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 three links in the Chain of Survival.
The links in the Chain of Survival are:
- Recognition of cardiac arrest and activation of the emergency response system
- Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions
- Rapid defibrillation
- Advanced resuscitation by Emergency Medical Services and other healthcare providers
- Post-cardiac arrest care
- Recovery (including additional treatment, observation, rehabilitation, and psychological support)
HISTORY
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 2020 version of the Chain of Survival included 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). 2025 guidelines include consolidating the chain of survival into one chain, which highlights the importance of doing compressions and breaths, especially in children and infants. Previously, there were separate chains of survival for adults, infants and children experiencing a cardiac emergency, and for cases of in-hospital and out-of-hospital cardiac arrest (Dezfulian C et al, Circulation, 2025).