Twenty years in the battle against sudden cardiac death: progress, pitfalls, and prospects for the future

Abstract

Sudden cardiac arrest (SCA) is a life-threatening emergency that requires immediate intervention from lay responders. To address this critical need, the national Sudden Cardiac Arrest Foundation (SCAF) was established in 2005 to raise awareness, promote community engagement, and support survivors. The history of cardiopulmonary resuscitation, defibrillation, and public response programs illustrates decades of progress in resuscitation science and has helped lay the groundwork for the creation of SCAF. In addition to serving as a trusted information hub, SCAF leads several key initiatives. The Cardiac Arrest Survivor Alliance™ provides an online community for those affected by cardiac arrest, offering connection, support, and resources. The Call-Push-Shock campaign promotes three lifesaving steps to address out-of-hospital cardiac arrest: call 911, perform CPR, and use an automated external defibrillator (AED). While SCA remains a major cause of death, significant progress has been made in public education and response. Technological innovations such as dispatcher-assisted CPR, the widespread placement of AEDs, and improved EMS and cardiac arrest registries, have all strengthened the chain of survival. Public understanding has also improved, with the media increasingly distinguishing SCA from heart attacks, thanks in part to SCAF’s tireless advocacy. As SCAF marks its 20th anniversary, the organization celebrates two decades of progress and looks ahead with optimism. Its mission remains steadfast: to raise awareness, empower bystanders to act, support survivors, and advance innovations that reduce preventable deaths from sudden cardiac arrest.

Introduction

Sudden cardiac arrest (SCA) is a life-threatening emergency that requires immediate intervention from lay responders. In 2005, the Sudden Cardiac Arrest Foundation (SCAF) was founded to raise awareness, support survivors, and promote community engagement. The history of cardiopulmonary resuscitation, defibrillation, and the public response programs is summarized to contextualize the development of the Sudden Cardiac Arrest Foundation and its role in advancing awareness and education efforts. In addition to serving as a vital information clearinghouse, a centralized source of education and support related to sudden cardiac arrest, one of SCAF’s key programs is the Cardiac Arrest Survivor Alliance™, an online community for those affected by cardiac arrest. Marking its 20th anniversary, SCAF aims to continue working towards its mission of raising awareness and saving lives. By empowering lay responders with the knowledge needed to act in times of need, SCAF is committed to strengthening the chain of survival, supporting survivors, and advancing innovative strategies to reduce preventable deaths from SCA.

History of resuscitation

Although the exact origin of resuscitation is unknown, various interventions attempted to revive unresponsive individuals can be traced back centuries. In one of the first, known as the flagellation method, rescuers would whip the victim with a wet cloth or use their hands to stimulate a response.¹ Another method applied hot ashes or warm water to the body. Next came the Bellow’s Method in 1530.¹ An early scientist discovered that placing a fireplace bellows into the nostril of a patient and pumping it with air allowed oxygen to flow into the lungs, similar to the modern-day method of assisted ventilation. In 1829, the Leroy Method was invented, marking the first time the victim was placed face up.¹ By placing the patient on the ground, the rescuer was able to apply pressure over the abdomen to release air through exhalation. This pressure became known as “chest compression” in 1831 and was termed the “Dalrymple Method”.¹ A cloth was tied around a patient and stretched to compress the lungs, which was believed to force air out of the body. However, it was not until 1891 that Dr. Friedrich Maass reportedly performed the first chest compression in humans using his hands, a pivotal milestone in the treatment of cardiac arrest, which laid the groundwork for future innovation.

Researchers in the mid-20th century began to focus on the physiological mechanisms behind chest compressions. In the 1960s, the laboratories of Peter Safar, MD, James Jude, MD, William Kouwenhoven, MD, and Guy Knickerbocker, PhD, were studying defibrillation for accidental electrocution cases in the workplace and noted arterial pressure changes during chest movement on animal models. These discoveries led to the understanding that manipulating the thorax could cause pressure changes that moved blood within the vascular system, ultimately giving rise to what we now know today as cardiopulmonary resuscitation (CPR).2, 3

Within a few years, a whole industry emerged, primarily supported by the American Heart Association, to train healthcare providers and the general public in essential skills to save lives during SCA. Under the leadership of Asmund S. Laerdal, Peter Safar, MD, and Hans H. Dahll, a new initiative was launched to develop and distribute CPR training manikins throughout the U.S. and beyond.⁴

Building on the momentum of Laerdal, Safar, and Dahll, another pivotal figure advanced cardiac care and championed widespread citizen CPR training. As the leader of the Advanced Coronary Treatment Foundation, James O. Page played a central role in promoting public education and awareness.⁵ Not only was he the founder and editor of the Journal of Emergency Medical Services, but he also published Citizen CPR and the CPR Bluebook, launched national conferences dedicated to Citizen CPR, and delivered countless speeches across the United States.⁵ Page also collaborated with Dahll and Tore Laerdal to create Currents in Emergency Cardiac Care, further solidifying his influence in the field.5, 6 Around the same era, Dr. Frank Pantridge helped extend resuscitation beyond the hospital through the development of the first portable defibrillator and mobile coronary care in Belfast. Recognizing that many deaths after myocardial infarction occurred before patients reached definitive care, his work helped establish early prehospital defibrillation as a practical and lifesaving component of emergency cardiac care.⁷

In addition to the timely performance of quality CPR, early defibrillation was another critical advancement in improving survival from SCA. One of the pioneers in the development of the automated external defibrillator (“AED”) is Marvin A. Wayne, MD. In the early 1970s, Wayne worked with physicians Arch Diack, MD and W. Stanley Welborn, MD and engineer Robert Rullman to create a device similar in size and simplicity to a fire extinguisher, readily accessible by individuals and requiring minimum training.⁸ Known as the Heart-Aid, this device was the precursor to our modern-day AED.⁸ Rhythm monitoring was provided through electrodes attached to an oropharyngeal airway (OPA) and a pad attached to the upper abdomen, allowing heart rhythm monitoring and, when needed, defibrillation.⁷

The original Heart-Aid had two main drawbacks: the need to place a device into someone’s mouth, as well as the lack of manual control over defibrillation. However, modern AEDs have been improved to include hands-free defibrillation and voice-prompted instructions.⁸ Over the years, Heart-Aid has evolved to become safer by implementing a semi-automatic defibrillation method through which the responder would need to push a button to shock the patient. Although the origins of the AED have not been widely recognized, the work of Dr. Wayne and the other inventors of Heart-Aid laid the foundation for public access defibrillation.⁸ Today, this life-saving technology is increasingly available in public locations associated with increased incidence of cardiac arrests, such as airports, gymnasiums, and schools.

Following the technological advancement of the AED, subsequent research showed that, if blood flow can be maintained, sufficient oxygen to potentially sustain life may remain in the vascular system for several minutes following cardiac arrest. This finding underscored the value of immediate chest compressions following SCA. Subsequently, a movement emerged to educate bystanders on “compression-only” CPR, especially as many studies revealed the hesitance among potential resuscitators in performing CPR at all because of the 'mouth-to-mouth' component.⁹ Concerns about disease transmission, which were brought to light during the influenza epidemics and COVID-19 pandemic, further highlighted the need for accessible and user-friendly CPR education.¹⁰

In the early 2000s, research efforts such as the multi-center Resuscitation Outcomes Consortium enhanced the understanding of key resuscitation elements, such as the need to control the rate of compressions (100–120 compressions per minute) and avoid aggressive ventilations. During this period, electronic data acquisition became widely available, allowing scientific pioneers to harness data mining to increase their understanding of SCA. The Cardiac Arrest Registry to Enhance Survival (CARES) emerged through the leadership of Bryan McNally, MD, MPH and colleagues at Emory University and closely affiliated centers.¹¹ CARES consolidated prehospital EMS health records with hospital outcome data to create one of the first nationwide systems to analyze resuscitation efforts.¹⁰ This allowed states and cities to compare their patient outcomes, uncovering disparities that could guide targeted interventions. For example, it has been shown that women may be less likely to receive CPR than men, presumably for fear of exposing the victim’s chest.¹² Additionally, Black and Hispanic individuals were found to be less likely than whites to receive CPR.¹³

The insights gained from CARES not only revealed critical disparities in the care of patients but also fueled innovations aimed at increasing bystander intervention. As public awareness of resuscitation science grew, so did the emphasis on bystander response. Chief Richard Price of the San Ramon Valley California Fire Protection District worked with the College of Informatics at Northern Kentucky University (NKU) to create an app that would inform bystanders during cardiac arrests with instructions for care.¹⁴ Launched in 2010, PulsePoint connects CPR-trained responders to nearby cardiac arrest emergencies in public places. When a 911 call is received, the app alerts users within walking distance, enabling them to initiate CPR before EMS arrives.¹⁴ It also shows the location of the nearest AEDs, improving response times and survival rates. The advancements in clinical knowledge, technology, and public engagement laid the groundwork for a unifying framework that guides the most effective response to SCA.

The chain of survival

Coined by Mary M. Newman, MS, the chain of survival metaphor described the five critical steps needed to improve survival from SCA: early recognition, early access, early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced life support.15, 16 The concept was later adopted and popularized by the American Heart Association and eventually became the industry standard.¹⁷ Newman's publications on the Chain of Survival (1989, 1990) preceded the AHA article (1991). The AHA later stated (in writing) that they would no longer claim to have developed the concept, but rather that they adopted it. Over time, the critical importance of early recognition of the patient in cardiac arrest and the prompt response to deliver CPR gained increased emphasis within the Chain of Survival.¹⁸ As post-resuscitation care options expanded to include therapeutic hypothermia and other treatments, integrated post-cardiac arrest care was added to the chain as another vital link.¹⁹ The most recent version of the Chain of Survival includes a new recovery link, which emphasizes physical, social, and emotional post-resuscitation needs of patients and their caregivers, addressing findings from multiple post-cardiac arrest surveys that show decreased quality of life and increased psychological and social challenges among survivors and caregivers.20, 21 (Image 1).

Image 1.

Chain of survival.¹⁵

Foundation beginnings

The Sudden Cardiac Arrest Foundation (SCAF) was incorporated in December 2005 and launched in January 2006 by colleagues who identified the need for an information clearinghouse on sudden cardiac arrest (SCA) and a platform for people affected by SCA to exchange ideas, information, and inspiration. SCAF’s mission is to raise awareness of SCA and promote initiatives that help save lives through education, research, and community engagement. Its vision is to eliminate preventable death and disability from sudden cardiac arrest and support people affected by SCA.

SCAF evolved from a predecessor program at the University of Pittsburgh Department of Emergency Medicine: The National Center for Early Defibrillation (NCED). NCED was established in 2000 by Paul Paris, MD, Vincent Mosesso, MD, and Mary M. Newman, MS, and generously funded by the Medtronic Foundation under the leadership of Joan Mellor. In addition to developing a robust information website, NCED established a survivor network and hosted national survivor meetings in Washington, D.C. in 2003 and 2004.²² Subsequently, NCED leadership decided to focus on national legislative advocacy and move its headquarters from Pittsburgh, PA, to Washington, DC. The successor organization was called the Sudden Cardiac Arrest Association (SCAA).

Understanding the continuing need for an information clearinghouse on SCA and a platform for people affected by SCA to exchange ideas, information, and inspiration, Newman and colleagues established the 501(c)(3) nonprofit Sudden Cardiac Arrest Foundation. In addition to Newman, the founding members were Robert Gillio, MD, Richard Lazar, Robert A. Niskanen, Edward M. Racht, MD, and Michael R. Sayre, MD. Newman’s colleagues served on the Founding Board of Directors, and she served as Executive Director (Jan 2006–Jan 2025). Initial funding was secured from corporate sponsorships and grants and later expanded to include individual donations.

Board chairs over the years include Michael R. Sayre, MD, Norman S. Abramson, MD, FACEP, FCCM; Bobby Khan, MD, PhD; Katie Koenig, MBA; Henry Jampel, MD, MHS; and Joseph P. Farrell, DPT. Gina Peattie, MPA, currently serves as Executive Director.

In addition to serving as an information clearinghouse through its website, newsletters, and social media platforms, SCAF reaches a broad national and international audience with approximately 160,000 visitors per year. In 2025, website visitors were from the US, China, UK, India, Canada, Australia, Singapore, Philippines, Ireland, and Indonesia. Key SCAF programs today include the Call-Push-Shock program (in collaboration with Parent Heart Watch), the Cardiac Arrest Survival Video Contest (in collaboration with Citizen CPR Foundation), the Cardiac Arrest Survivor Alliance™, H.E.A.R.T. (Heroes Empowering Action, Readiness, and Training) Champion program, the People Saving People Award, and Ready to Respond.

Research insights

SCAF led pivotal research studies to bolster the public perception of cardiac arrest. In 2015, SCAF partnered with strategic research firm StrataVerve to explore public awareness of SCA through an online quantitative survey of 1000 U.S. respondents, a benchmark sample of some 200 respondents from King County, Washington (an area recognized for its high cardiac arrest survival rates), and qualitative interviews among tourists in Orlando, Florida. Ultimately, this study revealed that SCA is not on the public’s “radar,” despite its prevalence as the third leading cause of death.²³ Cancer, diabetes, and heart disease dominated healthcare concerns, with many respondents also failing to distinguish between “heart attack” and cardiac arrest.²² When participants were provided with a definition of an SCA, there was a significant increase in their interest in learning how to perform CPR and use a defibrillator.²³ The lack of understanding, including the fear of causing harm, can contribute to public apathy and/or unwillingness to act, a critical barrier to lay responder intervention during cardiac emergencies.²³

In 2017, a follow-up study was conducted among a representative national sample of 2232 adults and in-depth qualitative interviews were conducted among 20 respondents from 10 states to expand on these findings, which revealed persistent confusion about SCA. As one participant expressed in an in-depth interview, “[heart attack and SCA] all sound the same to me”.²³ However, just as the 2015 study had initially predicted, a well-crafted, accessible definition in this study increased participants’ stated likelihood to act. Written at an 8th-grade reading level, this tested definition is crafted to be easily understood by the general public:

“Sudden Cardiac Arrest (SCA) is a life-threatening emergency that occurs when the heart suddenly stops beating. It strikes people of all ages who may seem to be healthy, even children and teens. When SCA happens, the person collapses and doesn’t respond or breathe normally. They may gasp or shake as if having a seizure. SCA leads to death in minutes if the person does not get help right away. Survival depends on people nearby calling 911, starting CPR, and using an AED (if available) as soon as possible.”²⁴

The likelihood of participants willing to perform CPR rose by 26% after exposure to this clear explanation of SCA, and their willingness to use an AED increased by 38%.²⁴ The inclusion of “sudden” in the definition conveyed urgency, while messaging emphasizing the ability to save a loved one resonated deeply with respondents.²⁴

Using data from 2015 and 2017 studies, as well as the Strategies to Improve Cardiac Arrest Survival report from the National Academy of Medicine, which SCAF co-sponsored, Parent Heart Watch (PHW) and SCAF co-launched Call-Push-Shock (CPS) in 2018.25, 26 Aimed at raising awareness and encouraging swift public action, this national campaign presented three simple steps for individuals to follow during an out-of-hospital cardiac arrest: calling 911, performing CPR, and using an automated external defibrillator (AED). Today, CPS has gained support from over 50 organizations, including the CDC, and has developed an array of educational assets, such as infographics and video toolkits. These resources are available in both English and Spanish language versions, and aim to demystify SCA and equip the public with knowledge needed to save lives.²⁷

In 2023, SCAF launched the Cardiac Arrest Survivor Alliance (CASA) to address and alleviate the hurdles that survivors, co-survivors, and lay rescuers face on the road to recovery after a cardiac arrest.28, 29 The alliance has seen remarkable growth, attracting more than 2000 members from the U.S. and 26 other countries as of September 2025. CASA’s members have not only actively participated in public forums but also have engaged in private conversations, demonstrating a deep sense of connection and support. As a part of CASA, individuals can attend webinars and virtual meetups, fostering direct interaction with experts in the field. As CASA continues to evolve, one vital area for focus is to strengthen survivorship care, particularly in underserved communities. Research conducted among CASA members and other survivors provides valuable insights into the experiences and needs of sudden cardiac arrest survivors and their families. As highlighted in research conducted among CASA members and other survivors, understanding the long-term impacts of sudden cardiac arrest is essential to informing patient-centered care and post-resuscitation support.²⁰ CASA was recently recognized by the European Resuscitation Council as the second largest online community for survivors and their loved ones worldwide, with over 1600 members at the time of the survey.³⁰

The impact of this program is exemplified through the personal reflections and experiences of survivorship from CASA members:

“Thank you for creating this wonderful community for us to all share our stories and make new friends.”

“Finding others who have experienced an SCA has already created a sense of belonging to a unique group of people who have shared the trauma and struggles of survivorship.”

“It makes me feel so less alone to see so many others with similar experiences. Thankful for this community.”

Prospects for the future

For two decades, the Sudden Cardiac Arrest Foundation (SCAF) has led the way in raising public awareness about sudden cardiac arrest through a powerful blend of education, research, and community engagement. These efforts have laid a strong foundation for continued momentum. SCAF’s website serves as an information clearinghouse, with approximately 160,000 users each year across the world. Furthermore, SCAF publishes a robust educational e-newsletter that informs over 11,000 email contacts about relevant SCA news, educational resources, programs, and research developments. Additionally, strong social media engagement continues to provide an avenue to educate a range of audiences, including members of the public, survivors, co-survivors, lay responders, medical professionals, and more.

It is crucial that SCAF continues to build on its current success while exploring innovative ways to enhance awareness and empower future generations with the fundamental knowledge and confidence to act in times of need. Future programs need to help expand the network of prepared responders from hospitals and organizations to families, friends, and communities. This vision is rooted in the belief that cultivating awareness and preparedness will foster lasting confidence and hope in all corners of society.

To achieve this reality, SCAF will focus on four programmatic areas:

• 1.Enhancing bystander confidence: Promoting more widespread CPR and AED training in schools and high-risk public settings to equip more bystanders with the confidence to act in times of need.
• 2.Improving communication and messaging: Using statistics that convey a sense of urgency as well as distinguishing between heart attack and SCA to further emphasize the need to act quickly
• 3.Leveraging community partners: Partnering with EMS, hospitals, and schools to help identify at-risk populations and tailor outreach efforts to meet community needs.
• 4.Exploring innovating technology: Working with medical advisors and industry leaders to explore how emerging tools, such as Artificial Intelligence, could enhance public training or emergency recognition.

SCAF leverages key national awareness campaigns, such as American Heart Month (February), National CPR & AED Awareness Week (first week of June), and National Sudden Cardiac Arrest Awareness Month (October), to amplify its messaging.³¹ These campaigns include educational content that dispels myths and provides facts about SCA. Sharing engaging and interactive content, such as videos and quizzes, will broaden the knowledge of potential responders, presenting clear calls to action. Ultimately, the foundation aims to empower individuals to consider how they can support educational and awareness efforts, as well as emergency preparedness within their homes, neighborhoods, and communities.

In 2025, SCAF launched the H.E.A.R.T. (Heroes Empowering Action, Readiness, and Training) Champion program.³² This program seeks to empower individuals to raise awareness of SCA, promote CPR and AED training, and help build more educated and prepared communities. H.E.A.R.T. Champions will host local events, distribute SCAF resources, help amplify messages of preparedness, and support fundraising efforts to strengthen SCAF’s programming. To support their efforts, SCAF provides Champions with a comprehensive toolkit that includes customizable flyers, talking points, social media templates, event planning guides, and more. Champions also have access to exclusive webinars, campaign opportunities, and one-on-one staff support to help implement outreach efforts locally.

Additionally, in 2025, SCAF hosted Ready to Respond, the inaugural Sudden Cardiac Arrest Training Week, during National Sudden Cardiac Arrest Awareness Month in October.33, 34 During this week, SCAF worked with volunteers, allies and partners to host training sessions in libraries, malls, gyms, and community centers focused on learning about SCA, hands-only CPR, and AED training. Additionally, schools, sports teams, and business organizations hosted private training sessions to empower their members with the knowledge and confidence to act in times of need. In total, there were 97 participating sites, training a total of 8891 people.³³

Conclusion

Sudden cardiac arrest remains one of the leading causes of death in the United States, but significant progress has been made to educate the public on the serious nature of this condition, how to recognize it, opportunities through which nearby responders can give care, and the critical need for immediate intervention. Numerous technological advances have accompanied the public response, including EMS dispatch-assisted CPR instructions prior to EMS arrival, the widespread placement of automated external defibrillators, and enhanced data-driven tracking of outcomes. Notably, the media is gradually shifting from describing sudden cardiac arrest as a heart attack, thanks to SCAF’s tireless outreach and the survival of famous sports figures such as Damar Hamlin and Christian Eriksen. The authors celebrate the remarkable strides made in the last two decades and look ahead with optimism, confident that continued advancements will lead to an even brighter future for those affected by SCA.

Sources of funding

N/A.

Disclosures

None.

CRediT authorship contribution statement

Mary M. Newman: Writing – original draft, Project administration, Methodology, Conceptualization. Gina Peattie: Writing – original draft, Project administration, Conceptualization. Arvind Subramanian: Writing – original draft. Henry Jampel: Writing – review & editing. Joseph Farrell: Writing – review & editing. Raymond L. Fowler: Writing – original draft, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.