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Comparative Efficacy and Safety of Intravenous Vasopressors in Pre-Hospital Cardiac Arrest: A Systematic Review and

Eman E Shaban1, Yavuz Yigit2, Ahmed Shaban3

  • 1Department of Cardiology, Al Jufairi Diagnosis and Treatment, MOH, Qatar.

The Journal of Emergency Medicine
|September 17, 2025
PubMed

Insights

Epinephrine improves return of spontaneous circulation (ROSC) and survival to hospital admission (SHA) in out-of-hospital cardiac arrest (OHCA) patients, but may negatively impact neurological outcomes. High-dose epinephrine offers no additional benefit over standard-dose epinephrine for long-term survival or neurological function.

Area of Science:

  • Cardiology
  • Emergency Medicine
  • Pharmacology

Background:

  • The efficacy of vasopressors in out-of-hospital cardiac arrest (OHCA) is not well-established.
  • Vasopressors are frequently administered to OHCA patients despite unclear benefits.

Purpose of the Study:

  • To evaluate the impact of various intravenous (IV) vasopressors on survival and neurological outcomes in OHCA patients.
  • To compare the effectiveness of epinephrine, vasopressin, and their combinations.

Main Methods:

  • A systematic meta-analysis of 30 studies involving 949,511 OHCA patients.
  • Data on return of spontaneous circulation (ROSC), survival to hospital admission (SHA), survival to hospital discharge (SHD), 1-month survival, and neurological outcomes were analyzed.
  • Random-effects modeling and odds ratios (OR) with 95% confidence intervals (CI) were used to determine effect sizes.

Main Results:

  • Intravenous epinephrine significantly increased prehospital ROSC and SHA, but not SHD or 1-month survival.
  • Fewer patients receiving epinephrine achieved favorable neurological outcomes.
  • High-dose epinephrine (HDE) showed improved ROSC and SHA compared to standard-dose epinephrine (SDE), but no difference in SHD or neurological outcomes.
  • Vasopressin demonstrated moderate benefits for SHA over epinephrine; combination therapies offered no additional advantages.

Conclusions:

  • Epinephrine enhances early survival markers (ROSC, SHA) in OHCA but may be associated with poorer neurological outcomes.
  • HDE improves initial resuscitation success over SDE without improving long-term survival or neurological function.
  • Vasopressin provides some benefit for SHA, but combined vasopressor strategies do not yield superior outcomes.
Abstract

Keywords:
epinephrineout-of-hospital cardiac arrest (OHCA)return of spontaneous circulation (ROSC)survival to hospital admission (SHA)vasopressinvasopressors

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