Does the 2025 acute coronary syndrome guideline discuss the timing of electrocardiogram (ECG) after Return of Spontaneous Circulation (ROSC)?

Timing of ECG After ROSC in the 2025 Acute Coronary Syndrome Guideline

The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes specifically addresses the timing of ECG after ROSC, recommending that a 12-lead ECG should be acquired and interpreted within 10 minutes of first medical contact (FMC) to identify patients with STEMI. 1

ECG Timing Recommendations

The 2025 guideline provides clear direction on ECG timing in post-ROSC patients:

• A 12-lead ECG should be acquired and interpreted within 10 minutes of first medical contact (FMC) to identify patients with STEMI (Class 1, Level of Evidence B-NR) 1
• First medical contact (FMC) is defined as "the time point when the patient is initially assessed by a health care professional who can obtain and interpret the ECG and deliver initial interventions (e.g., defibrillation)" 1
• This recommendation applies to all patients with suspected ACS, including those who have achieved ROSC after cardiac arrest

Post-ROSC ECG Interpretation Considerations

The guideline highlights several important considerations when interpreting post-ROSC ECGs:

• Patients with ST-segment elevation or equivalent findings on the post-ROSC ECG should follow the prescribed STEMI treatment algorithm 1
• For patients with ROSC after cardiac arrest with ST-elevation on ECG, emergency cardiac catheterization laboratory evaluation is recommended 1
• For select comatose patients with ROSC after cardiac arrest of suspected cardiac origin but without ST-elevation on ECG, emergency cardiac catheterization evaluation may still be considered 1

Challenges in Post-ROSC ECG Interpretation

The guideline acknowledges several challenges in interpreting post-ROSC ECGs:

• Post-ROSC ECGs may show signs of ischemia not necessarily of coronary origin 2
• The diagnostic accuracy of post-ROSC ECGs may be affected by peripheral perfusion status, with lower perfusion associated with higher rates of false-positive ECGs for STEMI 2
• The pre-hospital ROSC-ECG has been shown to have suboptimal diagnostic value in predicting STEMI, with a sensitivity of 74% and specificity of 65% 3

Clinical Implications

Based on the 2025 guideline and supporting evidence:

1. All patients with ROSC should receive a 12-lead ECG within 10 minutes of first medical contact
2. ST-segment elevation on post-ROSC ECG should prompt consideration for emergent coronary angiography
3. Clinicians should be aware of potential false positives in post-ROSC ECGs, particularly in patients with poor peripheral perfusion
4. The absence of ST-segment elevation does not rule out acute coronary syndrome as the cause of arrest

Evidence Gaps Identified in the Guideline

The 2025 guideline specifically mentions post-cardiac arrest patients as an area with evidence gaps:

• "Although the data support an invasive approach in patients who have been resuscitated and who have evidence of ST-segment elevation on the postarrest ECG, any potential benefit of coronary angiography may be attenuated in those who are comatose." 1
• Further research is needed to define the role of coronary angiography and revascularization in post-ROSC patient subgroups 1

The guideline emphasizes that rapid ECG acquisition and interpretation after ROSC is essential for appropriate triage and management of these critically ill patients.