Do antiarrhythmic infusions need to be started after Return of Spontaneous Circulation (ROSC)?

From the Guidelines

Antiarrhythmic infusions are not routinely needed after Return of Spontaneous Circulation (ROSC) unless specific arrhythmias persist or recur. The decision to start or continue an antiarrhythmic after ROSC should be based on the presence of ongoing arrhythmias, risk of recurrence, and the patient's overall clinical condition, as there is no evidence to support or refute continued or prophylactic administration of these medications 1. If a patient received an antiarrhythmic medication like amiodarone or lidocaine during cardiac arrest that successfully terminated ventricular fibrillation or pulseless ventricular tachycardia, it is reasonable to continue the medication as an infusion. For amiodarone, a typical maintenance infusion is 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours. For lidocaine, 1-4 mg/min is commonly used. However, these infusions should be tailored to the individual patient based on their specific arrhythmia, hemodynamic status, and underlying cardiac condition. Some key considerations in post-ROSC care include:

• Identifying and treating the underlying cause of the arrest
• Maintaining hemodynamic stability
• Preventing secondary injury
• Evaluating the patient’s 12-lead ECG and cardiac markers after ROSC, as recommended by the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1 It is also important to note that antiarrhythmics carry their own risks, including hypotension, bradycardia, and QT prolongation, so they should not be given prophylactically without a clear indication.

From the FDA Drug Label

Intravenous therapy allows most rapid control of serious arrhythmias, including those following myocardial infarction; it should be carried out in circumstances where close observation and monitoring of the patient are possible, such as in hospital or emergency facilities As soon as the patient's basic cardiac rhythm appears to be stabilized, oral antiarrhythmic maintenance therapy is preferable, if indicated and possible.

The FDA drug label does not directly answer whether antiarrhythmic infusions need to be started after Return of Spontaneous Circulation (ROSC).

From the Research

Antiarrhythmic Infusions After ROSC

• The need to start antiarrhythmic infusions after Return of Spontaneous Circulation (ROSC) is a topic of ongoing debate in the medical community.
• According to a study published in 2025 2, antiarrhythmics (e.g., amiodarone, lidocaine, procainamide) likely do not improve short-term or long-term survival or neurologic outcomes, though guidelines state that amiodarone may be used in those with cardiac arrest and refractory pulseless ventricular tachycardia (pVT)/ventricular fibrillation (VF).
• A systematic review and meta-analysis published in 2018 3 found that there is no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge, or neurological outcomes.
• However, a study published in 2023 4 found that lidocaine therapy was associated with statistically significantly higher rates of ROSC, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone.
• Another study published in 2022 5 found that procainamide had similar prehospital ROSC, ED ROSC, and survival compared to amiodarone and lidocaine.
• A feasibility study published in 2011 6 demonstrated that a post-cardiac arrest care bundle including therapeutic hypothermia and hemodynamic optimization can be implemented in the ED and intensive care unit collaboratively and can achieve similar clinical benefits compared to those observed in previous clinical trials.

Key Findings

• Antiarrhythmic infusions may not be necessary for all patients after ROSC.
• The choice of antiarrhythmic agent may depend on the specific clinical scenario and patient characteristics.
• Further research is needed to determine the optimal use of antiarrhythmic infusions in patients with cardiac arrest.
• A comprehensive approach to post-cardiac arrest care, including therapeutic hypothermia and hemodynamic optimization, may be beneficial in improving patient outcomes.