Archives of Academic Emergency Medicine. 2021; 9(1): e11 https://doi.org/10.22037/aaem.v9i1.1053 LE T T E R TO ED I TO R Cardiologists’ Knowledge and Perception towards Ameri- can Heart Association Guidelines of Cardiopulmonary Re- suscitation; a Letter to Editor Sajjad Ali1∗, Annam Zahid1, Syed Zahid Jamal2, Samahir Tariq Khan1, Nisha Lohana1, Raahim Ahmed1, Nobia Mehdi2 1. Internal Medicine Department, Ziauddin Medical University, Karachi, Pakistan. 2. National Institute of Cardiovascular Diseases, Karachi, Pakistan. Received: December 2020; Accepted: December 2020; Published online: 2 January 2021 Cite this article as: Ali S, Zahid A, Jamal SZ, Tariq Khan S, Lohana N, Ahmed R, Mehdi N. Cardiologists’ Knowledge and Perception towards American Heart Association Guidelines of Cardiopulmonary Resuscitation; a Letter to Editor. Arch Acad Emerg Med. 2021; 9(1): e11. Dear Editor, Sudden cardiac arrests (SCA) pose massive threats to millions of lives worldwide. Latest statistics report an annual death count of approximately 17.9 million for cardiovascular dis- eases (1). SCA has caused 15% of these deaths (2) and is con- sidered a major threat in both out-of-hospital and in-hospital settings. Early identification and prompt cardiopulmonary resuscitation (CPR) is essential to increase the survival rate of SCA patients from about 50% to 70% (3). To accomplish this increment, it is cardinal for each physician to be versed with the protocols of basic life support (BLS) and advanced cardiac life support (ACLS). Inadequacy with reference to both knowledge and aware- ness of guidelines has been witnessed in various low-income, lower-middle income, and middle-income countries such as Greece, India, and Nigeria (4-6). A study showed a significant lack of knowledge and practical approach regarding emer- gency cardiovascular care (ECC), among junior healthcare professionals (7). Once training has been undertaken, it is indicated that skills may decline in a year, especially if not frequently performed or reviewed (8). Several studies from Pakistan have identified similar knowledge deficits regarding resuscitation guidelines among healthcare professionals (9, 10); however, no such research has been solely aimed at car- diologists. We, surveyed cardiologists’ theoretical knowledge of resuscitation guidelines, with an additional set of ques- tions directed to test presumptive correlational factors, in National Institute of Cardiovascular Diseases (NICVD), Pak- ∗Corresponding Author: Sajjad Ali; Department of Internal Medicine, Ziaud- din Medical University, Karachi, Pakistan. Mobile: + 923362179123, Email: saj- jad110@live.com, ORCID: https://orcid.org/0000-0002-8024-5942. istan. Results showed that out of the 215 studied cardiologists, only 162 (75.3%) cases were certified and had high mean test scores. Surprisingly, the mean percentage of correctly marked theoretical questions was only 50.9 (ranging from 25.0 to 75.0). 212 participants believed that ACLS courses should be taken by students during medical school and 203 thought that annual retraining or refresher training of all healthcare professionals was necessary for having up-to-date knowledge on the AHA guidelines. The length of time prac- ticing in the sub-specialty had a negative correlation with knowledge scores (p = 0.039), as participants with less expe- rience had the highest average score (52.03%). Most respon- dents felt confident in their current knowledge of the AHA guideline displaying an average knowledge score of 50.92%. The results of this study concerning mean knowledge scores of participants regarding AHA-CPR guidelines based on dif- ferent baseline characteristics are illustrated in table 1. Table 2 shows the perception of participants regarding AHA-CPR guidelines’ education and training. Despite proven effectiveness of training courses, physicians may not fully comprehend the significance of recurring courses. The recommendation for refresher training, as pro- posed by previous study findings, is biannual i.e. every 6 months (11). Even though optimal timelines for recom- mended retraining is yet unknown, it is deduced that regular retraining is required to gain proper resuscitation skills. Another contributing element of resuscitation skills was lack of early training and exposure, especially during graduate school. Medical school curriculum is largely based on long- term patient care, possibly overlooking acquaintance with emergency care approaches, rendering them unimportant in the early years. ACLS courses could be included under Con- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem S. Ali and et. al 2 tinued Medical Education (CME), in our opinion. CME being included under CME makes it necessary for practitioners to undergo retraining to maintain licensure among other enti- tlements. Hospitals or medical councils, can subsidize the financial burden of these costly ACLS courses in conjunction with CME. With reference to the disparities in healthcare, pri- marily caused by low national budgets dispensed for health- related causes, cardiologists in Low and Low-middle income countries should be monetarily assisted to gain life-saving skills for both in-hospital and out-of-hospital emergencies. It could be concluded that, theoretical knowledge of CPR guidelines among Pakistani cardiologists remains unsatisfac- tory. Regular refresher and/or retraining courses of ACLS might improve the quality of CPR techniques implemented and hence, downsize the global health burden caused by SCAs. We further believe that BLS and ACLS courses should be integrated into the curriculums at all medical schools in Pakistan. 1. Declarations 1.1. Acknowledgement 1.2. Ethics approval The study has been approved by the ethical review commit- tee of National Institute of Cardiovascular Diseases (NICVD). Reference number #: ERC-31/2020. 1.3. Informed consent Subjects gave informed consent before filling out the ques- tionnaire. 1.4. Authors’ contributions Sajjad Ali: Conceptualization, Supervision, Project adminis- tration, Writing - Original Draft, Data Curation, Formal analy- sis. Annam Zahid: Writing - Original Draft, Writing - Review & Editing, Data Curation, Resources, Investigation. Syed Zahid Jamal: Supervision, Project administration. Samahir Tariq Khan: Writing - Original Draft, Writing - Review & Editing, Investigation. Nisha Lohana: Writing - Original Draft, Data Curation. Raahim Ahmed: Writing - Original Draft, Method- ology. Nobia Mehdi: Validation, Supervision 1.5. Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 1.6. Funding and support The authors received no financial support for the research, authorship, and/or publication of this article. References 1. Organization WH. Cardiovascular diseases (CVDs) 2017 [13 October 2020]. Available from: https://www.who.int/en/news-room/fact- sheets/detail/cardiovascular-diseases-(cvds). 2. Mawani M, Azam I, Kadir MM, Samad Z, Razzak JA. Estimation of the burden of out-of-hospital traumatic cardiac arrest in Karachi, Pakistan, using a cross- sectional capture-recapture analysis. International jour- nal of emergency medicine. 2020;13:1-7. 3. Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, Del Rios M, Cabañas JG, et al. 2019 American Heart Association focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorpo- real cardiopulmonary resuscitation during cardiac ar- rest: an update to the American Heart Association guide- lines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019;140(24):e881-e94. 4. Pantazopoulos I, Aggelina A, Barouxis D, Papapana- giotou P, Troupis G, Kotsiomitis E, et al. Cardiologists’ knowledge of the 2005 American Heart Association re- suscitation guidelines: the Athens study. heart & lung. 2011;40(4):278-84. 5. Chaudhari MS, Panchal NN, Kamat HV, Ganjiwale J. Knowledge of 2015 basic life support (BLS) guidelines among doctors and nursing staff of a rural based tertiary care hospital, in western India: current status and re- quirement. Indian J Anaesth. 2017;4:193-7. 6. Osinaike B, Aderinto D, Oyebamiji E, Dairo M, Diya K. Evaluation of knowledge of doctors in a Nigrian ter- tiary hospital of CPR. Nigerian Medical Practitioner. 2007;52(1):16-8. 7. Skinner DV, Camm A, Miles S. Cardiopulmonary resuscitation skills of preregistration house offi- cers. British medical journal (Clinical research ed). 1985;290(6481):1549. 8. Yang C-W, Yen Z-S, McGowan JE, Chen HC, Chiang W- C, Mancini ME, et al. A systematic review of retention of adult advanced life support knowledge and skills in healthcare providers. Resuscitation. 2012;83(9):1055-60. 9. Ghauri SK, Javaeed A, Shah F. Dismal situation of cardio pulmonary resuscitation knowledge and skills among ju- nior doctors in twin cities of Pakistan. Pakistan Journal of Medical Sciences. 2019;35(5):1295. 10. Zamir Q, Nadeem A, Rizvi AH. Awareness of cardiopul- monary resuscitation in medical-students and doctors in Rawalpindi-Islamabad, Pakistan. JPMA The Journal of the Pakistan Medical Association. 2012;62(12):1361. 11. Berden H, Willems FF, Hendrick J, Pijls N, Knape J. How frequently should basic cardiopulmonary resuscitation training be repeated to maintain adequate skills? BMJ: This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e11 Table 1: Comparison of mean knowledge scores of participants regarding AHA-CPR guidelines based on different baseline characteristics Characteristics Number Score* P Specialty Invasive 87 48.63 ± 11.53 0.033 Non-invasive 128 52.39 ± 10.37 Gender Male 171 50.54 ± 10.80 0.345 Female 44 52.13 ± 11.74 Positions Attending/consultant 49 48.47 ± 11.72 0.105 Resident 166 51.58 ± 10.69 Institution University hospital 92 50.06 ± 11.13 0.215 Educational research hospital 123 51.47 ± 10.88 Years in specialty 0 - 5 175 52.03 ± 10.76 6 - 10 30 45.41 ± 11.12 11 - 20 6 45.83 ± 9.41 0.039* 21 - 30 3 50.00 ± 12.50 > 30 1 50.87 ± 0.00 Updated with AHA guidelines? Yes 208 50.96 ± 11.08 0.438 No 7 48.21 ± 7.83 Attendance in an ACLS course Yes 179 51.46 ± 10.96 0.053 No 36 47.91 ± 10.77 Time from last ACLS course (years) < 1 82 48.85 ± 10.26 1 – 5 123 52.23 ± 11.54 0.095 6 – 10 10 50.62 ± 7.48 ACLS certification? Yes 162 51.81 ± 11.05 0.014* No 53 47.99 ± 10.38 *: Measures are presented as mean ± standard deviation. ACLS: Advanced Cardiac Life Supports; AHA: American Heart Association; CPR: cardiopulmonary resuscitation. British Medical Journal. 1993;306(6892):1576. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem S. Ali and et. al 4 Table 2: Perception of participants regarding AHA-CPR guidelines’ education and training Perception Number (%) Would you recommend medical students to take an ACLS course? Yes 212 (98.6) No 1 (0.5) Maybe 2 (0.9) Do you think healthcare professionals should update their knowledge on AHA guidelines as per the annual update release? Yes 203 (94.4) No 4 (19) Maybe 8 (3.7) Do you think ACLS courses should be re-evaluated frequently? Yes 177 (82.3) No 8 (3.7) Maybe 30 (14.0) Do you think you are confident in saving a life with your AHA guidelines knowledge? Yes 209 (97.2) No 2 (0.9) Maybe 4 (1.9) Is it important for healthcare professionals from all disciplines to attend ACLS courses? Yes 209 (97.2) No 2 (0.9) Maybe 4 (1.9) Data are presented as number and percentage. ACLS: Advanced Cardiac Life Support; AHA: American Heart Association; CPR: cardiopulmonary resuscitation. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Declarations References