Goal‑directed (haemodynamic‑targeted) intra‑arrest CPR versus standard guideline CPR in adult cardiac arrest
Date First Published:
January 21, 2026
Last Updated:
January 21, 2026
Report by:
Karl Cook, Advanced Clinical Practitioner (University Hospitals Group Liverpool - Aintree)
Search checked by:
Richard Evans, Advanced Clinical Practitioner
Three-Part Question:
Do adults with non‑traumatic cardiac arrest receiving goal‑directed intra‑arrest CPR guided by real‑time haemodynamic parameters such as arterial pressure or coronary perfusion pressure have improved ROSC, survival, or neurological outcomes compared with standard guideline‑based CPR?
Clinical Scenario:
A 58‑year‑old man suffers a witnessed out‑of‑hospital cardiac arrest. After initial defibrillation and high‑quality CPR, he is brought to the Emergency Department where an arterial line is rapidly inserted. Despite optimal guideline‑based chest compressions and standard epinephrine intervals, the arterial waveform shows very low diastolic pressures, suggesting inadequate coronary perfusion.
Your team considers titrating CPR to haemodynamic targets—for example SBP ≈ 100 mmHg and/or CPP > 20 mmHg—as described in experimental models.
You question whether goal‑directed intra‑arrest CPR is superior to fixed‑depth CPR.
AHA/ILCOR education material acknowledges that BP‑guided CPR may be reasonable if an arterial line already exists, but provides no numeric recommended targets.
Current ILCOR consensus states there is insufficient human evidence to recommend specific haemodynamic targets during CPR.
Your team considers titrating CPR to haemodynamic targets—for example SBP ≈ 100 mmHg and/or CPP > 20 mmHg—as described in experimental models.
You question whether goal‑directed intra‑arrest CPR is superior to fixed‑depth CPR.
AHA/ILCOR education material acknowledges that BP‑guided CPR may be reasonable if an arterial line already exists, but provides no numeric recommended targets.
Current ILCOR consensus states there is insufficient human evidence to recommend specific haemodynamic targets during CPR.
Search Strategy:
Databases Searched
MEDLINE, EMBASE, Cochrane Library
Websites Searched
AHA, ILCOR, ERC, ACC, BestBETs archive
Search Terms
“goal‑directed CPR”, “hemodynamic‑directed resuscitation”,
“coronary perfusion pressure”, “blood pressure‑targeted CPR”,
“intra‑arrest haemodynamic monitoring”, “diastolic pressure during CPR”
Filters Applied
Randomised trials, porcine models, CPR physiology studies, consensus statements, guideline documents.
MEDLINE, EMBASE, Cochrane Library
Websites Searched
AHA, ILCOR, ERC, ACC, BestBETs archive
Search Terms
“goal‑directed CPR”, “hemodynamic‑directed resuscitation”,
“coronary perfusion pressure”, “blood pressure‑targeted CPR”,
“intra‑arrest haemodynamic monitoring”, “diastolic pressure during CPR”
Filters Applied
Randomised trials, porcine models, CPR physiology studies, consensus statements, guideline documents.
Search Details:
The following key studies were retrieved:
Sutton RM et al., Resuscitation 2013 — CPP‑targeted CPR vs depth‑fixed CPR showed improved survival.
Friess SH et al., Crit Care Med 2013 — CPP‑targeted CPR improved short‑term survival in VF arrest.
Friess SH et al., Resuscitation 2014 — improved cerebral perfusion & brain oxygenation under CPP‑guided CPR.
Sutton RM et al., Am J Respir Crit Care Med 2014 — 24‑hour survival markedly higher with BP‑targeted CPR.
Naim MY et al., Crit Care Med 2016 — BP/CPP‑guided CPR improved survival vs guideline care.
Guideline/consensus sources:
AHA/ILCOR 2024 Consensus: insufficient human evidence for specific haemodynamic CPR targets.
AHA physiologic‑directed CPR guidance: BP‑guided CPR may be used if an arterial line already exists; no target values recommended.
Sutton RM et al., Resuscitation 2013 — CPP‑targeted CPR vs depth‑fixed CPR showed improved survival.
Friess SH et al., Crit Care Med 2013 — CPP‑targeted CPR improved short‑term survival in VF arrest.
Friess SH et al., Resuscitation 2014 — improved cerebral perfusion & brain oxygenation under CPP‑guided CPR.
Sutton RM et al., Am J Respir Crit Care Med 2014 — 24‑hour survival markedly higher with BP‑targeted CPR.
Naim MY et al., Crit Care Med 2016 — BP/CPP‑guided CPR improved survival vs guideline care.
Guideline/consensus sources:
AHA/ILCOR 2024 Consensus: insufficient human evidence for specific haemodynamic CPR targets.
AHA physiologic‑directed CPR guidance: BP‑guided CPR may be used if an arterial line already exists; no target values recommended.
Outcome:
ive randomised porcine experiments (2012–2016) consistently demonstrated improved ROSC and short‑ or medium‑term survival when CPR was titrated to haemodynamic targets (usually SBP ≈100 mmHg and CPP > 20 mmHg) compared with guideline‑based compression depth.
No human RCTs exist.
Consensus statements confirm the evidence gap and stop short of recommending haemodynamic targets, though BP‑guided CPR may be reasonable in already‑monitored ICU/ED arrests.
No human RCTs exist.
Consensus statements confirm the evidence gap and stop short of recommending haemodynamic targets, though BP‑guided CPR may be reasonable in already‑monitored ICU/ED arrests.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Hemodynamic Directed CPR Improves Short‑term Survival from Asphyxia‑Associated Cardiac Arrest. Sutton RM et al. 2013 | Randomised porcine (asphyxia‑VF). Intervention: SBP≈100 mmHg + CPP>20 mmHg vs depth‑targeted (33 or 51 mm) | 45‑min survival higher (6/6 vs 1/7 and 1/6, p=0.002); CPP higher. | Limitations: Preclinical; short‑term. | ||
| Hemodynamic Directed CPR Improves Short‑term Survival from Ventricular Fibrillation Cardiac Arrest Friess SH et al 2013 | Randomised porcine (VF). | 45‑min survival higher (8/8 vs 1/8 and 3/8, p=0.002); CPP higher. [europepmc.org] | |||
| Hemodynamic Directed CPR Improves Cerebral Perfusion Pressure and Brain Tissue Oxygenation Friess SH et al 2014 | Randomised porcine with ICP/PbtO₂ monitoring. | Higher cerebral perfusion pressure and brain oxygen in CPP‑targeted group. | |||
| Patient‑Centric Blood Pressure–Targeted CPR Improves Survival from Cardiac Arrest. Sutton RM et al. 2014 | Randomised porcine (asphyxia‑VF) | 24‑h survival 8/10 vs 0/10, P=0.001; higher CPP despite shallower compressions. | |||
| Blood Pressure– and Coronary Perfusion Pressure–Targeted CPR Improves 24‑Hour Survival from VF Cardiac Arrest Naim MY et al. 2016 | Randomised porcine (VF). | improved 24‑h survival with BP/CPP targeting. |
Author Commentary:
The evidence base—though entirely preclinical—is notably strong and remarkably consistent. Targeting intra‑arrest physiology (SBP, CPP) rather than fixed guideline depth produces superior haemodynamics, improved cerebral perfusion, and significantly higher survival in porcine VF and asphyxia models.
However:
No human RCTs exist.
AHA/ILCOR explicitly state there is insufficient evidence to set BP/CPP targets during real‑world CPR.
AHA education materials note BP‑guided CPR is reasonable only when invasive monitoring is already present.
Arterial waveforms during CPR must be interpreted directly; monitor‑calculated DBP can be misleading.
Thus, goal‑directed CPR remains a promising physiologic strategy, but not yet a guideline standard.
However:
No human RCTs exist.
AHA/ILCOR explicitly state there is insufficient evidence to set BP/CPP targets during real‑world CPR.
AHA education materials note BP‑guided CPR is reasonable only when invasive monitoring is already present.
Arterial waveforms during CPR must be interpreted directly; monitor‑calculated DBP can be misleading.
Thus, goal‑directed CPR remains a promising physiologic strategy, but not yet a guideline standard.
Bottom Line:
Goal‑directed intra‑arrest CPR using haemodynamic targets (typically SBP ≈100 mmHg, CPP > 20 mmHg) improves survival in multiple randomised porcine studies and has a strong physiologic rationale.
In humans, evidence is insufficient to recommend routine use.
Where an arterial line already exists (e.g., ICU arrests), carefully supervised haemodynamic‑guided CPR may be reasonable, provided uninterrupted high‑quality CPR is maintained.
Further clinical studies are required.
In humans, evidence is insufficient to recommend routine use.
Where an arterial line already exists (e.g., ICU arrests), carefully supervised haemodynamic‑guided CPR may be reasonable, provided uninterrupted high‑quality CPR is maintained.
Further clinical studies are required.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Sutton RM et al.. Hemodynamic Directed CPR Improves Short‑term Survival from Asphyxia‑Associated Cardiac Arrest.
- Friess SH et al. Hemodynamic Directed CPR Improves Short‑term Survival from Ventricular Fibrillation Cardiac Arrest
- Friess SH et al. Hemodynamic Directed CPR Improves Cerebral Perfusion Pressure and Brain Tissue Oxygenation
- Sutton RM et al.. Patient‑Centric Blood Pressure–Targeted CPR Improves Survival from Cardiac Arrest.
- Naim MY et al.. Blood Pressure– and Coronary Perfusion Pressure–Targeted CPR Improves 24‑Hour Survival from VF Cardiac Arrest