Role of AED’s

1. Role of AED’s Slides courtesy of Mark Estes, MD

2. AED Milestones 2005 PAD Trial 2004 Miami Trial 2003OHare Trial 2002 Casino Trial 2000 American Airlines Trial 1979 AED developed 1977 Implantable cardioverter defibrillator 1967 Portable defibrillators 1960 Bedside defibrillators 1940 Concept Developed

3. Approaches to Treatment of Sudden Cardiac Arrest • Out-of-hospital sudden cardiac arrest (SCA) accounts for over 300,000 deaths annually in the U.S. • In 1991, The American Heart Association (AHA) introduced the 4-step “Chain of Survival” • Early activation of emergency response system • CPR • Early defibrillation • Advanced Life Support Measures • Operation Heartbeat

4. SCD From VF Time in VF in minutes

5. Survival RatesFirst responders (AED) vs EMT P<0.02 First Responders EMT P <0.001 NS P <0.01 % Survival Mossesso Weaver White Weaver

6. AEDs Improve Survival White RD. Ann Emer Med. 96;28:480-485. Cobb LA. Circ. 92;85:I98-102. Smith SC. Circ. 97;13:1321-1324.

7. Boston-Survival from SCA USA Today July 30, 2003

8. Role of the AED in Preventing SCDLas Vegas Casinos Valenzuela TD NEJM 2003

9. Evidence Based Medicine AEDs *# of Survivors **total mortality

10. The Public Access Defibrillation Trial: Main Study Objective • To evaluate whether adding AEDs to a CPR based, community volunteer response system increases survival in victims of out-of-hospital cardiac arrest PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

11. PAD Trial Design Prospective, randomized, controlled clinical trialCompared two lay volunteer-based OOH-CA response systems PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

12. PAD Trial • 993 Community sites selected based on a 50% probability of OOH-CA in 15 months, EMS response < 15 minutes and no existing AED program • 24 US and Canadian cities • 20,000 lay volunteers received standard training • 1600 AEDs placed PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

13. PAD Trial Location of Cardiac Arrest PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

14. PAD Location of Cardiac Arrest Non-residential 85 % Residential 15% PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

15. PAD Trial-292 Resuscitation attempts P=0.042 PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

16. PAD Trial Results • Volunteer rescuers responded twice as frequently at CPR & AED sites (23%) as at CPR sites(11%) alone • No inappropriate shocks • No failure to shock PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

17. PAD Trial Results • 292 resuscitation attemptsSurvivors: 15-CPR 29-CPR &AED (p=0.04) • Use of public access defibrillators doubles survival from cardiac arrest • Results better in public versus residential locations (75% of cardiac arrests are at residential locations) PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

18. PAD Trial Conclusions • Trained laypersons can use AEDs safely to provide early defibrillation • Survival doubles when AEDs are added to CPR trained volunteer response systems • The survival rate in residential facilities is very low PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

19. AEDs Available for Home Use With Rx Estes NAM Circulation 2005

20. PAD Trial-Implications • The PAD Study strengthens the concept that AEDs should be widely available in public locations • Survival was dependent on the presence of the AED, trained lay persons, and the presence of an emergency response plan PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

21. Bethesda 36 Guidelines: AEDs Myerberg R, Estes NAM, Fontaine J, Link, M Zipes Bethesda #36 Conference AEDs, JACC 2005

22. AED-Public Policy, Legislation and Legal Liability • State and Federal Polices • Legal Protection for Owners, Users,Medical Directors • Court Opinions • As evidence-based medicine has defined the clinical benefits of AED use, public policy, laws, funding programs, and court decisions have served the societal interest of promoting use of AEDs by minimizing legal liability. England, H Weinberg P, Estes N JAMA 2006

23. AED Initiatives

24. AED Initiatives • Good Samaritan legislation in all states • Public Access to Defibrillation Programs • AED in Schools-NY, PA, WI, MA • Neigborhood AEDs • AEDs should be available in all schools and public locations where the emergency medical response time for a cardiac arrest is 5 minutes or greater • AEDs should be used in cardiac arrest for all children older than 2 years of age

25. Future research • Home AED Trial (HAT) • Prospective randomized trial of high risk patients post MI • Randomized to AED &CPR Training versus CPR training in high risk post MI patients

26. Role of the AED in Preventing SCA-The US Experience • Evidence based medicine demonstrates decreased time to definitive therapy with defibrillation with AED use • This results in improved survival in victims of SCA • The benefit of AEDs is mainly in non-residential settings • Organizational, institutional, state and federal policies, legislation, a laws serve to promote the widespread use of AED • Further research is need to define optimal strategies for use of AEDs to improve outcomes from SCD