Data from LMICs have consistently reported low rates of initial shockable rhythms (ventricular fibrillation (VF) and ventricular tachycardia (VT)) relative to HRS. Shockable rhythms are associated with higher STHD after IHCA and OHCA, with early defibrillation associated with improved survival. In the United States, around 15% of adult IHCA and 18% of OHCA have an initial shockable rhythm. In contrast, IHCA studies in RLS generally show a VT/VF incidence of 5% to 8%, including studies of IHCA in Kenya and Haiti ^, and of both IHCA and OHCA in South India. There are exceptions to these trends, such as a 25% incidence of VT/VF in patients receiving CPR in an ED in Pakistan.

In general, the presence of an initial shockable rhythm during IHCA is lower in children than adults, with incidence of shockable rhythms higher in adolescents than younger children. In a US registry study, VF/VT was the first pulseless rhythm in 8.8% of IHCA in ages 1 to 18, but only 1.9% in infants below the age of 1. Data suggest even fewer shockable rhythms in pediatric cardiac arrests in LMICs, with studies generally showing incidence under 3%. ^,,,

Some authors postulate that the prevalence of asystole in RLS may be due to delayed CPR initiation and defibrillation, as untreated VF often deteriorates to asystole. This is likely particularly true in OHCA due to the delayed or absent early resuscitation efforts including bystander CPR (BCPR) and defibrillation. Alternatively, the higher prevalence of nonshockable rhythms could also reflect different disease burdens between high-resource and low-resource settings.

Numerous studies have shown that BCPR improves survival from OHCA with survival decreasing by 7% to 10% each minute without CPR. ^,, While BCPR rates as high as 72% have been cited in HRS, very low rates have been reported in RLS. In a study from Karachi, Pakistan, 92.9% of patients had a witnessed cardiac arrest; however, only 2.3% received BCPR. Similar results were seen in studies from India (56.5% witnessed, 1.3% BCPR) and Cameroon (89% witnessed, 3.7% BCPR), and researchers have correlated BCPR rates with national gross domestic product (GDP) per capita.

Reasons for low-BCPR rates are multifactorial and include knowledge and legal frameworks. Notably, although cultural practices may contribute in some locations, this should not be overgeneralized to other settings: in a survey in Ghana, fewer than 10% were unwilling to perform CPR, while lack of skills (44.9%) and fear of causing harm (25.5%) were the main barriers.

The limited data suggest variable rates of CPR during IHCA. IHCA studies in Uganda, Haiti, and Tanzania show that CPR was performed in 18%, 27%, and 53% of patients respectively. Limited data on interventions requiring medications or biomedical equipment suggest that epinephrine is commonly administered for IHCA in RLS (81% of patients in Haiti and 76.3% in China), while use of defibrillators (56% in Haiti), intubation (7.4% of patients in Pakistan and 20.3% of OHCA in Vietnam), and other medication administration is more variable.

There are limited data on the presence of families during CPR in RLS. In 1 study in Iran, more than half of staff supported family presence during resuscitation, though it was commonly perceived to add stress and risk.

BLS and ALS education are critical to cardiac arrest care. High-quality CPR improves outcomes but requires delivering compressions at the optimal depth and speed, minimizing interruptions, ^, and allowing full chest recoil—all of which require specific training. OHCA outcomes are heavily dependent on early bystander intervention and BLS/ALS-trained responders. Despite international recommendations, there remains a significant gap in BLS/ALS training rates that mirrors the wide socioeconomic disparities between countries, with HICs reporting significantly higher training prevalence.

BLS education among the public varies by country income level: the median CPR training rate reported across studies is 50% in HICs but only 23% in upper MICs. In 1 meta-analysis, the single lower middle-income study included reported a 3% training rate. Studies have noted barriers that hinder widespread BLS training in LMICs, including logistical constraints and varying perceptions related to relevance and importance.

Health care providers in RLS frequently have low-CPR competency due to limited and inconsistent access to training. In 1 Tanzanian study, only 16% and 25% of health care providers passed written and practical CPR tests respectively. In another study in South Africa, only 22.5% of doctors achieved a preset competency in CPR training, despite 96.7% acknowledging its importance. In Botswana, only 28% of health care providers had formal CPR training, though 40% performed resuscitations at least once monthly. Competency also varies between resuscitation components; for example, South African registrars were better at compressions than ventilation.

In LMICs, high-quality, widespread BLS and ALS training is constrained by financial plus logistical barriers, ^,, and the high cost associated with ALS courses and certification remains a major deterrent in LMICs. However, there is increasing success of locally led, contextually adapted courses, and educational innovations in RLS that are discussed in greater detail later.

LMICs bear a disproportionate burden of acute illness and trauma compared to HICs, yet access to ECC services is limited. These system and resource challenges hamper the provision of quality cardiac arrest care.

Many hospitals lack well-staffed, adequately equipped, and efficiently organized EDs and ICUs; as a result, ECC is often delivered in general wards. In South Africa, shortages of well-trained and equipped resuscitation teams were identified as major challenges to ED resuscitation. This challenge is likely more pronounced in primary health centers and rural hospitals in LMICs, where emergency care is delivered in acute intake areas staffed by junior and rotating providers. It is estimated that only 19% to 50% of hospitals in sub-Saharan Africa can deliver 24-h emergency care, before accounting for care quality or materials. Though specialty training programs for emergency medicine have been increasing over time in LMICs, they are present in a minority of countries and there remains a severe deficit of emergency physicians relative to the population.

ICUs are similarly limited in RLS. Many LMIC ICUs are small with limited capacity and lack specialty-trained staff and standardized processes for critical care services. The high costs and resource-intensive nature of running ICUs discourage many LMICs from investing heavily in such services. However, there is increasing focus on low-cost, essential ECC as an initial step. For settings with ICUs, there are cost-effective interventions that have demonstrated potential to improve care and outcomes for cardiac arrest in these settings, including quality-driven critical care training, telemedicine-supported resuscitation, and implementation of context-appropriate ICU tools like capnography.

Prevention and management of IHCA and OHCA require biomedical equipment, including external defibrillators, vital sign monitors, and oxygen sources, as well as supplies and medications, such as bag-valve mask devices, epinephrine, and antiarrhythmic medications. Postarrest care often involves ventilatory and vasopressor support. Limitations of these supplies in RLS are well documented. In Malawi, only 33% of district hospitals could reliably perform bag-valve mask ventilation and none could reliably perform external defibrillation, while in Botswana significant gaps in equipment and medications on resuscitation trolleys at district hospitals were documented. In 1 Ugandan study, authors attributed low rates of CPR partially to poor monitoring of vital signs due to absence of monitoring equipment and low staff-to-patient ratios. In Haiti, only 23% of ED patients were on cardiac monitors before their cardiac arrest due to limited equipment. These studies were both at tertiary hospitals, one of which is NGO supported; monitoring capacity and equipment gaps are greater at smaller and/or less resourced facilities.

Within the context of these equipment and medication gaps, cardiac arrest care can be facilitated both by strengthening the overall system while encouraging adaptations to current limitations. Inclusion of necessary medications and equipment on national essential supply lists and advocacy are the first steps to improved availability, while adapting training and guidelines to address anticipated resource limitations facilitates care.

Multiple models have been proposed to conceptualize cardiac arrest care. Nadarajan and colleagues discuss a range of factors that influence prehospital planning and propose a framework for improving OHCA outcomes in developing prehospital systems, while the chainmail of survival endorsed by ILCOR illustrates how cardiac arrest care touches all aspects of a health system. While stronger components of this chainmail can offset weaker ones, improving care ultimately requires a holistic approach to health systems strengthening.

For implementers and practitioners, translating theoretic frameworks into concrete, detailed lists of inputs is the first step to improving care. This can be done by conceptualizing how the chain of survival intersects with health system building blocks at the national, local, or facility level for OHCA or IHCA. Fig. 2 shows an example for IHCA at an individual facility; similar maps could be created for different links of the chainmail of survival or levels of the health system.

Inputs to improve cardiac arrest care within a health facility. This figure includes a non-exhaustive list of interventions and inputs needed for in hospital cardiac arrest care across the chain of survival in a resource-limited setting, classified by health system domain. Specific inputs and interventions will vary by facility and context, with some facilities including more advanced interventions. ^a Prevention here refers to specific activities to prevent in IHCA during or just prior to hospital admission. Other prevention activities, including non-communicable disease screening and outpatient treatment, are important to long-term prevention of cardiac arrest.

With these inputs in mind, several key themes emerge.

The inputs in Fig. 2 overlap with building blocks for strong ECC systems. This reflects the reciprocal relationship between ECC and cardiac arrest care: strengthening ECC will improve cardiac arrest care, and after a system has a baseline level of ECC, improving cardiac arrest care will further strengthen ECC.

Lost-cost and cost-effective improvements in basic ECC have been achieved using the World Health Organization Basic Emergency Care course and Emergency Care toolkit. Triage—fundamental to emergency care—can be implemented in RLS with validated systems designed to successfully address human resource and equipment constraints. ^, Similarly, a focus on basic critical care will improve outcomes until ICU capacity can expand.

Given this reciprocal relationship between ECC and cardiac arrest care, as well as the numerous hospitals globally that lack any access to advanced postcardiac arrest care, extra emphasis on prevention as a core component of cardiac arrest care is warranted in RLS. Earlier detection of critical illness and/or clinical deterioration allows rapid intervention and treatment. Rapid response systems and medical emergency teams are recommended to reduce IHCA. Limited evidence from RLS suggests a role for similar systems. In both Egypt and Brazil, rapid response team implementation decreased cardiac arrest rates and inpatient mortality. ^, Further study is needed to understand the feasibility, impact of, and best practices for these teams in RLS.

Early intervention and response team activation requires early recognition of patient deterioration. Early warning systems (EWS) have been validated in RLS for both adults (Modified Early Warning Score ^, and National Early Warning Score) and pediatrics (Pediatric Early Warning Score for Resource-Limited Settings). However, EWS implementation remains limited. Barriers to implementation include staffing levels and turnover, missing equipment to measure vital signs, and insufficient implementation support, while facilitators of implementation include stakeholder engagement, leadership support, local adaptation, and preexisting system structures. ^,, Missing vital signs due to staffing, equipment, and system limitations are a significant barrier, with several studies showing that vital sign parameters used in EWS were often not documented leading up to cardiac arrests, reducing EWS sensitivity to predict adverse outcomes. ^,

Additional research in RLS is needed to understand how to overcome these barriers and/or modify systems for use in more constrained settings—for example, ability to walk has been identified as an independent predictor of mortality, and though it did not improve score performance in 1 study, may be an example of a variable that could be combined into other scores that may be easier to implement.

There is an urgent need for accessible and contextually appropriate BLS and ALS training programs in RLS. Effective training improves survival outcomes, yet LMICs face significant challenges in integrating ALS education into health care systems. ALS educational efforts in RLS are often limited by rigid course structures designed for HRS that are not adaptable to local needs, ^, inconsistent access to training resources and equipment, and limited availability of certified ALS instructors. In addition, many efforts to date have been dependent on short-term foreign-led projects with limited sustainability. Studies in Tanzania and Botswana confirm that ALS training programs can fail to persist due to reliance on external trainers and lack of local capacity-building efforts. ^, All these suggest the need for an adapted approach to training in RLS.

Table 1 suggests adaptations with examples of previous LMIC implementations. Linguistically and culturally appropriate training can be facilitated through locally-led initiatives with institutional backing, integration into existing health care education systems, and the development of regionally coordinated training frameworks. Train-the-Trainer (TTT) models improve long-term sustainability by developing local faculty, which is essential as skills decline as quickly as 6 months after training. In addition, training should be adapted to the local disease burden and resources. Qualitative research also suggests including when to initiate and terminate resuscitation relative to local resources.

ILCOR highlighted the extensive scientific knowledge gaps in RLS, including a need for more data on epidemiology, outcomes, ethics, and variations between settings and subpopulations.

Use of standardized definitions of data variables such as those found in Utstein reporting guidelines is essential to limit the heterogeneity that currently exists. Yet, certain answer choices and options for the collected variables may need to be adjusted for RLS context. Glaring disparities in RLS due to limitations of resources, infrastructure, and education require adaptation and refinement of operational frameworks that are specific to the challenges in RLS. ILCOR has previously described this need, but the gap still exists.

Cardiac arrest registries built around the Utstein guidelines with tracer methodology are essential to improving cardiac arrest care; however, most are from HICs. While several Utstein-based registries exist in or include MICs, ^,,, uptake remains limited and LICs under-represented. Widespread institution of Utstein-based registries in RLS would allow benchmarking of outcomes, help identify gaps and solutions, and inform policy and resource allocation. One implementation strategy would be to include resource-limited sites into existing registries, accompanied by the necessary capacity building, financial resources, and local ownership to ensure equity and success.

In addition to registry-based research, implementation science research to understand why interventions succeed and fail is essential. This should be locally led to avoid imparting external and colonialist biases. Best clinical practices in the absence of full resources and with differing burdens of diseases should also be analyzed. To do this, research outcomes may need to be reconsidered. In HRS, STHD or neurologically intact survival are the preferred outcomes. In RLS, Schnaubelt and colleagues suggest that shorter term outcomes such as ROSC may be more achievable when intensive care is limited. Focusing on earlier outcomes such as ROSC and cardiac arrest prevention in addition to long-term outcomes can assess the effectiveness of interventions prearrest or intra-arrest, in hopes that as critical care capacity improves over time, gains in ROSC may translate into overall improved survival.

Further research on the cost-effectiveness of cardiac arrest care interventions in RLS is also needed. When scarcity of resources exists, more data are needed to determine the optimal allocation of resources. A systematic review of the cost-effectiveness of OHCA interventions identified only a few MIC and no LIC studies, limiting its generalizability. However, interventions for OHCA care were less cost-effective than other basic emergency care interventions used in RLS.

Numerous ethical considerations surrounding cardiac arrest care in RLS exist. Friesen and colleagues highlight the nuances of how patient autonomy, beneficence, and maleficence during CPR and cardiac arrest care interact with varying cultural, religious, and societal beliefs. How beliefs and practices intersect with each health system’s capacity and structure must be weighed when considering ethical frameworks during stakeholder and policy discussions.

Ethical cardiac arrest care cannot be considered without considering ethical end-of-life care. End-of-life practices and the acceptability of withholding and withdrawing life-sustaining therapies show regional, religious and cultural differences, with regional variation in rates of withholding and withdrawing life-sustaining therapies in ICUs. In some settings, it may be seen as more ethical to withdraw care at home rather than in the hospital. In South Africa, research shows multiple influences on paramedic decisions to initiate and continue ALS, including patient prognosis, patient families, paramedic emotion and contemplation, safety, resources, and bystander response. Given this diversity, ethical discussions must be locally led by experts from RLS with community engagement to ensure contextual relevance and reduce paternalism.

Multiple policies can support cardiac arrest care, including policies on health system structure, administration and functioning, legal frameworks for bystander care and end of life care, and support for local medical institutions.

Support for local initiatives and clinical practice guidelines

Countries should support local medical and resuscitation societies to develop guidelines, trainings, and policies, as few emergency care clinical practice guidelines currently originate from LMICs. Organizations can be supported to offer subsidized and low-cost trainings for health care professionals, starting at referral centers. Finally, when contextually appropriate and prioritized, promotion of mass media campaigns for BCPR training can be considered.

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