Electrocardiogram Characteristics as Prognostic Indicators in Pulseless Electrical Activity A Systematic Review
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Abstract
Background: The incidence of patients presenting with pulseless electrical activity (PEA) is increasing. Much existing research has focused upon guidance for the termination of resuscitation, rather than to identify indicators of survivability. ECG-based phenotyping of PEA may aid clinicians with prognostication during resuscitation.
Methods: Systematic literature searches for articles containing key words within the MEDLINE, EMBASE, and CINAHL Plus databases were undertaken to identify literature investigating the relationship between ECG characteristics and prognosis in PEA. Risk of bias assessments were performed for each included study.
Findings: Ten studies were identified, containing a total of 9,979 patients. A narrow QRS width was demonstrated to be associated with ROSC in four out of the seven studies investigating this component. An increased QRS amplitude was also associated with ROSC, however, this was only investigated within one study. The relationship between QRS rate and ROSC was variable. Assessing combined ECG components may offer some prognostic insight with the presence of P waves, a QRS rate < 60 and QRS width < 120 ms linked to an increased likelihood of survival. A moderate risk of bias was found within all included studies.
Conclusion: The presence of ECG component changes may assist decision-making with the ongoing resuscitation strategy for patients with PEA. Several studies had missing ECG or patient outcome data therefore were at risk of bias due to incomplete patient inclusion. Further prospective research is needed to evaluate the use of ECG components to identify subgroups of PEA with a high likelihood of survival.
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References
Aufderheide, T. (2007). Etiology, electrophysiology, and myocardial mechanics of pulseless electrical activity. Cardiac arrest: The science and practice of resuscitation medicine (2nd ed.), p. 426. http://ndl.ethernet.edu.et/bitstream/123456789/4168/1/434.pdf#page=461
Bergström, M., Schmidbauer, S., Herlitz, J., Rawshani, A., & Friberg, H. (2018). Pulseless electrical activity is associated with improved survival in out-of-hospital cardiac arrest with initial non-shockable rhythm. Resuscitation, 133, 147–152. https://doi.org/10.1016/j.resuscitation.2018.10.018
Bergum, D., Skjeflo, G. W., Nordseth, T., Mjølstad, O. C., Haugen, B. O., Skogvoll, E., & Loennechen, J. P. (2016). ECG patterns in early pulseless electrical activity—Associations with aetiology and survival of in-hospital cardiac arrest. Resuscitation, 104, 34–39. https://doi.org/10.1016/j.resuscitation.2016.03.029
Bunch, T. J., White, R. D., Friedman, P. A., Kottke, T. E., Wu, L. A., & Packer, D. L. (2004). Trends in treated ventricular fibrillation out-of-hospital cardiac arrest: A 17-year population-based study. Heart Rhythm, 1(3), 255-259. https://doi.org/10.1016/j.hrthm.2004.04.017
Coppola, A., Black, S., & Endacott, R. (2021b). How senior paramedics decide to cease resuscitation in pulseless electrical activity out of hospital cardiac arrest: A mixed methods study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 29, 1–13. https://doi.org/10.1186/s13049-021-00946-7
Coppola, A., Smyth, M., Black, S., Johnston, S., & Endacott, R. (2021a). The regional resuscitation guidelines for pulseless electrical activity in emergency medical services in the United Kingdom: A systematic review. Australasian Journal of Paramedicine, 18. https://doi.org/10.33151/ajp.18.928
Cournoyer, A., Cavayas, Y. A., Albert, M., Segal, E., Lamarche, Y., Potter, B. J., de Montigny, L., Chauny, J. M., Paquet, J., Marquis, M., & Cossette, S. (2022). Association of initial pulseless electrical activity heart rate and clinical outcomes following adult non-traumatic out-of-hospital cardiac arrest. Prehospital Emergency Care, 27(6), 1–8. https://doi.org/10.1080/10903127.2022.2096160
Elhalwagy, O., Singer, B., Grier, G., & Wong, A. (2024). Contextualizing pseudo-pulseless electrical activity in cardiac arrest: A meta-analysis and systematic review. Air Medical Journal, 44(1), 83-92. https://doi.org/10.1016/j.amj.2024.11.010
Gander, B., & Laws, S. (2025). ECG characteristics as indicators of the aetiology of pulseless electrical activity: A systematic review. British Paramedic Journal, 9(4), 27-36. https://doi.org/10.29045/14784726.2025.3.9.4.27
Hauck, M., Studnek, J., Heffner, A. C., & Pearson, D. A. (2015). Cardiac arrest with initial arrest rhythm of pulseless electrical activity: Do rhythm characteristics correlate with outcome? The American Journal of Emergency Medicine, 33(7), 891–894. https://doi.org/10.1016/j.ajem.2015.03.050
Ho, M., Gatien, M., Vaillancourt, C., Whitham, V., & Stiell, I. G. (2016). The utility of ECG characteristics as prognostic markers in pulseless electrical activity arrests: A retrospective observational cohort study. Canadian Journal of Emergency Medicine, 18(S1), S36. https://doi.org/10.1017/cem.2016.55
JBI (n.d.). JBI Critical Appraisal Tools. https://jbi.global/critical-appraisal-tools
Kim, J. H., Ryoo, H. W., Kim, J. Y., Ahn, J. Y., Moon, S., Lee, D. E., Mun, Y. H., & Son, J. W. (2020). QRS complex characteristics and patient outcomes in out-of-hospital pulseless electrical activity cardiac arrest. Emergency Medicine Journal, 38(1), 53–58. http://dx.doi.org/10.1136/emermed-2020-209623
Kim, J. H., Lee, J., Shin, H., Lim, T. H., Jang, B. H., Cho, Y., Kim, W., Choi, K. S., Kim, J. G., Ahn, C., & Lee, H. (2024). Association between QRS characteristics in pulseless electrical activity and survival outcome in cardiac arrest patients: A systematic review and meta-analysis. Prehospital Emergency Care, 29(2), 1–12. https://doi.org/10.1080/10903127.2024.2360139
Nguyen, D., Kritek, P. A., Greco, S. A., & Prutkin, J. M. (2020). Bradycardia at the onset of pulseless electrical activity arrests in hospitalized patients is associated with improved survival to discharge. Heliyon, 6(2), e03491. https://doi.org/10.1016/j.heliyon.2020.e03491
Norvik, A., Unneland, E., Bergum, D., Buckler, D. G., Bhardwaj, A., Eftestøl, T., Aramendi, E., Nordseth, T., Abella, B. S., Kvaløy, J. T., & Skogvoll, E. (2022). Pulseless electrical activity in in-hospital cardiac arrest—A crossroad for decisions. Resuscitation, 176, 117–124. https://doi.org/10.1016/j.resuscitation.2022.04.024
Norvik, A., Kvaløy, J. T., Skjeflo, G. W., Bergum, D., Nordseth, T., Loennechen, J. P., Unneland, E., Buckler, D. G., Bhardwaj, A., Eftestøl, T., & Aramendi, E. (2023). Heart rate and QRS duration as biomarkers predict the immediate outcome from pulseless electrical activity. Resuscitation, 185, 109739. https://doi.org/10.1016/j.resuscitation.2023.109739
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., & Chou, R. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. International Journal of Surgery, 88, 105906. https://doi.org/10.1016/j.ijsu.2021.105906
Rabjohns, J., Quan, T., Boniface, K., & Pourmand, A. (2020). Pseudo-pulseless electrical activity in the emergency department: An evidence-based approach. The American Journal of Emergency Medicine, 38(2), 371–375. https://doi.org/10.1016/j.ajem.2019.158503
Skjeflo, G. W., Nordseth, T., Loennechen, J. P., Bergum, D., & Skogvoll, E. (2018). ECG changes during resuscitation of patients with initial pulseless electrical activity are associated with return of spontaneous circulation. Resuscitation, 127, 31–36. https://doi.org/10.1016/j.resuscitation.2018.03.039
Skjeflo, G. W., Skogvoll, E., Loennechen, J. P., Olasveengen, T. M., Wik, L., & Nordseth, T. (2019). The effect of intravenous adrenaline on electrocardiographic changes during resuscitation in patients with initial pulseless electrical activity in out-of-hospital cardiac arrest. Resuscitation, 136, 119–125. https://doi.org/10.1016/j.resuscitation.2019.01.021
Soar, J., Böttiger, B. W., Carli, P., Couper, K., Deakin, C. D., Djärv, T., Lott, C., Olasveengen, T., Paal, P., Pellis, T., & Perkins, G. D. (2021). European Resuscitation Council guidelines 2021: Adult advanced life support. Resuscitation, 161, 115–151. https://doi.org/10.1016/j.resuscitation.2021.02.010
Tsou, P. Y., Kurbedin, J., Chen, Y. S., Chou, E. H., Lee, M. T. G., Lee, M. C. H., Ma, M. H. M., Chen, S. C., & Lee, C. C. (2017). Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Resuscitation, 114, 92–99. https://doi.org/10.1016/j.resuscitation.2017.02.021
Unneland, E., Norvik, A., Bergum, D., Buckler, D. G., Bhardwaj, A., Eftestøl, T. C., Aramendi, E., Nordseth, T., Abella, B. S., Kvaløy, J. T., & Skogvoll, E. (2023). Non-shockable rhythms: A parametric model for the immediate probability of return of spontaneous circulation. Resuscitation, 191, 109895. https://doi.org/10.1016/j.resuscitation.2023.109895
Wang, H., Tang, W., Ristagno, G., Li, Y., Sun, S., Wang, T., & Weil, M. H. (2009). The potential mechanisms of reduced incidence of ventricular fibrillation as the presenting rhythm in sudden cardiac arrest. Critical Care Medicine, 37(1), 26-31. https://doi.org/10.1097/CCM.0b013e3181928914
Weiser, C., Poppe, M., Sterz, F., Herkner, H., Clodi, C., Schriefl, C., Warenits, A., Vossen, M., Schwameis, M., Nürnberger, A., & Spiel, A. (2018). Initial electrical frequency predicts survival and neurological outcome in out-of-hospital cardiac arrest patients with pulseless electrical activity. Resuscitation, 125, 34–38. https://doi.org/10.1016/j.resuscitation.2018.01.041
Youngquist, S. T., Kaji, A. H., & Niemann, J. T. (2008). Beta-blocker use and the changing epidemiology of out-of-hospital cardiac arrest rhythms. Resuscitation, 76(3), 376-380. https://doi.org/10.1016/j.resuscitation.2007.08.022