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

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

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

Time in VF in minutes SCD From VF

First Responders MossessoWeaverWeaver % Survival Survival Rates First responders (AED) vs EMTEMT White P <0.01 P <0.001 P<0.02 NS

AEDs Improve Survival White RD. Ann Emer Med. 96;28: Cobb LA. Circ. 92;85:I Smith SC. Circ. 97;13:

Boston-Survival from SCA USA Today July 30, 2003

Role of the AED in Preventing SCD Las Vegas Casinos Valenzuela TD NEJM 2003

Evidence Based Medicine AEDs ReportDesign% Survival STD Rx AEDP ValueBenefit WhiteOBS4246<.02√ WeaverOBS1838<.001√ SmithOBS2236<.001√ MossencoOBS826<.01√ WeaverOBS2830NSX PageOBS44√ MyerburgRCT1128<0.05√ ValenzuelaOBS44√ CaffreyOBS48√ CapucciRCT2144<.01√ PADRCT15*29*<.04√ HATRCT6.5**6.4**0.77X *# of Survivors**total mortality

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; The Public Access Defibrillation Trial: Main Study Objective

PAD Trial Design High Risk Community Units Call 911 CPR Call 911 CPR AED PAD Investigators The Public Access to Defibrillation Study NEJM 2004; Prospective, randomized, controlled clinical trial Compared two lay volunteer-based OOH-CA response systems

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;

PAD Trial Location of Cardiac Arrest PAD Investigators The Public Access to Defibrillation Study NEJM 2004;

PAD Location of Cardiac ArrestNon-residential 85 % Residential 15% PAD Investigators The Public Access to Defibrillation Study NEJM 2004;

PAD Trial-292 Resuscitation attempts P=0.74 P=0.042 PAD Investigators The Public Access to Defibrillation Study NEJM 2004;

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;

PAD Trial Results 292 resuscitation attempts Survivors: 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;

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;

AEDs Available for Home Use With Rx Estes NAM Circulation 2005

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;

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

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

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 AED Initiatives

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

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