Assessment of knowledge and awareness of cardiopulmonary resuscitation and heart attack symptoms amongst medical students in Syria - a cross-sectional study

Abstract

Background

Cardiovascular diseases, especially acute myocardial infarction (AMI), cause a major global health burden and are also highly prevalent in Syria. Early recognition of myocardial infarction (MI) symptoms and timely delivery of high-quality basic life support are core competencies expected of graduating medical students, yet evidence on these competencies in Syria remains limited.

Methods

We conducted a confidential, online cross-sectional survey of undergraduate medical students from nine Syrian medical schools between 13 and 30 June 2025, using a Google Forms questionnaire that required sign-in to restrict submissions to one response per participant. CPR knowledge was assessed using an 11-item guideline-mapped composite score (range 0–11), and MI symptom knowledge using an 18-item score (range 0–18), awarding 1 point per correct response.

Results

Amongst 500 respondents (54.0% female), the mean CPR knowledge score was 5.03 (SD 2.50) out of 11 and the mean MI knowledge score was 11.50 (SD 2.67) out of 18. The largest CPR knowledge gaps involved time-critical defibrillation concepts, including when to use an AED (18.6% correct), the recommended reassessment interval (36.8%), and monophasic defibrillation energy (35.4%). In adjusted analyses, CPR scores were higher amongst clinical-year students (adjusted B 1.66; 95% CI 1.10 to 2.22) and amongst students in public versus private universities (adjusted B 1.07; 95% CI 0.62 to 1.51).

Conclusions

Syrian medical students demonstrated important gaps in guideline-critical CPR knowledge and variable recognition of MI symptoms. Embedding structured BLS/AED training early in the curriculum, reinforced through simulation and competency-based assessment, may address these deficits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08800-z.

Background

Cardiovascular disease remains a leading cause of premature mortality worldwide and is an increasing public health challenge in Syria [1, 2]. In acute myocardial infarction (MI) and sudden cardiac arrest, survival depends on time-sensitive actions: early symptom recognition, rapid activation of emergency services, high-quality cardiopulmonary resuscitation (CPR), and prompt defibrillation for shockable rhythms [3, 4]. Because medical students are expected to graduate with competence in these core emergency responses, gaps in basic life support and MI symptom recognition represent a direct patient-safety risk, particularly in settings where prehospital care and access to structured resuscitation training may be variable.

Evidence from the region suggests that knowledge deficits are common, but the actionable details are often unclear. Multicentre work from Syria, Iraq and Jordan, and studies from Egypt, have reported low-to-moderate BLS/CPR knowledge and inconsistent confidence in initiating resuscitation [5–7]. However, many surveys emphasise overall scores or attitudes rather than identifying which guideline-critical steps are most frequently missed (e.g., AED timing, reassessment interval, defibrillation parameters), and MI symptom recognition is not always measured alongside resuscitation knowledge in the same cohort. These limitations reduce the ability of educators to translate survey findings into targeted curriculum priorities.

To address these gaps, we conducted a multi-institutional cross-sectional assessment across nine Syrian medical schools, using a guideline-mapped CPR knowledge score and a structured MI symptom knowledge score. By reporting item-level performance for high-stakes steps and modelling independent predictors of knowledge (including training exposure and academic stage), this study provides an actionable ‘gap profile’ that can inform early, competency-based BLS/AED education and reinforcement strategies tailored to Syrian undergraduate curricula.

Methods

Study design and setting

We conducted a multi-institution, cross-sectional online survey of undergraduate medical students in Syria (nine medical schools). Data were collected between 13 and 30 June 2025. This study is reported in accordance with STROBE (cross-sectional).

Participants

Eligible participants were currently enrolled undergraduate medical students. We excluded graduates/non-medical students and incomplete questionnaires. The nine medical schools were purposively sampled with the objective of getting a representative sample of medical students in the country’s medical institutions. Three factors were taken into consideration for the selection of the medical institutions to provide the representative sample: (1) Geographic diversity across major governorates; (2) Institutional diversity, including both public and private universities; and (3) Feasibility of survey distribution through existing academic networks. The survey link was disseminated through official student groups and university communication channels. To minimise duplicate submissions, Google Forms sign-in was required (one response per account); Email collection was disabled; accounts were used only to restrict duplicate entries; no identifiers were exported; and the analysis used fully de-identified data. Participation metrics were high: 92.6% of those who opened the survey link submitted a response (511/552), 90.6% completed the questionnaire (500/552), and 97.8% of submitted surveys were fully completed and eligible for analysis (500/511). (Fig. 4)

Fig. 4.

Duplicate submissions were limited to one response per account sign-in. Email addresses were not collected; data were analysed de-identified

Variables and outcomes

The primary outcomes were (1) CPR knowledge score and (2) myocardial infarction (MI) symptom knowledge score. CPR knowledge was assessed using an 11-item, guideline-mapped subset with unambiguous correct answers (score range 0–11). MI symptom knowledge was assessed using 18 items (score range 0–18). Each item was scored 1 for a correct response, and 0 for incorrect/“not sure”, and item scores were summed. Remaining questionnaire items captured awareness, prior exposure, attitudes, and training preferences, and were analysed descriptively.

Data sources and measurement

The questionnaire was developed by adapting a previously validated instrument (obtained with author’s permission) [5, 8] and aligning knowledge items with 2020 American Heart Association resuscitation guidance [4]. It was translated from English to Arabic and reviewed by bilingual investigators. The instrument was pilot-tested for usability (n = 10) and clarity/length (n = 12); pilot responses were excluded from the main analysis.

Bias

Because recruitment occurred via online dissemination, selection bias is possible (e.g., differential internet access or interest in emergency medicine). Duplicate responses were limited through the one-submission-per-account restriction, and item wording was piloted to reduce misclassification.

Study size

Sample size was estimated using the single population proportion formula (expected prevalence 50%, 95% confidence level, 5% precision), yielding 385 participants. Allowing 10% nonresponse, the target sample was 427.

Statistical analysis

Analyses were conducted using IBM SPSS Statistics (v23). Continuous variables are reported as mean (SD) and categorical variables as n (%). Internal consistency was assessed using Cronbach’s alpha for the CPR knowledge scale (11 items; α = 0.65) and MI knowledge scale (18 items; α = 0.58). Two-sided p < 0.05 was considered statistically significant. There were no missing data in the analytical dataset (n = 500); incomplete submissions were excluded before analysis. No sensitivity analyses were performed.

Group differences in mean knowledge scores were assessed using independent-samples t-tests (Welch’s correction when variances were unequal) and one-way ANOVA with Tukey HSD or Games-Howell post-hoc tests, as appropriate. Associations between categorical variables were examined using Pearson’s chi-square test (or Fisher’s exact test where expected cell counts were small). Multivariable linear regression models were fitted with CPR (0–11) and MI (0–18) scores as outcomes using prespecified covariates; robust (HC3) standard errors were used. To control family-wise error across related comparisons, Holm-Bonferroni adjusted p-values are reported where relevant.

Normality was evaluated primarily using visual inspection of histograms and normal Q-Q plots for the composite outcome scores and, for regression models, standardised residuals. Given the sample size (n = 500), Shapiro-Wilk statistics were interpreted as supportive rather than determinative; distributional plots and summary statistics (skewness/excess kurtosis and Shapiro-Wilk W and p) are provided in Supplementary Figure.1 (Fig. 1 A, B, C, D) and Table 1.

Fig. 1.

A, B, C, D: Histograms and normal Q-Q plots for (A-B) CPR knowledge score (0–11) and (C-D) MI knowledge/awareness score (0–18)

Table 1.

Distributional diagnostics for composite scores

Variable	n	Mean (SD)	Median (IQR)	Min-Max	Skewness	Excess kurtosis	Shapiro-Wilk W	Shapiro-Wilk p
CPR knowledge score (0-11)	500	5.042 (2.495)	5.0 (4.0)	0-11	0.255	-0.653	0.969	7.722e-09
MI knowledge/awareness score (0-18)	500	11.504 (2.671)	12.0 (3.0)	2-17	-0.712	0.792	0.956	4.854e-11

Skewness and excess kurtosis are reported as bias-corrected estimates. Shapiro-Wilk statistics are provided as supportive information and should be interpreted alongside graphical diagnostics, particularly in moderate-to-large samples

Model and test assumptions were evaluated primarily using visual inspection (distributional plots and residual diagnostics) alongside Levene’s test for homogeneity of variances. Effect sizes were reported as Cohen’s d (t-tests), η² (ANOVA), and Cramér’s V (chi-square), interpreted using conventional thresholds.

Overall, this multistep analytical approach enabled the identification of statistically significant associations between CPR/MI knowledge scores and demographic, educational, and experiential variables amongst medical students, whilst also clarifying where differences lacked both statistical and practical significance.

Ethical approval

Ethical approval was obtained from Damascus University, Syria. Ethical approval for this study was obtained from the Research Ethics Committee at Damascus University prior to data collection. Due to administrative delays in the issuance of formal documentation, official verbal authorization to commence data collection was granted by the committee, with written approval issued subsequently on 20 August 2025. Data collection began only after this authorization. Participation was voluntary and anonymous, and completion of the online questionnaire was taken as informed consent. The study involved an anonymous questionnaire and did not collect any sensitive or identifiable personal data.

Results

Participant characteristics

A total of 500 medical students completed the survey (Table 2); 270 (54.0%) were female and 230 (46.0%) were male. Overall, the mean CPR knowledge score was 5.03 ± 2.50 out of 11, and the mean myocardial infarction (MI) symptom knowledge score was 11.50 ± 2.67 out of 18 (Table 2). Because recruitment relied on open online dissemination, a formal response rate could not be calculated.

Table 2.

Participant demographics and descriptive statistics

Variable	Category	n (%) or Mean ± SD
Total Participants		500 (100%)
Gender	Female	270 (54.0%)
	Male	230 (46.0%)
University Type	Public	124 (24.8%)
	Private	376 (75.2%)
Academic Stage	Pre-clinical (Years 1–3)	157 (31.4%)
	Clinical (Years 4–6)	343 (68.6%)
CPR Knowledge Score		5.03 ± 2.50 (out of 11)
MI Symptoms Knowledge Score		11.50 ± 2.67 (out of 18)

SD standard deviation, MI myocardial infarction, CPR cardiopulmonary resuscitation

CPR knowledge

CPR knowledge was operationalized as an objective composite score ranging from 0 to 11, constructed from 11 CPR items with unambiguous correct answers. Each item was scored 1 for a correct response, and 0 for incorrect/“not sure”, and item scores were summed. The remaining CPR questionnaire items captured attitudes, perceived barriers, and training preferences and were analyzed separately [4, 9]. Overall, CPR knowledge was moderate (Table 4), with the clearest gaps concentrated in AED workflow and defibrillation parameters (Table 4). In unadjusted comparisons, CPR scores were higher amongst clinical-year students and those enrolled in public universities, while gender differences were negligible; greater self-reported willingness to intervene in emergencies was associated with higher CPR knowledge (Tables 3 and 4; Figures 2-3).

Table 4.

Association between willingness to act and CPR knowledge

Willingness to Act	Mean CPR Score ± SD	p-value
Avoid situation	3.94 ± 2.10	< 0.001
Uncomfortable	4.80 ± 2.43
Comfortable	5.79 ± 2.57

p-value based on one-way ANOVA

Table 3.

CPR knowledge scores by student characteristics

Variable	Category	Mean ± SD	95% CI	p-value
Gender	Male	5.13 ± 2.62	4.79–5.47	0.468 (Holm p = 0.468)
	Female	4.97 ± 2.39	4.68–5.25
Academic Stage	Pre-clinical (Years 1–3)	3.83 ± 2.24	3.48–4.19	< 0.001 (Holm p < 0.001)
	Clinical (Years 4–6)	5.59 ± 2.41	5.34–5.85
University Type	Public	5.99 ± 2.26	5.59–6.39	< 0.001 (Holm p < 0.001)
	Private	4.73 ± 2.49	4.48–4.98
Clinical Experience	Yes	5.62 ± 2.13	5.23–6.02	0.002 (Holm p = 0.004)
	No	4.87 ± 2.57	4.62–5.13

Mean differences assessed using independent samples t-tests. SD = standard deviation

Fig. 2.

A: Boxplot showing higher median CPR knowledge amongst clinical-year students compared to pre-clinical peers. B: Students who self-reported comfort 'comfortable' had the highest CPR knowledge scores

Fig. 3.

Symptom recognition improved progressively with age, peaking in the 24–25 years group

In multivariable regression, CPR knowledge remained independently higher amongst clinical-year students (adjusted B 1.66 (95% CI 1.10 to 2.22)) and public university students (adjusted B 1.07 (95% CI 0.62 to 1.51)). Prior AED exposure was also associated with higher CPR knowledge (adjusted B 0.63 (95% CI 0.10 to 1.15)). Other covariates (age, gender, clinical work experience, prior cardiac emergency participation, and prior certified CPR course) were not independently associated after adjustment (Tables 5 and 6).

Table 5.

Item-level performance on CPR knowledge items (objective score 0–11) (n = 500)

Item	Correct answer	Correct, n (%)	Knowledge gap	Priority
First step in chain of survival	Ensure scene safety	197 (39.4%)	60.6%	High
Adult chest compression rate	100–120/min	255 (51.0%)	49.0%	Moderate
Single‑rescuer adult compression: ventilation	30:2	237 (47.4%)	52.6%	Moderate
Adult compression depth	≈ 5–6 cm (option: ~5 cm)	298 (59.6%)	40.4%	Moderate
Hand position	Middle/lower half of sternum	356 (71.2%)	28.8%	Lower
Duration before reassessment	2 min	184 (36.8%)	63.2%	High
Awareness of COVID‑19 modified CPR	Aware (Yes/Heard only)	232 (46.4%)	53.6%	Moderate
When to use AED	As soon as available	93 (18.6%)	81.4%	High
Monophasic defibrillator energy	360 J	177 (35.4%)	64.6%	High
Stop CPR after ROSC	Yes	209 (41.8%)	58.2%	Moderate
Indication to start CPR	No breathing and no pulse	279 (55.8%)	44.2%	Moderate

Table 6.

Multivariable linear regression predicting CPR knowledge score (0–11) (n = 500)

Predictor	Comparison	Adjusted B	95% CI	p-value	Std. β*
Age (years)	per 1-year increase	−0.00	−0.12 to 0.12	0.952	−0.00
Gender	Male vs. Female	0.08	−0.35 to 0.50	0.725	0.03
University type	Public vs. Private	1.07	0.62 to 1.51	< 0.001	0.43
Academic stage	Clinical vs. Pre-clinical	1.66	1.10 to 2.22	< 0.001	0.66
Clinical work experience	Yes vs. No	−0.01	−0.51 to 0.50	0.979	−0.00
Prior cardiac emergency participation	Yes vs. No	0.40	−0.07 to 0.87	0.094	0.16
Prior certified CPR course	Yes vs. No	0.39	−0.10 to 0.89	0.121	0.16
Witnessed/used AED	Yes vs. No	0.63	0.10 to 1.15	0.019	0.25
Model fit		R² = 0.174	Adj. R² = 0.161	Overall p < 0.001
Note	Robust (HC3) standard errors. Std. β* = coefficient divided by SD of CPR score (approximate standardization).

In adjusted analyses, CPR knowledge remained higher amongst clinical-year students (adjusted B 1.66; 95% CI 1.10 to 2.22), public university students (adjusted B 1.07; 95% CI 0.62 to 1.51), and students who had witnessed or used an AED (adjusted B 0.63; 95% CI 0.10 to 1.15)

MI symptom knowledge

MI symptom knowledge was lower than ideal (Table 2). In unadjusted analyses, MI knowledge varied by age group (Figure 4) and was higher amongst clinical-year students, with minimal differences by gender (Table 7). The weakest items related to time-critical recognition and early actions in suspected acute coronary syndrome (Table 8).

Table 7.

Myocardial infarction symptom knowledge by demographics

Variable	Category	Mean ± SD	95% CI	p-value
Age Group	< 20	9.89 ± 2.54	9.16 to 10.62	< 0.001 (Holm p < 0.003)
	20–21	11.03 ± 3.04	10.49 to 11.57
	22–23	11.91 ± 2.44	11.56 to 12.25
	24–25	12.00 ± 2.42	11.56 to 12.25
	26+	11.80 ± 2.81	10.83 to 12.76
Gender	Male	11.47 ± 2.72	11.12 to 11.82	0.845 (Holm p = 0.845)
	Female	11.52 ± 2.69	11.20 to 11.85
Academic Stage	Pre-clinical (Year 1–3)	10.12 ± 2.92	9.66 to 10.58	< 0.001 (Holm p < 0.003)
	Clinical (Year 4–6)	12.14 ± 2.34	11.89 to 12.39

Age and stage comparisons used ANOVA and t-tests, respectively

Table 8.

Item-level performance on MI knowledge/awareness items (objective score 0–18) (n = 500)

Item	Correct answer	Correct, n (%)	Knowledge gap	Priority
MI can occur without chest pain	Yes	302 (60.4%)	39.6%	Moderate
Chest pain	Yes	473 (94.6%)	5.4%	Lower
Jaw pain	Yes	304 (60.8%)	39.2%	Moderate
Abdominal pain	No	201 (40.2%)	59.8%	High
Shoulder pain	Yes	402 (80.4%)	19.6%	Lower
Sweating	Yes	455 (91.0%)	9.0%	Lower
Dizziness/nausea	Yes	376 (75.2%)	24.8%	Lower
Shortness of breath	Yes	480 (96.0%)	4.0%	Lower
Skin rash	No	351 (70.2%)	29.8%	Moderate
Max time to benefit from CPR	10 min	78 (15.6%)	84.4%	High
Most common cause of MI	Coronary artery occlusion	408 (81.6%)	18.4%	Lower
MI may present with non-specific symptoms	Yes	403 (80.6%)	19.4%	Lower
Knows difference: MI vs. cardiac arrest	Yes	311 (62.2%)	37.8%	Moderate
Warning signs of MI	All of the above	357 (71.4%)	28.6%	Moderate
MI risk factors	Select all listed	252 (50.4%)	49.6%	Moderate
First action when suspect MI	Call emergency immediately	311 (62.2%)	37.8%	Moderate
Initial treatment for ACS	Aspirin	104 (20.8%)	79.2%	High
Knows “golden hour” term	Yes	182 (36.4%)	63.6%	High

In adjusted analysis, MI knowledge was independently associated with clinical stage (adjusted B 2.06 (95% CI 1.45 to 2.66)), public university enrolment (adjusted B 0.99 (95% CI 0.55 to 1.42)), and prior AED exposure (adjusted B 0.88 (95% CI 0.37 to 1.40)). Age, gender, clinical work experience, prior cardiac emergency participation, and prior certified CPR course were not significant in the adjusted model (Table 9).

Table 9.

Multivariable linear regression predicting MI knowledge/awareness score (0–18) (n = 500)

Predictor	Comparison	Adjusted B	95% CI	p-value	Std. β*
Age (years)	per 1-year increase	−0.05	−0.18 to 0.07	0.402	−0.05
Gender	Male vs. Female	−0.13	−0.59 to 0.33	0.581	−0.02
University type	Public vs. Private	0.99	0.55 to 1.42	< 0.001	0.16
Academic stage	Clinical vs. Pre-clinical	2.06	1.45 to 2.66	< 0.001	0.36
Clinical work experience	Yes vs. No	0.05	−0.49 to 0.59	0.846	0.01
Prior cardiac emergency participation	Yes vs. No	−0.33	−0.81 to 0.14	0.172	−0.06
Prior certified CPR course	Yes vs. No	0.03	−0.49 to 0.54	0.920	0.00
Witnessed/used AED	Yes vs. No	0.88	0.37 to 1.40	< 0.001	0.14
Model fit		R² = 0.164	Adj. R² = 0.149	Overall p < 0.001
Note	Robust (HC3) standard errors. Std. β* = coefficient divided by SD of MI score (approximate standardization).

Age and stage comparisons used ANOVA and t-tests, respectively

Training exposure, readiness, and preferences

Participation in real-life cardiac emergencies increased with greater self-reported clinical training exposure (Table 10). Most students reported willingness to attend future training (approximately 80%), and willingness did not differ meaningfully by prior emergency participation (Table 11). Hands-on practical workshops were the dominant preferred format (approximately 87–92%) with no meaningful differences by academic stage or university type (Table 12). Perceived adequacy of previous CPR training differed modestly by preferred training format (Table 13).

Table 10.

Participation in cardiac emergencies by clinical training level

Clinical Training Level	Participated in Emergency (%)	p-value
No	15.4%	< 0.001(Holm p < 0.004)
To some extent	23.9%
Yes	36.7%

 Chi-square test used to assess association

Table 11.

Willingness to attend future training by experience and knowledge

Group	Category	Willing to Attend (%)	Mean CPR Score ± SD	p-value
Prior Emergency Participation	Yes	81.4%	5.56 ± 2.33	< 0.001
	No	79.4%	4.78 ± 2.55
Willingness to Attend	Yes		5.14 ± 2.50	0.149
	Depends on timing		4.65 ± 2.54
	No		4.27 ± 2.15

Chi-square and ANOVA used respectively

Table 12.

Preferred training format by academic stage and university type

Group	Mode	Proportion (%)	p-value
Academic Stage	Hands-on workshops	Pre-clinical: 86.6%, Clinical: 90.7%	0.120 (Holm p = 0.240)
	Lectures	Pre-clinical: 3.8%, Clinical: 1.2%
	Video/simulation	Pre-clinical: 9.6%, Clinical: 8.2%
University Type	Hands-on workshops	Public: 91.9%, Private: 88.6%	0.455 (Holm p = 0.0455)
	Lectures	Public: 0.8%, Private: 2.4%
	Video/simulation	Public: 7.3%, Private: 9.0%

p-values based on chi-square tests

Table 13.

Perceived CPR training adequacy by preferred mode

Preferred Training Mode	Perceived Adequacy Mean ± SD	p-value
Lectures	1.60 ± 1.35	0.014 (Holm p = 0.042)
Workshops	0.93 ± 0.87
Videos/Simulations	1.19 ± 0.88

One-way ANOVA used to assess differences

Discussion

Using a guideline-mapped CPR composite, we found that CPR knowledge amongst Syrian medical students was suboptimal, with the most pronounced deficits concentrated in AED timing and defibrillation parameters steps that are strongly time-dependent and central to survival in shockable cardiac arrest. MI symptom recognition was moderate overall and improved with training stage, suggesting that clinical exposure may strengthen recognition of classic presentations while leaving less typical symptoms under-recognized. Importantly, the item-level ‘gap profile’ generated by this study provides an evidence-based priority list for curriculum designers, rather than a single global score that is difficult to translate into teaching action.

Our findings align with multicentre evidence from Syria and neighbouring countries showing suboptimal BLS/CPR knowledge amongst medical undergraduates. In a recent survey across Syria, Jordan, and Iraq, Syrian students demonstrated low-to-moderate performance overall, with most respondents classified at an intermediate level of knowledge [5]. Consistent with that pattern, we observed higher CPR knowledge amongst students with greater clinical exposure, suggesting that the training stage contributes to performance gains, although important guideline-critical gaps remain. Prior work also reports higher knowledge amongst students who completed BLS courses, underscoring the need for early, structured, and skills-based training reinforced longitudinally through practice and assessment.

Our results also align closely with another study that evaluated CPR knowledge and attitudes amongst junior doctors and medical students in Upper Egypt [6]. They reported that only 41 % of the medical students were able to identify the correct compression to ventilation ratio, and fewer than half felt confident initiating CPR independently. Similar to our study, students in clinical years demonstrated significantly better knowledge scores than pre clinical peers, suggesting that increasing patient exposure alone leads to incremental, but insufficient gains. It was also found that prior CPR training was independently associated with higher knowledge scores (adjusted OR = 2.3, p < 0.05), reinforcing that structured, skill-based courses remain essential for competency.

Similar results were reported in a cross-sectional study conducted at Al-Qassim University, Saudi Arabia [8]. The study reported that CPR knowledge at the university was limited, and that students lacked hands-on training during their academic years. They also found that students in clinical years had better knowledge and attitudes towards CPR than pre-clinical students.

Moreover, a similar cross-sectional study was conducted at Al-Azhar University, Cairo, to evaluate the awareness of basic life support amongst medical students [7]. Their findings revealed that 72–84% of participants failed basic CPR steps. Their clinical-year students showed better BLS knowledge (p <0.001). Furthermore, only 22% of participants answered correctly about MI symptoms. Our study also found that students were aware of chest pain as a common symptom of MI, but they had lower recognition of less common symptoms, such as nausea and jaw pain.

These studies clearly suggest an important gap in knowledge during the undergraduate stage of medical training, and align with international guidelines in emphasising the importance of hands-on training for CPR/BLS to improve resuscitation outcomes [10].

Cultural attitudes and perceived social/medico-legal risks can meaningfully shape whether students (and later, clinicians) initiate emergency interventions, particularly in public settings. In an international survey across Arab countries, respondents commonly cited reluctance to touch a female victim, fear of being blamed by relatives, and the lack of anatomically female CPR manikins as barriers to providing CPR to women [11]. This aligns with wider evidence from out-of-hospital cardiac arrest research showing sex disparities in bystander CPR, and qualitative work indicating that sexualisation of women’s bodies, fear of causing injury, and misinterpretation of women’s symptoms can reduce intervention rates [12, 13]. Educational infrastructure may unintentionally reinforce these barriers: a scoping review found that CPR training manikins and educational media rarely represent female or racially diverse bodies, and that manikin “sex” can influence comfort and performance during training [14]. In Syria, these cultural factors likely interact with structural constraints in medical education, including gaps in formal first-aid/BLS exposure and limited practical simulation opportunities reported in Syrian and regional student populations [5, 15], a challenge exacerbated by conflict-related disruptions (faculty displacement, reduced training capacity, limited space/funding, and fragmented accreditation/oversight) [16, 17]. Pragmatic approaches with demonstrated feasibility in Syrian settings (such as peer-led BLS training) may help mitigate resource constraints while curricula are redesigned toward competency-based, standardised emergency-skills training supported by robust governance and accreditation mechanisms [18].

From an educational perspective, these findings support a structured approach that introduces BLS/AED concepts early (pre-clinical years), reinforces them through spaced repetition and simulation, and verifies competence through objective assessment (e.g., OSCE stations focused on AED workflow, reassessment timing, and defibrillation safety checks.

Strengths

One of the most important strengths of our study is that it included students from nine different medical universities in Syria, of both pre-clinical and clinical years. This allowed us to compare between different groups based on the institution and academic stage, which allows for deeper analysis and understanding of the results.

Additionally, our study included 500 participants. This large sample size made the results more reliable and allowed better comparison between different groups [19].

Another strength is that this study used a comprehensive questionnaire that assessed both CPR knowledge and awareness of MI symptoms in the same population, which gave us a broader understanding of the students’ knowledge [20].

Limitations

Our study has some limitations that should be considered. Firstly, the data of our study was collected using a self-reported questionnaire, which may result in bias or inaccurate answers [21]. The study questionnaire focused only on the theoretical knowledge of CPR, without any practical assessment, which limited the ability to assess real CPR skills. Future studies should incorporate simulation-based assessment/OSCE-style scenarios.

Second, the online distribution method may have introduced selection bias, as students with greater internet access or interest in emergency medicine may have been more likely to participate. In addition, because the survey link was shared through open channels, we were unable to conduct a formal non-responder analysis.

Furthermore, the number of students from some universities was lower than others, which could have affected the balance of the sample and reduced how well the results represent all medical schools.

Finally, findings should be interpreted in the context of structural constraints affecting medical education in Syria, including variable access to formal resuscitation training and limited opportunities for supervised emergency participation [22].

Conclusion

Syrian medical students demonstrated clinically meaningful gaps in guideline-directed CPR and MI knowledge, with particularly weak performance in high-stakes domains such as AED use and defibrillation parameters. These findings suggest that current training exposure is insufficiently standardised and that knowledge may not translate reliably into first-response readiness during cardiovascular emergencies.

Curriculum improvement should be guided by established redesign models. Using this study as a targeted needs assessment, programmes can apply Kern’s six-step approach to define competency-based outcomes for CPR and MI recognition, select educational strategies (blended learning, structured skills stations, and simulation-based mastery learning with deliberate practice), implement a spiral sequence with low-dose, high-frequency refreshers across academic years, and evaluate impact for continuous improvement. Assessment should align with Miller’s framework by combining knowledge testing (“knows”), simulation/OSCE-based performance (“shows how”), and supervised drills or clinical exposure where feasible (“does”).

Authors’ contributions

A.T. contributed to writing the Results section, performed the statistical analysis, and critically revised the manuscript. M.A. followed up on the writing process, performed the statistical analysis, critically reviewed the final version for both academic and language accuracy, and contributed to the development of the questionnaire. M.A.M. contributed to writing the Methods section and participated in the submission process. B.A. and M.S. wrote the Discussion section and contributed to the development of the questionnaire. S.N. and Y.A. wrote the Introduction and Abstract sections and contributed to the development of the questionnaire. A.H. was responsible for collecting the majority of the sample data. O.T. contributed to the development of the questionnaire. K.K. served as the statistical consultant. F.A.M. reviewed the final manuscript for accuracy and clarity. All authors read and approved the final manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participte

Ethical approval was obtained from Damascus University, Syria (ID number: [MD-200825-503], date [20/8/2025]). All procedures conducted in this study involving human subjects adhered to the ethical criteria set out by the institutional and/or national research committee, as well as the 1964 Helsinki Declaration and its subsequent updates or similar ethical standards. Written informed consent was obtained from all the participants for the participation of this study. A copy of the written consent is available for the Editor-in-Chief of this journal upon request.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

not applicable.