine administration is not devoid of risks; potential adverse effects such as hypersalivation, laryngospasm, or emergence reactions can occur, necessitating careful monitoring and preparation (Ip & Saincher, 2000).

The empirical data supporting ketamine's use in procedural sedation is robust, driving its adoption in various clinical settings. Research has consistently shown that ketamine can effectively reduce analgesic consumption compared to other methods, thereby improving comfort and outcomes for patients undergoing painful interventions (Javid et al., 2015; (Hopper et al., 2015). Additionally, studies suggest that ketamine's rapid onset and short duration of action enable efficient management of acutely agitated patients, particularly in emergency departments where quick disposition is often necessary (Hopper et al., 2015).

In conclusion, ketamine’s unique dissociative properties and its ability to provide effective sedation and analgesia make it a valuable agent for procedural sedation in medicine. As further research elucidates its mechanisms and optimizes its clinical use, ketamine is expected to continue playing a crucial role in enhancing patient care during various procedures.

References:
Afify, E., Mohamed, S., & Khedr, M. (2023). Ketamine: recent evidence and current uses. Benha Journal of Applied Sciences, 8(2), 111-117.
https://doi.org/10.21608/bjas.2023.208756.1165
Ballard, E. and Zarate, C. (2020). The role of dissociation in ketamine’s antidepressant effects. Nature Communications, 11(1).
https://doi.org/10.1038/s41467-020-20190-4
Chen, G., Chen, L., Zhang, Y., Li, X., Lane, R., Lim, P., … & Drevets, W. (2022). Relationship between dissociation and antidepressant effects of esketamine nasal spray in patients with treatment-resistant depression. The International Journal of Neuropsychopharmacology, 25(4), 269-279.
https://doi.org/10.1093/ijnp/pyab084
Dakwar, E., Anerella, C., Hart, C., Levin, F., Mathew, S., & Nunes, E. (2014). Therapeutic infusions of ketamine: do the psychoactive effects matter?. Drug and Alcohol Dependence, 136, 153-157.
https://doi.org/10.1016/j.drugalcdep.2013.12.019
Gitlin, J., Chamadia, S., Locascio, J., Ethridge, B., Pedemonte, J., Hahm, E., … & Akeju, O. (2020). Dissociative and analgesic properties of ketamine are independent. Anesthesiology, 133(5), 1021-1028.
https://doi.org/10.1097/aln.0000000000003529
Goddard, K., Sampson, C., Bedy, S., Ghadban, R., & Stilley, J. (2021). Effect of ketamine on cardiovascular function during procedural sedation of adults. Cureus.
https://doi.org/10.7759/cureus.14228
Grabski, M., Borissova, A., Marsh, B., Morgan, C., & Curran, H. (2020). Ketamine as a mental health treatment: are acute psychoactive effects associated with outcomes? a systematic review. Behavioural Brain Research, 392, 112629.
https://doi.org/10.1016/j.bbr.2020.112629
Hahm, E., Chamadia, S., Locascio, J., Pedemonte, J., Gitlin, J., Mekonnen, J., … & Akeju, O. (2021). Dissociative and analgesic properties of ketamine are independent and unaltered by sevoflurane general anesthesia. Pain Reports, 6(2), e936.
https://doi.org/10.1097/pr9.0000000000000936
Hopper, A., Vilke, G., Castillo, E., Campillo, A., Davie, T., & Wilson, M. (2015). Ketamine use for acute agitation in the emergency department. Journal of Emergency Medicine, 48(6), 712-719.
https://doi.org/10.1016/j.jemermed.2015.02.019
Ip, U. and Saincher, A. (2000). Safety of pediatric procedural sedation in a canadian emergency department. Canadian Journal of Emergency Medicine, 2(01), 15-20.
https://doi.org/10.1017/s1481803500004346
Javid, M. and Shaabani, S. (2015). Subcutaneous dissociative conscious sedation a new approach to endobronchial intubation: awake endobronchial intubation. International Journal of Anesthesiology & Research, 154-157.
https://doi.org/10.19070/2332-2780-1500038
Javid, M., Alinejad, Z., Hajipour, A., & Khazaeipour, Z. (2015). Subcutaneous dissociative conscious sedation (sdcs) an alternative method of anesthesia for fiberoptic bronchoscopy. Open Journal of Anesthesiology, 05(07), 149-154.
https://doi.org/10.4236/ojanes.2015.57027
Kishimoto, T., Chawla, J., Hagi, K., Zarate, C., Kane, J., Bauer, M., … & Correll, C. (2016). Single-dose infusion ketamine and non-ketaminen-methyl-d-aspartate receptor antagonists for unipolar and bipolar depression: a meta-analysis of efficacy, safety and time trajectories. Psychological Medicine, 46(7), 1459-1472.
https://doi.org/10.1017/s0033291716000064
Lee, J. and Tham, L. (2022). Incidence and predictors of respiratory adverse events in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department. Singapore Medical Journal, 63(1), 28-34.
https://doi.org/10.11622/smedj.2020095
Lin-ying, L., Huang, H., Li, Y., Zhang, R., Wei, Y., & Wu, W. (2021). Severe encephalatrophy and related disorders from long-term ketamine abuse: a case report and literature review. Frontiers in Psychiatry, 12.
https://doi.org/10.3389/fpsyt.2021.707326
Luckenbaugh, D., Niciu, M., Ionescu, D., Nolan, N., Richards, E., Brutsché, N., … & Zarate, C. (2014). Do the dissociative side effects of ketamine mediate its antidepressant effects?. Journal of Affective Disorders, 159, 56-61.
https://doi.org/10.1016/j.jad.2014.02.017
Mollaahmetoğlu, Ö., Keeler, J., Ashbullby, K., Argyri, E., Grabski, M., & Morgan, C. (2021). “this is something that changed my life”: a qualitative study of patients' experiences in a clinical trial of ketamine treatment for alcohol use disorders. Frontiers in Psychiatry, 12.
https://doi.org/10.3389/fpsyt.2021.695335
Morgan, C., Dodds, C., Furby, H., Pepper, F., Fam, J., Freeman, T., … & Stone, J. (2014). Long-term heavy ketamine use is associated with spatial memory impairment and altered hippocampal activation. Frontiers in Psychiatry, 5.
https://doi.org/10.3389/fpsyt.2014.00149
Schalkwyk, G., Wilkinson, S., Davidson, L., Silverman, W., & Sanacora, G. (2018). Acute psychoactive effects of intravenous ketamine during treatment of mood disorders: analysis of the clinician administered dissociative state scale. Journal of Affective Disorders, 227, 11-16.
https://doi.org/10.1016/j.jad.2017.09.023
Scheppke, K., Braghiroli, J., Shalaby, M., & Chait, R. (2014). Prehospital use of im ketamine for sedation of violent and agitated patients. Western Journal of Emergency Medicine, 15(7), 736-741.
https://doi.org/10.5811/westjem.2014.9.23229
Shabani, S., Javid, M., & Zebardast, J. (2014). The feasibility of endotracheal intubation with subcutaneous dissociative conscious sedation versus general anesthesia: a prospective randomized trial. Open Journal of Anesthesiology, 04(02), 41-45.
https://doi.org/10.4236/ojanes.2014.42006
Suryaprakash, S. and Tham, L. (2017). Predictors of emesis in children undergoing procedural sedation with intramuscular ketamine in a paediatric emergency department. Singapore Medical Journal, 58(11), 660-665.
https://doi.org/10.11622/smedj.2016187
Zaki, H., Ibrahim, T., Osman, A., Elnabawy, W., Gebril, A., Hamdi, A., … & Mohamed, E. (2023). Comparing the safety and effectiveness of ketamine versus benzodiazepine/opioid combination for procedural sedation in emergency medicine: a comprehensive review and meta-analysis. Cureus.
https://doi.org/10.7759/cureus.36742

Ketamine is associated with rapid antidepressant effects and temporary dissociative experiences, and this review examines whether these dissociative symptoms are necessary for antidepressant efficacy. Although the current literature does not support this relationship, further work is needed to explo...

10/25/2025

In person resuscitation instruction superior to online training.
– Michael Christie

https://www.resuscitationgroup.com/blog/66/in-person-resuscitation-instruction-superior-to-online-training/

The efficacy of online resuscitation education versus instructor-led education, particularly with immersive simulation, remains a pertinent topic in the field of medical education. While online training methods have emerged as a convenient alternative for teaching cardiopulmonary resuscitation (CPR), evidence suggests that instructor-led education with immersive, simulation-based methodologies leads to more effective learning outcomes.

Studies indicate that traditional instructor led approaches enhance both the quality of training and retention of skills among participants. For example, instructor-led CPR training has been shown to result in superior skill retention compared to automated feedback training alone, suggesting an inherent value in instructor interaction and mentorship in the learning process (Sutton et al., 2011). Collaborative learning settings facilitated by instructors allow for immediate feedback, corrections, and a nuanced understanding of the resuscitation process (Cheng et al., 2018). The American Heart Association (AHA) has also underscored the need for effective educational strategies to ensure skill retention among healthcare providers, noting that skills tend to decay over time without frequent reinforcement through guided practice (Cheng et al., 2018; Hasselager et al., 2019).

Furthermore, studies on immersive simulation, including virtual reality (VR), highlight limitations when compared to live instructor-led sessions. While VR offers an innovative platform for skill acquisition, it often falls short in preparing individuals for real-world scenarios due to a lack of personal interaction and dynamic feedback provided by instructors (Nas et al., 2020). Notably, a study indicated that CPR quality, measured through performance metrics, was not significantly improved by VR training in comparison to traditional, instructor-based methods (Nas et al., 2020). The element of human oversight, which ensures that learners develop the necessary cognitive and psychomotor skills effectively, is often replaced by a less interactive learning experience in online or VR settings.

Moreover, the incorporation of high-fidelity simulations in instructor-led courses facilitates deeper learning experiences, such as improved teamwork and situational awareness in crisis scenarios. Evidence supports that the realistic nature of immersive simulations allows participants to engage in complex problem-solving, which is crucial in high-stakes environments like resuscitation (Chang et al., 2020). In this context, debriefing after simulations has been shown to enhance learning outcomes significantly, reinforcing the advantages of structured instructor-led sessions over self-directed online education (Sawyer et al., 2012).

In conclusion, while online resuscitation education provides accessibility and convenience, instructor-led, immersive simulations remain superior regarding the effectiveness of skill acquisition and retention in CPR training. The human element in education fosters interactive learning and leads to better preparedness in life-saving scenarios. Future iterations of training programs may benefit from integrating both modalities, harnessing the strengths of each while addressing the shortcomings identified in isolated approaches.

References:
Chang, T., Hollinger, T., Dolby, T., & Sherman, J. (2020). Development and considerations for virtual reality simulations for resuscitation training and stress inoculation. Simulation in Healthcare the Journal of the Society for Simulation in Healthcare, 16(6), e219-e226.
https://doi.org/10.1097/sih.0000000000000521
Cheng, A., Nadkarni, V., Mancini, M., Hunt, E., Sinz, E., Merchant, R., … & Bhanji, F. (2018). Resuscitation education science: educational strategies to improve outcomes from cardiac arrest: a scientific statement from the american heart association. Circulation, 138(6).
https://doi.org/10.1161/cir.0000000000000583
Hasselager, A., Bohnstedt, C., Østergaard, D., Sønderskov, C., Bihrmann, K., Tolsgaard, M., … & Lauritsen, T. (2019). Improving the cost-effectiveness of laypersons’ paediatric basic life support skills training: a randomised non-inferiority study. Resuscitation, 138, 28-35.
https://doi.org/10.1016/j.resuscitation.2019.02.032
Nas, J., Thannhauser, J., Vart, P., Geuns, R., Muijsers, H., Mol, J., … & Brouwer, M. (2020). Effect of face-to-face vs virtual reality training on cardiopulmonary resuscitation quality. Jama Cardiology, 5(3), 328.
https://doi.org/10.1001/jamacardio.2019.4992
Sawyer, T., Sierocka-Castaneda, A., Chan, D., Berg, B., Lustik, M., & Thompson, M. (2012). The effectiveness of video-assisted debriefing versus oral debriefing alone at improving neonatal resuscitation performance. Simulation in Healthcare the Journal of the Society for Simulation in Healthcare, 7(4), 213-221.
https://doi.org/10.1097/sih.0b013e3182578eae
Sutton, R., Niles, D., Meaney, P., Aplenc, R., French, B., Abella, B., … & Nadkarni, V. (2011). Low-dose, high-frequency cpr training improves skill retention of in-hospital pediatric providers. Pediatrics, 128(1), e145-e151.
https://doi.org/10.1542/peds.2010-2105

10/11/2025

Current recommendations on the assessment of acute coronary syndrome patients – Michael Christie

https://www.resuscitationgroup.com/blog/65/current-recommendations-on-the-assessment-of-acute-coronary-syndrome-patients/

Current recommendations for the assessment and treatment of acute coronary syndromes (ACS) focus on a multifaceted, evidence-based approach that builds on prior guidelines while integrating advancements in pharmacotherapy and diagnostic techniques. ACS encompasses conditions such as unstable angina and myocardial infarction (both ST-elevation and non-ST-elevation), necessitating prompt identification and management to optimize patient outcomes.

Initial assessment should prioritize a comprehensive clinical evaluation, utilizing clinical decision tools such as the HEART score (https://www.heartscore.nl/), which aids in stratifying risk among patients presenting with chest pain (Wang et al., 2024)Babu et al., 2023). The integration of these tools, alongside traditional metrics such as electrocardiogram (ECG) findings and troponin levels, forms the cornerstone of early risk stratification, helping to rule in or rule out ACS (Damani & Roongsritong, 2025). The use of computed tomography coronary angiography is also highlighted as a valuable tool in selected cases to assist in diagnosis (Wang et al., 2024).

Pharmacological management remains pivotal in the treatment of ACS, particularly regarding antiplatelet therapy. Current guidelines recommend dual antiplatelet therapy (DAPT) combining aspirin with a P2Y12 inhibitor, such as clopidogrel, for at least 12 months following percutaneous coronary intervention (PCI) to reduce the risk of recurrent thrombotic events (Cheng et al., 2025). Emerging evidence suggests modifications in antiplatelet regimens may be warranted depending on individual patient characteristics and the presence of specific complications such as spontaneous coronary artery dissection (SCAD) (Park et al., 2024; Ilić et al., 2023).

A particular emphasis has been placed on tailoring treatment strategies according to the demographic and clinical profile of patients, particularly older adults, who may present unique challenges due to comorbidities and frailty (Damluji et al., 2023). The recommendations advocate for an individual approach to therapy, factoring in the complexities of polypharmacy and the need for careful monitoring of potential adverse effects (Damluji et al., 2023).

Furthermore, the guidelines encourage healthcare providers to optimize adherence to evidence-based therapies through comprehensive patient education and awareness of secondary prevention measures. These include lifestyle modifications, the management of comorbid conditions, and engagement in cardiac rehabilitation programs, which have been shown to improve clinical outcomes significantly (Gebremichael et al., 2024).

As part of evolving care strategies, attention to socioeconomic factors and barriers to accessing care is increasingly recognized as crucial in the management of ACS. The American Heart Association recommends that healthcare systems work to address disparities in treatment and outcomes across different patient populations (Sarrafzadegan et al., 2024).

In conclusion, current recommendations emphasize a holistic and personalized approach to the assessment and management of ACS, incorporating the latest evidence in pharmacotherapy, technology, and patient-centered care practices to enhance outcomes for individuals at risk of or suffering from acute coronary syndromes.

References:
Ahmadi, A., Sabri, M., Navabi, Z., Dehghan, B., Taheri, M., & Mahdavi, C. (2024). The impact of self-care recommendations with and without tilt-training on quality of life in children and adolescents with vasovagal syncope: a randomized clinical trial. Iranian Journal of Nursing and Midwifery Research, 29(3), 358-367.
https://doi.org/10.4103/ijnmr.ijnmr_137_23
Amin, S., Gupta, V., Du, G., McMullen, C., Sirrine, M., Williams, M., … & Li, J. (2021). Developing and demonstrating the viability and availability of the multilevel implementation strategy for syncope optimal care through engagement (mission) syncope app: evidence-based clinical decision support tool. Journal of Medical Internet Research, 23(11), e25192.
https://doi.org/10.2196/25192
Babu, M., Parimala, L., & Barathi, K. (2023). Assess the risk level of acute coronary syndrome (acs) among patients with chest pain in emergency department. CM, (26), 696-700.
https://doi.org/10.18137/cardiometry.2023.26.696700
Brieger, D., Tofler, G., & Chia, K. (2024). Use of a leadless pacemaker in the management of swallow syncope: a case report. Pacing and Clinical Electrophysiology, 47(8), 1061-1064.
https://doi.org/10.1111/pace.14923
Cheng, B., Xiang-hai, K., Chen, J., He, Q., Zhou, M., & Deng, A. (2025). Assessing the efficacy and safety of low dose clopidogrel in chinese acs patients undergoing pci: a retrospective study. Medicine, 104(22), e42551.
https://doi.org/10.1097/md.0000000000042551
Damani, D. and Roongsritong, C. (2025). Zero coronary artery calcification: a promising value in acute chest pain evaluation. Cureus.
https://doi.org/10.7759/cureus.78365
Damluji, A., Forman, D., Wang, T., Chikwe, J., Kunadian, V., Rich, M., … & Alexander, K. (2023). Management of acute coronary syndrome in the older adult population: a scientific statement from the american heart association. Circulation, 147(3).
https://doi.org/10.1161/cir.0000000000001112
Francisco‐Pascual, J., Jordán, P., Silva, J., & Rivas-Gándara, N. (2023). Arrhythmic syncope: from diagnosis to management. World Journal of Cardiology, 15(4), 119-141.
https://doi.org/10.4330/wjc.v15.i4.119
Gebremichael, L., Beleigoli, A., Foote, J., Bulamu, N., Ramos, J., Suebkinorn, O., … & Clark, R. (2024). missed opportunity: a clinical data linkage study of guideline‐directed medical therapy and clinical outcomes of patients discharged with acute coronary syndrome who attended cardiac rehabilitation programs. Journal of Pharmacy Practice and Research, 54(4), 314-322.
https://doi.org/10.1002/jppr.1923
Ghariq, M., Bodegom‐Vos, L., Brignole, M., Peeters, S., Groot, B., Kaal, E., … & Thijs, R. (2021). Factors facilitating and hindering the implementation of the european society of cardiology syncope guidelines at the emergency department: a nationwide qualitative study. International Journal of Cardiology, 333, 167-173.
https://doi.org/10.1016/j.ijcard.2021.02.067
Ghariq, M., Hout, W., Dekkers, O., Bootsma, M., Groot, B., Groothuis, J., … & Fokke, C. (2023). Diagnostic and societal impact of implementing the syncope guidelines of the european society of cardiology (synergy study). BMC Medicine, 21(1).
https://doi.org/10.1186/s12916-023-03056-6
Ilić, I., Radunović, A., Timčić, S., Odanović, N., Radoicic, D., Dukuljev, N., … & Apostolović, S. (2023). Drugs for spontaneous coronary dissection: a few untrusted options. Frontiers in Cardiovascular Medicine, 10.
https://doi.org/10.3389/fcvm.2023.1275725
Johnston, S. (2025). The hope and the hype of artificial intelligence for syncope management. European Heart Journal - Digital Health, 6(5), 1046-1054.
https://doi.org/10.1093/ehjdh/ztaf061
Loughlin, E., Judge, C., Gorey, S., Costello, M., Murphy, R., Waters, R., … & Canavan, M. (2020). Increased salt intake for orthostatic intolerance syndromes: a systematic review and meta-analysis. The American Journal of Medicine, 133(12), 1471-1478.e4.
https://doi.org/10.1016/j.amjmed.2020.05.028
Park, H., Cho, L., Fendrikova-Mahlay, N., Chaudhury, P., & Cameron, S. (2024). Antiplatelet therapy following spontaneous coronary artery dissection: systemic review..
https://doi.org/10.1101/2024.09.03.24312989
Reed, M., Karuranga, S., Kearns, D., Alawiye, S., Clarke, B., Möckel, M., … & Laribi, S. (2023). Management of syncope in the emergency department: a european prospective cohort study (seed). European Journal of Emergency Medicine, 31(2), 136-146.
https://doi.org/10.1097/mej.0000000000001101
Sarrafzadegan, N., Bagherikholenjani, F., Shahidi, S., Ghasemi, G., Shirvani, E., Rajati, F., … & Abdi, A. (2024). Development of the first iranian clinical practice guidelines for the diagnosis, treatment, and secondary prevention of acute coronary syndrome. Journal of Research in Medical Sciences, 29(1).
https://doi.org/10.4103/jrms.jrms_851_23
Shabbir, M., Shaukat, M., Ehtesham, M., Murawski, S., Singh, S., & Alimohammad, R. (2022). Bifascicular block in unexplained syncope is underrecognized and under-evaluated: a single-center audit of esc guidelines adherence. Plos One, 17(2), e0263727.
https://doi.org/10.1371/journal.pone.0263727
Wang, K., Taggart, C., McDermott, M., O’Brien, R., Oatey, K., Keating, L., … & Gray, A. (2024). Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary syndrome. Emergency Medicine Journal, 41(8), 488-494.
https://doi.org/10.1136/emermed-2024-213904
Wen, C., Wang, S., Zou, R., Wang, Y., Tan, C., Xu, Y., … & Wang, C. (2020). Duration of treatment with oral rehydration salts for vasovagal syncope in children and adolescents. The Turkish Journal of Pediatrics, 62(5), 820-825.
https://doi.org/10.24953/turkjped.2020.05.014

f Life (QoL) of children and adolescents with syncope. Materials and Methods: This randomized controlled clinical trial was conducted in Isfahan, Iran, from April 2017 to June 2021 and included 120 patients with syncope. Eligible children and adolescents (aged 6–18 years) who met inclusion criteri...