Amiodarone use post Return Of Spontaneous Circulation (ROSC)

From the Guidelines

Amiodarone use post Return Of Spontaneous Circulation (ROSC) is not recommended as there is currently insufficient evidence to support its routine use in this context 1.

Key Points

• The confidence in effect estimates is currently too low to support an ALS Task Force recommendation about the use of prophylactic antiarrhythmic drugs immediately after ROSC in adults with VF/pVT cardiac arrest 1.
• There is no statistically significant difference in survival between amiodarone and placebo in patients with VF/pVT cardiac arrest refractory after at least 1 shock, although survival to hospital admission was higher in patients receiving either amiodarone or lidocaine than in those receiving placebo 1.
• No randomized trials were identified that address the use of amiodarone during in-hospital cardiac arrest or its use after ROSC following cardiac arrest 1.
• The writing group acknowledges that there are circumstances when recurrence of VF/pVT might prove logistically challenging to treat, and in such situations, the use of lidocaine may be considered to prevent recurrence, but there is insufficient evidence to recommend for or against the routine initiation or continuation of other antiarrhythmic medications after ROSC following cardiac arrest 1.

Considerations

• The timing and sequence of amiodarone versus epinephrine administration were not explored in randomized trials 1.
• Early administration of antiarrhythmics during cardiac arrest is supported by studies, as survival decreased with longer times to drug administration 1.
• The use of amiodarone or lidocaine may be considered in specific situations, such as during emergency medical services transport of a resuscitated patient after VF/pVT arrest, to prevent recurrence of VF/pVT 1.

From the FDA Drug Label

Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy. Use amiodarone for acute treatment until the patient's ventricular arrhythmias are stabilized. Most patients will require this therapy for 48 to 96 hours, but amiodarone may be safely administered for longer periods if necessary.

The use of amiodarone post Return Of Spontaneous Circulation (ROSC) is indicated for the treatment and prophylaxis of ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT). The duration of therapy is typically 48 to 96 hours, but may be extended if necessary 2.

• Key points:
  • Indication: Treatment and prophylaxis of VF and VT
  • Duration: 48 to 96 hours, but may be extended
  • Administration: IV infusion, with close monitoring and adjustment of dose as necessary 2

From the Research

Amiodarone Use Post Return Of Spontaneous Circulation (ROSC)

• The use of amiodarone after ROSC has been studied in various contexts, including out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) 3, 4, 5, 6, 7.
• A study published in Resuscitation plus in 2023 found that amiodarone administration within 28 minutes of the emergency call was associated with a higher likelihood of ROSC and event survival in patients with shock-refractory VF/pVT 3.
• Another study published in the Journal of the American Heart Association in 2022 found that the probability of ROSC decreased as time to drug administration increased, and that amiodarone administration was associated with a higher likelihood of ROSC compared to placebo 4.
• A retrospective cohort study published in Chest in 2023 found that lidocaine was associated with higher odds of ROSC, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone in patients with in-hospital cardiac arrest from VT/VF 5.
• A study published in Resuscitation plus in 2025 found that early administration of amiodarone or lidocaine, particularly prior to the second defibrillator shock, was associated with an increased odds of survival outcomes in IHCA with shockable rhythms 6.
• The use of undiluted amiodarone in the management of out-of-hospital cardiac arrest has also been studied, with one study published in Acta anaesthesiologica Scandinavica in 2004 finding that it can be administered without unmanageable hemodynamical side-effects 7.

Timing of Amiodarone Administration

• The timing of amiodarone administration has been found to be important, with earlier administration associated with improved survival outcomes 3, 4, 6.
• A study published in Resuscitation plus in 2023 found that amiodarone administration within 23 minutes of the emergency call was associated with a higher likelihood of survival to hospital discharge 3.
• Another study published in the Journal of the American Heart Association in 2022 found that the effect of amiodarone on ROSC declined with longer times to drug administration 4.

Comparison with Lidocaine

• Lidocaine has been compared to amiodarone in several studies, with one study published in Chest in 2023 finding that lidocaine was associated with higher odds of ROSC, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome 5.
• Another study published in Resuscitation plus in 2025 found that early administration of amiodarone or lidocaine was associated with an increased odds of survival outcomes in IHCA with shockable rhythms, but that the effect of lidocaine was not significantly different from that of amiodarone 6.