Chain of Survival

The “Chain of Survival” refers to the chain of events that must occur in rapid succession to maximize the chances of survival from sudden cardiac arrest (SCA). The metaphor is a simple way to educate the public about its vital role in helping SCA victims. It suggests that each link is critical and interdependent, and the Chain of Survival is only as strong as its weakest link. Bystanders can help save lives by addressing the first four links in the Chain of Survival.

The links in the Chain of Survival are:

  1. Recognize SCA: If a person is unresponsive and not breathing normally, call 911.
  2. Call 911: Call 911 to get help. Follow the emergency dispatcher’s instructions.
  3. Start CPR: Start CPR to triple the chance of survival. Push hard and fast in the center of the chest (100-120 pumps/minute).
  4. Use AED: Use an automated external defibrillator (AED) to restart the heart. Follow the step-by-step audio/visual instructions.
  5. EMS response: Transfer care to emergency medical services professionals, who will provide advanced life support.
  6. Hospital care: Hospital professionals will continue integrated post-cardiac arrest care, including mild therapeutic hypothermia.


When the Chain of Survival metaphor was first created and described, it included early recognition, early access, early CPR, early defibrillation and early advanced life support (Newman M, Journal of EMS, 1989, Newman M, Currents in Emergency Cardiac Care, 1990). The concept was later adopted by the American Heart Association (Cummins R, et al., Circulation, 1991) and other health organizations. Subsequently, the Chain of Survival was revisited to emphasize the importance of early recognition and response (Newman M, Bahr R, Journal of EMS, 1998). As post-resuscitation care options expanded to include mild therapeutic hypothermia and other treatments, another link, integrated post-cardiac arrest care, was added to the Chain (Hazinski M, et al, Circulation, 2010). The latest version of the Chain of Survival includes the recovery link, which emphasizes physical, social, and emotional needs of patients and their caregivers after survivors leave the hospital. (Sawyer KN, et al, Circulation, 2020).