Race and Sex Differences in the Association of Bystander CPR for Cardiac Arrest

Abstract

Background: Bystander cardiopulmonary resuscitation (CPR) is associated with higher survival for out-of-hospital cardiac arrest, but whether its association with survival differs by patients' sex and race and ethnicity is less clear.

Methods: Within a large US registry, we identified 623 342 nontraumatic out-of-hospital cardiac arrests during 2013 to 2022 for this observational cohort study. Using hierarchical logistic regression, we examined whether there was a differential association between bystander CPR and survival outcomes by patients' sex and race and ethnicity, overall and by neighborhood strata.

Results: Mean age was 62.1±17.1 years, and 35.9% were women. Nearly half of patients (49.8%) were non-Hispanic White; 20.6% were non-Hispanic Black; 7.3% were Hispanic; 2.9% were Asian; and 0.4% were Native American. Overall, 58 098 (9.3%) survived to hospital discharge. Although bystander CPR was associated with higher survival in each race and ethnicity group, the association of bystander CPR compared with patients without bystander CPR in each racial and ethnic group was highest in individuals who were White (adjusted odds ratio [OR], 1.33 [95% CI, 1.30-1.37]) and Native American (adjusted OR, 1.40 [95% CI, 1.02-1.90]) and lowest in individuals who were Black (adjusted OR, 1.09 [95% CI, 1.04-1.14]; P_interaction<0.001). The adjusted OR for bystander CPR compared with those without bystander CPR for Hispanic patients was 1.29 (95% CI, 1.20-1.139), for Asian patients, it was 1.27 (95% CI, 1.12-1.42), and for those of unknown race, it was 1.31 (95% CI, 1.25-1.36). Similarly, bystander CPR was associated with higher survival in both sexes, but its association with survival was higher in men (adjusted OR, 1.35 [95% CI, 1.31-1.38]) than women (adjusted OR, 1.15 [95% CI, 1.12-1.19]; P_interaction<0.001). The weaker association of bystander CPR in Black individuals and women was consistent across neighborhood race and ethnicity and income strata. Similar results were observed for the outcome of survival without severe neurological deficits.

Conclusions: Although bystander CPR was associated with higher survival in all patients, its association with survival was weakest for Black individuals and women with out-of-hospital cardiac arrest.

Keywords: cardiopulmonary resuscitation; heart arrest; racial groups; sex; survival.

Figure 1.. Association Between Bystander CPR and Survival Outcomes by the OHCA Person’s Race/Ethnicity and Sex.*

Given the significant interaction, the associations between bystander CPR and survival to discharge (panel A) and favorable neurological survival (panel B) are reported, stratified by patients’ race/ethnicity and sex. Favorable neurological survival was defined as survival to discharge without severe neurological disability. * Models adjusted for EMS agency as random effect and the following as fixed effects: patient age, race/ethnicity, and sex; whether bystander CPR was provided; calendar year of arrest, etiology of arrest; witnessed status of arrest; location of arrest; and initial cardiac arrest rhythm. The adjusted OR compares survival outcome rates between those with and without bystander CPR.

Figure 2.. Interaction between Black vs. White Race, Sex and Bystander CPR on Survival Outcomes for OHCA.

Intersectionality analyses with a 3-way interaction analysis was significant for both survival outcomes, with the association of bystander CPR being the weakest for Black women and strongest for White men.