By Betty Tran, MD, MSc
Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago
SYNOPSIS: Based on a large U.S. registry that included information on witnessed out-of-hospital cardiac arrests, Black and Hispanic people were less likely than white people to receive bystander cardiopulmonary resuscitation, independent of the neighborhood where the cardiac arrest occurred.
SOURCE: Garcia RA, Spertus JA, Girotra S, et al. Racial and ethnic differences in bystander CPR for witnessed cardiac arrest. N Engl J Med 2022;387:1569-1578.
Using the Cardiac Arrest Registry to Enhance Survival (CARES) registry, a prospective U.S. record of out-of-hospital cardiac arrests as reported by emergency medical service (EMS) agencies capturing 51% of the population, Garcia et al focused on a cohort of 110,054 witnessed out-of-hospital cardiac arrests involving white, Black, or Hispanic persons between January 2013 and December 2019. The primary outcome was initiation of bystander cardiopulmonary resuscitation (CPR) by a layperson, which could be any person (even a medical provider) who was not a 911 first responder, and the independent variable was race or ethnic group (Black or Hispanic vs. white). Analyses were stratified by location (home, public locations), racial/ethnic neighborhood makeup [majority white (> 80% white), majority Black or Hispanic (> 50% Black or Hispanic), or integrated (did not meet either previous category)], and income [high income (median annual household income > $80,000), middle income ($40,000-$80,000), or low income (< $40,000)].
A more in-depth analysis also was done looking for differences depending on the type of public location (workplace, street/highway, recreational facility, public transportation center, or other). Multivariable hierarchical logistic regression models were adjusted for age, sex, calendar year of the arrest, cause of the arrest, and urbanicity (per U.S. census tract classification). Further analyses included survival to hospital discharge and favorable neurologic outcome by race/ethnicity; these were adjusted additionally for the presence/absence of bystander CPR and cardiac arrest rhythm.
Of the 110,054 cardiac arrests included in the study, 32.2% occurred in Black (24.7%) or Hispanic (7.5%) persons, which was reflective of the U.S population. More cardiac arrests occurred at home (76.6%) compared to public locations (23.4%). Compared to white persons, Black and Hispanic persons with out-of-hospital witnessed cardiac arrests tended to be younger, more frequently women, more likely to reside in urban areas, and more likely to have a cardiac arrest in a low income or majority Black or Hispanic neighborhood.
Overall, Black and Hispanic persons were less likely than their white counterparts to receive bystander CPR both at home (adjusted odds ratio [OR], 0.74; 95% CI, 0.72-0.76) and in public locations (adjusted OR, 0.63; 95% CI, 0.60-0.66). This finding persisted even after stratification according to racial/ethnic neighborhood makeup and neighborhood income. Compared to white persons, Black and Hispanic persons had a lower incidence of survival to hospital discharge and favorable neurologic outcome for cardiac arrests occurring both at home and in public locations; these findings were mildly attenuated after adjusting for receipt of bystander CPR and initial cardiac arrest rhythm (shockable or not). Specific public location was not a factor; Black and Hispanic persons were less likely to receive bystander CPR in every public location category.
COMMENTARY
It is well documented that every minute counts during cardiac arrest. Survival from cardiac arrest declines by 7% to 10% for each minute without CPR delivery1, and bystander CPR can improve survival two- to three-fold while waiting for EMS arrival.2 Therefore, bystander CPR is a crucial link in the chain of survival after sudden cardiac arrest.1-2
The study by Garcia et al expands on prior findings that Black and Hispanic persons are less likely than white persons to survive cardiac arrest and are less likely to receive bystander CPR.3 Some of these differences were previously hypothesized to be because of a lower incidence of bystander CPR in predominantly Black or Hispanic communities (because of training or other structural/access differences). However, the current study was able to provide more robust detail by restricting their analyses to witnessed events only (i.e., situations where bystander CPR was most likely to occur) and providing in-depth stratification by neighborhood race/ethnicity and income as well as specific location (home vs. various public locations).
Their results provide more insights into not only the problem but also the breadth of management strategies potentially needed. Certainly, a lack of CPR training and dispatcher-assisted bystander CPR programs in lower income communities due to cost, language barriers, and lack of trust can account for some of the differences seen. However, the finding that racial and ethnic differences in bystander CPR persist even in public locations and neighborhoods despite stratification for race/ethnic makeup and income is concerning for implicit and explicit biases in layperson response to cardiac arrest. Resolution of this inequity will be more complex than merely increasing CPR training and funding in majority Black and Hispanic neighborhoods and low-income neighborhoods. It will involve continuing to dismantle the roots and legacy of structural racism at the individual, organizational, community, and national level.4
REFERENCES
- [No authors listed]. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 3: Adult basic life support. Circulation 2000;102 (Suppl_1):I22-I59.
- Rao P, Kern KB. Improving community survival rates from out-of-hospital cardiac arrest. Curr Cardiol Rev 2018;14:79-84.
- Becker LB, Han BH, Meyer PM, et al. Racial differences in the incidence of cardiac arrest and subsequent survival. The CPR Chicago Project. N Engl J Med 1993;329:600-606.
- Bailey ZD, Feldman JM, Bassett MT. How structural racism works — Racist policies as a root cause of U.S. racial health inequities. N Engl J Med 2021;384:768-773.
