Surveillance Reports

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Public Health Weekly Report 2022; 15(51): 3007-3020

Published online December 22, 2022

https://doi.org/10.56786/PHWR.2022.15.51.3007

© The Korea Disease Control and Prevention Agency

Incidences of Out-of-hospital Sudden Cardiac Arrest in the Republic of Korea, 2021

Jisu Kim, Jihyun Jeong, Sanghui Kweon*

Division of Injury Prevention and Control, Director General for Health Hazard Response, Korea Disease Control and Prevention Agency (KDCA), Cheongju, Korea

Sanghui Kweon, Tel: +82-43-719-7410, E-mail: knhanes@korea.kr

Received: November 11, 2022; Accepted: November 21, 2022

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Korea Sudden Cardiac Arrest Survey has been conducted annually, which could be support to make and evaluate policy for the prevention and treatment of sudden cardiac arrest. Based on the first aid activity log of 2021, 33,235 cases of out-of-hospital sudden cardiac arrest occurred in the Republic of Korea. The rate of sudden cardiac arrest in men was higher than that in women, and 53.3% of the cases were among individuals aged 70 years and over. There were 7,638 cases in Gyeonggi, which the highest number among cities and provinces, Jeju was the highest region in the rate of sudden cardiac arrest (101.8 persons per 100,000 population). The survival rate in 2021 was 7.3%, similar to 7.5% in 2020, while the rate in 2019 was 8.7%, higher than that in 2020 and 2021. The survival rate of patients with cardiopulmonary resuscitation (CPR) by bystanders was 11.6%, relatively high compared to cases without CPR by bystanders. The rate of patients with CPR by bystanders was 28.8% in 2021, which has been increased annually, and the rate of Seoul was 44.0%, the highest level among cities and provinces. The rate of brain function recovery in 2021 was 4.4%, which was lower than that in 2019, similar to the rate of survival. The rates of survival and brain function recovery should be elevated to the level before the pandemic of the coronavirus disease 2019, and the strategies to control the quality of CPR might be concerned.

Key words Cardiac arrest; Survival rate; Cardiopulmonary resuscitation by bystander; Brain function recovery rate

Key messages

① What is known previously?

Because sudden cardiac arrest cause death of critical damage on brain function in short times, the urgent response is important to survive patients. There is the surveillance system of out-of-hospital cardiac arrest (OHCA) in Korea to evaluate the policy related to emergency medical system.

② What new information is presented?

In the 2021, 33,235 cases of OHCA occurred in the Republic of Korea. The survival rate in 2021 was 7.3%, while the higher rate of 2019. The survival rate of patients with cardiopulmonary resuscitation (CPR) by bystanders was relatively high compared to cases without CPR.

③ What are implications?

The rate of patients with CPR by bystanders has been increased annually, which is affirmative result. The strategies to control the quality of CPR might be concerned, the differences between the survival rates of patients with CPR and without CPR, have been decreased.

In sudden cardiac arrest, the heart’s function to circulate blood suddenly stops, and the body does not function normally, which can result in death if not treated immediately. Nonetheless, a patient can survive a sudden cardiac arrest and recover without sequelae, with integrated and appropriate actions, such as rapid reporting by witnesses, cardiopulmonary resuscitation (CPR), first aid and transport by 119 Emergency Medical Services (EMS), and appropriate treatment at medical institutions. Several countries, including the United States, Japan, and Northern European countries have registered and established data related to cardiac arrest. The Republic of Korea (ROK) has also conducted the survey of out-of-hospital sudden cardiac arrest since 2008; which has role of systems to monitor the status, response process, and survival results of sudden cardiac arrest. The number of patients with sudden cardiac arrest in the ROK has reached 30 thousands per year in the past 10 years, and three-fourth of cases of sudden cardiac arrest are likely to be caused by diseases. Among these, cardiological causes account for approximately 70% of the total number of cases of sudden cardiac arrest [1].

In the survey of out-of-hospital sudden cardiac arrest, patients of sudden cardiac arrest are extracted based on the first aid activity log of 119 EMS. Collected data include information on the occurrence of cardiac arrest, treatment process, survival, recovery upon visiting the first transported and transfered hospital [2]. In addition, some data are prepared from the first aid activity log prepared by 119 EMS to decrease the data of uncertain and non-response. Approximately 90% of patients of out-of-hospital sudden cardiac arrest die during resuscitation, making it challenging to collect data in addition to the limited patient information.

In this article, we introduce the primary results of the recently released statistics of the 2021 Sudden Cardiac Arrest Survey and suggest considerations when using the data. Since sudden cardiac arrest occurs relatively more often in men and older adults and is largely influenced by age, the age should be adjusted statistically to examine the increase or decrease without the effect of the population structure. However, preparation of transportation and establishment of medical systems, distribution of equipment, and education should be considered to reflect the actual scale of the outbreak. This report is based on non-standardized statistics.

1. Survey Participants

This sudden cardiac arrest survey included all patients with sudden cardiac arrest transported by 119 EMS from January to December 2021. Under the contract of a memorandum of understanding with the National Fire Agency regarding cooperation in the survey, first aid activity logs of the 119 EMS are provided annually, through which a list of patients was extracted. Over 30,000 presumed cases of sudden cardiac arrest were extracted from the transport data of the 119 EMS in 2021. The inclusion criteria for the extraction were patients with cardiac or respiratory arrest at presentation or CPR or automatic external defibrillator use at treatment. Patients without cardiac arrest were excluded based on the transported hospital’s medical records. To survey the medical records, the cooperation of those hospitals was required (Table 1). In the 2021 Sudden Cardiac Arrest Survey, 433 of 440 hospitals participated in the survey, resulting in a completion rate of 98.4%, and 194 patients did not complete the investigation, resulting in a completion rate of 99.4%.

Table 1.

Occurrence of sudden cardiac arrest in paramedic transfera) and surveyb)

Year20062007200820092010201120122013
119 Paramedic transferHospitals812757708742757739712661
Persons19,48020,35321,90524,44225,90926,38227,82329,356
Survey of medical recordCompleted hospitals616619634623644585593575
Rate of completion (%)75.981.889.584.085.179.283.387.0
Completed persons16,34818,06020,09122,66724,47924,90226,53128,170
Rate of completion (%)83.988.791.792.794.594.495.496.0
Year20062007200820092010201120122013
Year20142015201620172018201920202021
119 Paramedic transferHospitals644590556536492476454440
Persons30,30930,77129,83229,26230,53930,78231,65233,235
Survey of medical recordCompleted hospitals566547505514477458446433
Rate of completion (%)87.992.790.895.997.096.298.298.4
Completed persons29,28229,95928,96328,62930,17930,27931,41733,041
Rate of completion (%)96.697.497.197.898.898.499.399.4

a)Based on the first aid activity log, cases with ‘cardiac arrest’ or ‘respiratory arrest’ as the main symptoms, or with ‘resuscitation’ or ‘use of an automated external defibrillator’ in treatment. b)Among the cases of 119 paramedic transfers of sudden cardiac arrest, cases completed with the survey of medical record in transfered hospitals.



2. Data Collection and Procedures

After identifying the survey participants, the activity logs of the 119 EMS and medical records obtained at hospital visits were used to investigate circumstances at the time of sudden cardiac arrest, details of transports and treatments, and results of treatments. Patient characteristics (gender, age, area of residence, underlying medical conditions, smoking status, alcohol consumption, etc.), circumstances at the time of sudden cardiac arrest (areas and places of occurrence, activities when it occurred, presence/absence of witnesses), emergency treatments (whether or not CPR was performed by the general public), information related to the activities and transportation of the 119 EMS (time of reporting and arrival at the emergency room, details of CPR performed by paramedics, electrocardiograph results, spontaneous circulation, etc.), and hospital treatment information (treatment detail and time, information on discharge from emergency rooms and administration/discharge, information of death, neurological status, etc.) were collected.

The professional survey personnel conducting the survey comprised eight people, including employees from the Korea Disease Control and Prevention Agency (KDCA)’s Capital Regional Center for Disease Control and Prevention and Chungcheong Regional Center for Disease Control and Prevention and researchers participating in the Establishment of an Emergency Based Sudden Cardiac Arrest Database project. The professional survey personnel first received over 3 weeks of training on guidance and participated in continuous survey performance enhancement programs, such as monthly quality management meetings and professional enhancement training.

The surveys were performed separately in the first and second halves of the year to reduce the gap between the time of sudden cardiac arrest and investigation. Sudden cardiac arrests that occurred in the first half of 2021 were investigated by extracting participants in August 2021, who completed the survey in February 2022. Sudden cardiac arrests that occurred in the second half of 2021 were investigated by extracting participants in February 2022, who completed the survey in August 2022. Quality management was performed while conducting the survey, and errors were corrected monthly using external specialized organizations. After completion of the survey, errors were further checked and supplemented according to the survey guidelines. The results were analyzed and then reviewed by the National Cardiac Arrest Surveillance Advisory Committee.

The outbreak results were calculated based on the 33,235 patients transported by the 119 EMS. After excluding patients without medical records, the data of 33,041 patients with completed medical records were used for the examination of survival, CPR by bystanders, and so on.

In 2021, 119 EMS transported 33,235 patients because of sudden cardiac arrest, with an incidence rate of 64.7 per 100,000 population. Since 2006, when the survey was first introduced, the incidence rate had increased in 2021 by 39.8 per 100,000 people. The participants included 82.4 men and 47.2 women. The annual incidence rate was 1.7–1.9 times higher in men than in women (Figure 1). Per 100,000 people, 513.5 people were over 80 years of age, while 6.9 people were 0–9 years of age (Table 2). A total of 17,704 people were over 70 years of age, accounting for 53.3% of the population. Among all cities and provinces, Gyeonggi (n=7,638) showed the highest prevalence, while Jeju showed the highest incidence rate (101.8 per 100,000 population). Gangwon and Jeonnam also showed relatively high prevalence. Sejong showed the lowest incidence rate, followed by Gwangju and Seoul (Table 3).

Table 2.

Cases of sudden cardiac arrest by gender and age in 2021

Gender‧ageCasesProportion (%)Cases per 100,000 populationa)
Total33,235(100.0)64.7
GenderMen21,077(63.4)82.4
Women12,156(36.6)47.2
Unknown-b)
Age (yr)0–9265(0.8)6.9
10–19390(1.2)8.2
20–29913(2.7)13.6
30–391,206(3.6)17.9
40–492,402(7.2)29.5
50–594,409(13.3)51.6
60–695,946(17.9)86.4
70–797,317(22.0)199.2
80 and over10,387(31.3)513.5
Unknown-

a)Estimated population in 2021, Commissioner of Statistics Korea. b)Not presented under 10 cases.



Table 3.

Cases of sudden cardiac arrest by city and province in 2021

Cities and provincesCasesProportion (%)Cases per 100,000 populationa)
Total33,235(100.0)64.7
Seoulb)4,576(13.8)48.4
Busan2,419(7.3)72.4
Daegu1,254(3.8)52.5
Incheon1,796(5.4)61.5
Gwangju680(2.0)47.3
Daejeon824(2.5)56.8
Ulsan676(2.0)60.1
Sejong161(0.5)44.4
Gyeonggi7,638(23.0)57.0
Gangwon1,466(4.4)95.8
Chungbuk1,395(4.2)87.7
Chungnam1,882(5.7)89.2
Jeonbuk1,509(4.5)84.5
Jeonnam1,649(5.0)90.0
Gyeongbuk2,193(6.6)83.7
Gyeongnam2,434(7.3)73.5
Jeju683(2.1)101.8

a)Estimated population in 2021, Commissioner of Statistics Korea. b)Based on the location of the occurrence.



Of the 33,041 patients with complete medical records, 2,410 (7.3%) had survived in 2021, similar to 7.5% in 2020 but significantly lower than 8.7% in 2019 (Figure 2). Seoul showed the highest survival at 10.1%, followed by Sejong and Incheon, while Ulsan showed the lowest survival (Figure 3). Survival rates were higher when bystander performed CPR than when bystander did not. In 2021, the survival rates were 11.6% and 5.3% among patients with and without CPR by the general public, respectively (Table 4). The CPR rate by the general public was 28.8% in 2021 and had increased continuously since the survey began (Table 5). Seoul showed the highest CPR rate at 44.0%, followed by Sejong, Gyeonggi, and Daegu. Jeonnam showed the lowest CPR rate, with over a 30%p difference from Seoul. CPR rates by the general public increased in 2020 in most regions, except for Gangwon, Jeonnam, Gyeongnam, and Jeju, where they decreased. The brain function recovery rate was 4.4% in 2021, which was under the 5.4% in 2019 (Figure 4).

Table 4.

Survival ratesa) of sudden cardiac arrest according to cardiopulmonary resuscitation by bystandersb) in 2016–2021 (unit: %)

Cardiopulmonary resuscitation by bystanders201620172018201920202021
Total6.98.07.88.06.76.5
Yes15.516.514.315.011.911.6
No4.77.97.46.24.95.3

a)Discharged alive. b)Cardiopulmonary resuscitation performed by a bystander excluding paramedics and medical staff before arriving at the hospital.



Table 5.

The rate of cardiopulmonary resuscitation by bystandersa), by city and province in 2016–2021 (unit: %)

Cities and provinces201620172018201920202021
Total16.821.023.524.726.428.8
Seoulb)29.635.837.038.440.744.0
Busan13.316.517.118.719.720.8
Daegu23.633.434.335.035.135.6
Incheon16.614.717.823.227.231.2
Gwangju8.111.414.612.212.817.2
Daejeon20.823.826.832.728.931.2
Ulsan20.718.715.014.816.820.0
Sejong13.413.722.825.817.840.9
Gyeonggi18.925.328.929.931.836.0
Gangwon16.218.518.322.425.524.2
Chungbuk13.913.120.222.422.332.1
Chungnam12.118.117.617.615.720.1
Jeonbuk9.716.318.418.817.823.8
Jeonnam6.18.912.612.520.510.4
Gyeongbuk8.010.013.616.815.520.7
Gyeongnam11.515.118.115.923.721.1
Jeju17.016.619.619.120.917.7

a)Cardiopulmonary resuscitation performed by a bystander excluding paramedics and medical staff before arriving at the hospital. b)Based on the location of the occurrence.


In sudden cardiac arrest, the heart stops abruptly, and the longer the stop, the lower are the chances of survival and recovery, thereby requiring emergency response. According to the 2022 National Fire Agency Statistics Yearbook, a total of 1.82 million patients were transported, including 310,000 confirmed coronavirus disease (COVID-19) cases [3], of which 30,000 were because of sudden cardiac arrest. The number of patients with sudden cardiac arrest was 33,235 in 2021, which was the highest since 2006, when the sudden Cardiac Arrest survey began. Approximately 53.3% of patients with sudden cardiac arrest were ≥70 years of age, which is expected to continue to increase, considering population aging.

The Sudden Cardiac Arrest Survey investigates medical records by visiting the hospital where patients were initially transported and transferred from emergency room of the first-visit-hospital. As of 2021, 2,410 patients had survived, and the number of patients who died had exceeded 30,000 for the first time since the survey was started. The result is comparable to the cumulative number of patients who died from COVID-19 in the 3 years since the ROK’s first patient with COVID-19 appeared in January 2020 (29,479 cumulative cases as of November 9, 2022). The survival rate was 7.5% in 2020, 7.3% in 2021, and 8.7% in 2019, showing a decrease after the COVID-19 pandemic. Similar to the ROK, the United States and United Kingdom reported decreased survival rates in 2020 compared to 2019 [4,5]. A combination of factors, such as insufficient emergency teams on call, difficulty finding hospitals for transfer, and delayed specialized treatment because of the COVID-19 pandemic, may have contributed to these results.

The rate of CPR by the public has increased, reaching 28.8% in 2021. In the 5th Health Plan, the target for the CPR implementation rate by the public was set at 37% by 2030 [6]. This target is achievable if an increase of approximately 2%p per year is maintained. However, despite the increase in CPR performance rates, the survival rate has not increased, and the regional disparity remains significant, suggesting the requirement for improvements. Although the survival rate when the public performed CPR was higher than when CPR was not performed, the difference between performance and non-performance has been decreasing. If a patient is reported for suspected cardiac arrest to the 119 call centers, the person who reported is encouraged to perform CPR before the paramedics arrive at the scene. CPR performed by untrained people may be less efficient than that performed by trained people. Therefore, opportunities for CPR training should be expanded, and CPR quality should be increased through regular re-training.

Immediately after encountering an unconscious patient, a bystander should be designated to call 119 and perform a series of procedures, such as requesting an automatic external defibrillator, checking for breathing, and chest compressions [7]. However, in some cases, when such a patient is encountered in a real situation, calling 119 can be delayed because of panicking, calling an acquaintance first, or trying to communicate with the patient. According to CPR guidelines, the public should quickly call professional paramedics and minimize the amount of time the heart remains stopped. Regular training, including practical and video training, should be conducted to enable quick implementation of necessary measures when a real case occurs. The KDCA has developed and distributed CPR guidelines and standard training courses. Relevant materials are available from the KDCA’s representative website (http://www.kdca.go.kr) and the National Injury Information Portal (http://www.kdca.go.kr/injury). Also, The Nara Learning Center also provides online education to the general public under the course name “CPR Standard Training Course for the general public,” consisting of short lectures to learn theoretical contents.




Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Data curation: SK. Formal analysis: SK. Writing – original draft: JK, JJ, SK. Writing – review & editing: JK, JJ, SK.

  1. Korea Disease Control and Prevention AgencyNational Fire Agency. 2021 sudden cardiac arrest survey statistics. Cheongju: Korea Disease Control and Prevention Agency; 2022.
  2. Korea Disease Control and Prevention Agency. 2022 sudden cardiac arrest survey manual. Cheongju: Korea Disease Control and Prevention Agency; 2022.
  3. National Fire Agency. 2022 national fire agency statistical yearbook. Sejong: National Fire Agency; 2022.
  4. myCARES.net. CARES Annual Report 2020 [Internet]. myCARES.net; 2020 [[cited 2022 Nov 7].
    Available from: https://mycares.net/
  5. Warwick Clinical Trials Unit. Out-of-hospital Cardiac Arrest Overview [Internet]. Warwick Clinical Trials Unit; 2020 [cited 2022 Nov 7].
    Available from: https://warwick.ac.uk/fac/sci/med/research/ctu/trials/ohcao/
  6. Ministry of Health and Welfare. The 5th national health plan. Sejong: Ministry of Health and Welfare; 2022.
  7. Korea Disease Control and Prevention AgencyKorean Association of Cardiopulmonary Resuscitation. 2020 Korean Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Cheongju: Korea Disease Control and Prevention Agency; 2021.

Surveillance Reports

Public Health Weekly Report 2022; 15(51): 3007-3020

Published online December 22, 2022 https://doi.org/10.56786/PHWR.2022.15.51.3007

Copyright © The Korea Disease Control and Prevention Agency.

Incidences of Out-of-hospital Sudden Cardiac Arrest in the Republic of Korea, 2021

Jisu Kim, Jihyun Jeong, Sanghui Kweon*

Division of Injury Prevention and Control, Director General for Health Hazard Response, Korea Disease Control and Prevention Agency (KDCA), Cheongju, Korea

Correspondence to:Sanghui Kweon, Tel: +82-43-719-7410, E-mail: knhanes@korea.kr

Received: November 11, 2022; Accepted: November 21, 2022

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The Korea Sudden Cardiac Arrest Survey has been conducted annually, which could be support to make and evaluate policy for the prevention and treatment of sudden cardiac arrest. Based on the first aid activity log of 2021, 33,235 cases of out-of-hospital sudden cardiac arrest occurred in the Republic of Korea. The rate of sudden cardiac arrest in men was higher than that in women, and 53.3% of the cases were among individuals aged 70 years and over. There were 7,638 cases in Gyeonggi, which the highest number among cities and provinces, Jeju was the highest region in the rate of sudden cardiac arrest (101.8 persons per 100,000 population). The survival rate in 2021 was 7.3%, similar to 7.5% in 2020, while the rate in 2019 was 8.7%, higher than that in 2020 and 2021. The survival rate of patients with cardiopulmonary resuscitation (CPR) by bystanders was 11.6%, relatively high compared to cases without CPR by bystanders. The rate of patients with CPR by bystanders was 28.8% in 2021, which has been increased annually, and the rate of Seoul was 44.0%, the highest level among cities and provinces. The rate of brain function recovery in 2021 was 4.4%, which was lower than that in 2019, similar to the rate of survival. The rates of survival and brain function recovery should be elevated to the level before the pandemic of the coronavirus disease 2019, and the strategies to control the quality of CPR might be concerned.

Keywords: Cardiac arrest, Survival rate, Cardiopulmonary resuscitation by bystander, Brain function recovery rate

Body

Key messages

① What is known previously?

Because sudden cardiac arrest cause death of critical damage on brain function in short times, the urgent response is important to survive patients. There is the surveillance system of out-of-hospital cardiac arrest (OHCA) in Korea to evaluate the policy related to emergency medical system.

② What new information is presented?

In the 2021, 33,235 cases of OHCA occurred in the Republic of Korea. The survival rate in 2021 was 7.3%, while the higher rate of 2019. The survival rate of patients with cardiopulmonary resuscitation (CPR) by bystanders was relatively high compared to cases without CPR.

③ What are implications?

The rate of patients with CPR by bystanders has been increased annually, which is affirmative result. The strategies to control the quality of CPR might be concerned, the differences between the survival rates of patients with CPR and without CPR, have been decreased.

Introduction

In sudden cardiac arrest, the heart’s function to circulate blood suddenly stops, and the body does not function normally, which can result in death if not treated immediately. Nonetheless, a patient can survive a sudden cardiac arrest and recover without sequelae, with integrated and appropriate actions, such as rapid reporting by witnesses, cardiopulmonary resuscitation (CPR), first aid and transport by 119 Emergency Medical Services (EMS), and appropriate treatment at medical institutions. Several countries, including the United States, Japan, and Northern European countries have registered and established data related to cardiac arrest. The Republic of Korea (ROK) has also conducted the survey of out-of-hospital sudden cardiac arrest since 2008; which has role of systems to monitor the status, response process, and survival results of sudden cardiac arrest. The number of patients with sudden cardiac arrest in the ROK has reached 30 thousands per year in the past 10 years, and three-fourth of cases of sudden cardiac arrest are likely to be caused by diseases. Among these, cardiological causes account for approximately 70% of the total number of cases of sudden cardiac arrest [1].

In the survey of out-of-hospital sudden cardiac arrest, patients of sudden cardiac arrest are extracted based on the first aid activity log of 119 EMS. Collected data include information on the occurrence of cardiac arrest, treatment process, survival, recovery upon visiting the first transported and transfered hospital [2]. In addition, some data are prepared from the first aid activity log prepared by 119 EMS to decrease the data of uncertain and non-response. Approximately 90% of patients of out-of-hospital sudden cardiac arrest die during resuscitation, making it challenging to collect data in addition to the limited patient information.

In this article, we introduce the primary results of the recently released statistics of the 2021 Sudden Cardiac Arrest Survey and suggest considerations when using the data. Since sudden cardiac arrest occurs relatively more often in men and older adults and is largely influenced by age, the age should be adjusted statistically to examine the increase or decrease without the effect of the population structure. However, preparation of transportation and establishment of medical systems, distribution of equipment, and education should be considered to reflect the actual scale of the outbreak. This report is based on non-standardized statistics.

Methods

1. Survey Participants

This sudden cardiac arrest survey included all patients with sudden cardiac arrest transported by 119 EMS from January to December 2021. Under the contract of a memorandum of understanding with the National Fire Agency regarding cooperation in the survey, first aid activity logs of the 119 EMS are provided annually, through which a list of patients was extracted. Over 30,000 presumed cases of sudden cardiac arrest were extracted from the transport data of the 119 EMS in 2021. The inclusion criteria for the extraction were patients with cardiac or respiratory arrest at presentation or CPR or automatic external defibrillator use at treatment. Patients without cardiac arrest were excluded based on the transported hospital’s medical records. To survey the medical records, the cooperation of those hospitals was required (Table 1). In the 2021 Sudden Cardiac Arrest Survey, 433 of 440 hospitals participated in the survey, resulting in a completion rate of 98.4%, and 194 patients did not complete the investigation, resulting in a completion rate of 99.4%.

Table 1 . Occurrence of sudden cardiac arrest in paramedic transfera) and surveyb).

Year20062007200820092010201120122013
119 Paramedic transferHospitals812757708742757739712661
Persons19,48020,35321,90524,44225,90926,38227,82329,356
Survey of medical recordCompleted hospitals616619634623644585593575
Rate of completion (%)75.981.889.584.085.179.283.387.0
Completed persons16,34818,06020,09122,66724,47924,90226,53128,170
Rate of completion (%)83.988.791.792.794.594.495.496.0
Year20062007200820092010201120122013
Year20142015201620172018201920202021
119 Paramedic transferHospitals644590556536492476454440
Persons30,30930,77129,83229,26230,53930,78231,65233,235
Survey of medical recordCompleted hospitals566547505514477458446433
Rate of completion (%)87.992.790.895.997.096.298.298.4
Completed persons29,28229,95928,96328,62930,17930,27931,41733,041
Rate of completion (%)96.697.497.197.898.898.499.399.4

a)Based on the first aid activity log, cases with ‘cardiac arrest’ or ‘respiratory arrest’ as the main symptoms, or with ‘resuscitation’ or ‘use of an automated external defibrillator’ in treatment. b)Among the cases of 119 paramedic transfers of sudden cardiac arrest, cases completed with the survey of medical record in transfered hospitals..



2. Data Collection and Procedures

After identifying the survey participants, the activity logs of the 119 EMS and medical records obtained at hospital visits were used to investigate circumstances at the time of sudden cardiac arrest, details of transports and treatments, and results of treatments. Patient characteristics (gender, age, area of residence, underlying medical conditions, smoking status, alcohol consumption, etc.), circumstances at the time of sudden cardiac arrest (areas and places of occurrence, activities when it occurred, presence/absence of witnesses), emergency treatments (whether or not CPR was performed by the general public), information related to the activities and transportation of the 119 EMS (time of reporting and arrival at the emergency room, details of CPR performed by paramedics, electrocardiograph results, spontaneous circulation, etc.), and hospital treatment information (treatment detail and time, information on discharge from emergency rooms and administration/discharge, information of death, neurological status, etc.) were collected.

The professional survey personnel conducting the survey comprised eight people, including employees from the Korea Disease Control and Prevention Agency (KDCA)’s Capital Regional Center for Disease Control and Prevention and Chungcheong Regional Center for Disease Control and Prevention and researchers participating in the Establishment of an Emergency Based Sudden Cardiac Arrest Database project. The professional survey personnel first received over 3 weeks of training on guidance and participated in continuous survey performance enhancement programs, such as monthly quality management meetings and professional enhancement training.

The surveys were performed separately in the first and second halves of the year to reduce the gap between the time of sudden cardiac arrest and investigation. Sudden cardiac arrests that occurred in the first half of 2021 were investigated by extracting participants in August 2021, who completed the survey in February 2022. Sudden cardiac arrests that occurred in the second half of 2021 were investigated by extracting participants in February 2022, who completed the survey in August 2022. Quality management was performed while conducting the survey, and errors were corrected monthly using external specialized organizations. After completion of the survey, errors were further checked and supplemented according to the survey guidelines. The results were analyzed and then reviewed by the National Cardiac Arrest Surveillance Advisory Committee.

The outbreak results were calculated based on the 33,235 patients transported by the 119 EMS. After excluding patients without medical records, the data of 33,041 patients with completed medical records were used for the examination of survival, CPR by bystanders, and so on.

Results

In 2021, 119 EMS transported 33,235 patients because of sudden cardiac arrest, with an incidence rate of 64.7 per 100,000 population. Since 2006, when the survey was first introduced, the incidence rate had increased in 2021 by 39.8 per 100,000 people. The participants included 82.4 men and 47.2 women. The annual incidence rate was 1.7–1.9 times higher in men than in women (Figure 1). Per 100,000 people, 513.5 people were over 80 years of age, while 6.9 people were 0–9 years of age (Table 2). A total of 17,704 people were over 70 years of age, accounting for 53.3% of the population. Among all cities and provinces, Gyeonggi (n=7,638) showed the highest prevalence, while Jeju showed the highest incidence rate (101.8 per 100,000 population). Gangwon and Jeonnam also showed relatively high prevalence. Sejong showed the lowest incidence rate, followed by Gwangju and Seoul (Table 3).

Table 2 . Cases of sudden cardiac arrest by gender and age in 2021.

Gender‧ageCasesProportion (%)Cases per 100,000 populationa)
Total33,235(100.0)64.7
GenderMen21,077(63.4)82.4
Women12,156(36.6)47.2
Unknown-b)
Age (yr)0–9265(0.8)6.9
10–19390(1.2)8.2
20–29913(2.7)13.6
30–391,206(3.6)17.9
40–492,402(7.2)29.5
50–594,409(13.3)51.6
60–695,946(17.9)86.4
70–797,317(22.0)199.2
80 and over10,387(31.3)513.5
Unknown-

a)Estimated population in 2021, Commissioner of Statistics Korea. b)Not presented under 10 cases..



Table 3 . Cases of sudden cardiac arrest by city and province in 2021.

Cities and provincesCasesProportion (%)Cases per 100,000 populationa)
Total33,235(100.0)64.7
Seoulb)4,576(13.8)48.4
Busan2,419(7.3)72.4
Daegu1,254(3.8)52.5
Incheon1,796(5.4)61.5
Gwangju680(2.0)47.3
Daejeon824(2.5)56.8
Ulsan676(2.0)60.1
Sejong161(0.5)44.4
Gyeonggi7,638(23.0)57.0
Gangwon1,466(4.4)95.8
Chungbuk1,395(4.2)87.7
Chungnam1,882(5.7)89.2
Jeonbuk1,509(4.5)84.5
Jeonnam1,649(5.0)90.0
Gyeongbuk2,193(6.6)83.7
Gyeongnam2,434(7.3)73.5
Jeju683(2.1)101.8

a)Estimated population in 2021, Commissioner of Statistics Korea. b)Based on the location of the occurrence..



Of the 33,041 patients with complete medical records, 2,410 (7.3%) had survived in 2021, similar to 7.5% in 2020 but significantly lower than 8.7% in 2019 (Figure 2). Seoul showed the highest survival at 10.1%, followed by Sejong and Incheon, while Ulsan showed the lowest survival (Figure 3). Survival rates were higher when bystander performed CPR than when bystander did not. In 2021, the survival rates were 11.6% and 5.3% among patients with and without CPR by the general public, respectively (Table 4). The CPR rate by the general public was 28.8% in 2021 and had increased continuously since the survey began (Table 5). Seoul showed the highest CPR rate at 44.0%, followed by Sejong, Gyeonggi, and Daegu. Jeonnam showed the lowest CPR rate, with over a 30%p difference from Seoul. CPR rates by the general public increased in 2020 in most regions, except for Gangwon, Jeonnam, Gyeongnam, and Jeju, where they decreased. The brain function recovery rate was 4.4% in 2021, which was under the 5.4% in 2019 (Figure 4).

Table 4 . Survival ratesa) of sudden cardiac arrest according to cardiopulmonary resuscitation by bystandersb) in 2016–2021 (unit: %).

Cardiopulmonary resuscitation by bystanders201620172018201920202021
Total6.98.07.88.06.76.5
Yes15.516.514.315.011.911.6
No4.77.97.46.24.95.3

a)Discharged alive. b)Cardiopulmonary resuscitation performed by a bystander excluding paramedics and medical staff before arriving at the hospital..



Table 5 . The rate of cardiopulmonary resuscitation by bystandersa), by city and province in 2016–2021 (unit: %).

Cities and provinces201620172018201920202021
Total16.821.023.524.726.428.8
Seoulb)29.635.837.038.440.744.0
Busan13.316.517.118.719.720.8
Daegu23.633.434.335.035.135.6
Incheon16.614.717.823.227.231.2
Gwangju8.111.414.612.212.817.2
Daejeon20.823.826.832.728.931.2
Ulsan20.718.715.014.816.820.0
Sejong13.413.722.825.817.840.9
Gyeonggi18.925.328.929.931.836.0
Gangwon16.218.518.322.425.524.2
Chungbuk13.913.120.222.422.332.1
Chungnam12.118.117.617.615.720.1
Jeonbuk9.716.318.418.817.823.8
Jeonnam6.18.912.612.520.510.4
Gyeongbuk8.010.013.616.815.520.7
Gyeongnam11.515.118.115.923.721.1
Jeju17.016.619.619.120.917.7

a)Cardiopulmonary resuscitation performed by a bystander excluding paramedics and medical staff before arriving at the hospital. b)Based on the location of the occurrence..


Conclusion

In sudden cardiac arrest, the heart stops abruptly, and the longer the stop, the lower are the chances of survival and recovery, thereby requiring emergency response. According to the 2022 National Fire Agency Statistics Yearbook, a total of 1.82 million patients were transported, including 310,000 confirmed coronavirus disease (COVID-19) cases [3], of which 30,000 were because of sudden cardiac arrest. The number of patients with sudden cardiac arrest was 33,235 in 2021, which was the highest since 2006, when the sudden Cardiac Arrest survey began. Approximately 53.3% of patients with sudden cardiac arrest were ≥70 years of age, which is expected to continue to increase, considering population aging.

The Sudden Cardiac Arrest Survey investigates medical records by visiting the hospital where patients were initially transported and transferred from emergency room of the first-visit-hospital. As of 2021, 2,410 patients had survived, and the number of patients who died had exceeded 30,000 for the first time since the survey was started. The result is comparable to the cumulative number of patients who died from COVID-19 in the 3 years since the ROK’s first patient with COVID-19 appeared in January 2020 (29,479 cumulative cases as of November 9, 2022). The survival rate was 7.5% in 2020, 7.3% in 2021, and 8.7% in 2019, showing a decrease after the COVID-19 pandemic. Similar to the ROK, the United States and United Kingdom reported decreased survival rates in 2020 compared to 2019 [4,5]. A combination of factors, such as insufficient emergency teams on call, difficulty finding hospitals for transfer, and delayed specialized treatment because of the COVID-19 pandemic, may have contributed to these results.

The rate of CPR by the public has increased, reaching 28.8% in 2021. In the 5th Health Plan, the target for the CPR implementation rate by the public was set at 37% by 2030 [6]. This target is achievable if an increase of approximately 2%p per year is maintained. However, despite the increase in CPR performance rates, the survival rate has not increased, and the regional disparity remains significant, suggesting the requirement for improvements. Although the survival rate when the public performed CPR was higher than when CPR was not performed, the difference between performance and non-performance has been decreasing. If a patient is reported for suspected cardiac arrest to the 119 call centers, the person who reported is encouraged to perform CPR before the paramedics arrive at the scene. CPR performed by untrained people may be less efficient than that performed by trained people. Therefore, opportunities for CPR training should be expanded, and CPR quality should be increased through regular re-training.

Immediately after encountering an unconscious patient, a bystander should be designated to call 119 and perform a series of procedures, such as requesting an automatic external defibrillator, checking for breathing, and chest compressions [7]. However, in some cases, when such a patient is encountered in a real situation, calling 119 can be delayed because of panicking, calling an acquaintance first, or trying to communicate with the patient. According to CPR guidelines, the public should quickly call professional paramedics and minimize the amount of time the heart remains stopped. Regular training, including practical and video training, should be conducted to enable quick implementation of necessary measures when a real case occurs. The KDCA has developed and distributed CPR guidelines and standard training courses. Relevant materials are available from the KDCA’s representative website (http://www.kdca.go.kr) and the National Injury Information Portal (http://www.kdca.go.kr/injury). Also, The Nara Learning Center also provides online education to the general public under the course name “CPR Standard Training Course for the general public,” consisting of short lectures to learn theoretical contents.




Declarations

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Data curation: SK. Formal analysis: SK. Writing – original draft: JK, JJ, SK. Writing – review & editing: JK, JJ, SK.

Fig 1.

Figure 1.Changes in sudden cardiac arrest incidence per 100,000 population
Public Health Weekly Report 2022; 15: 3007-3020https://doi.org/10.56786/PHWR.2022.15.51.3007

Fig 2.

Figure 2.Changes in survival ratea) of sudden cardiac arrest patients
a)Discharged alive.
Public Health Weekly Report 2022; 15: 3007-3020https://doi.org/10.56786/PHWR.2022.15.51.3007

Fig 3.

Figure 3.Survival ratesa) of sudden cardiac arrest by city and provinceb) in 2021
a)Discharged alive. b)Based on the location of the occurrence.
Public Health Weekly Report 2022; 15: 3007-3020https://doi.org/10.56786/PHWR.2022.15.51.3007

Fig 4.

Figure 4.Changes in brain function recovery ratea) of sudden cardiac arrest patients
a)Brain function recovered enough to enable daily life.
Public Health Weekly Report 2022; 15: 3007-3020https://doi.org/10.56786/PHWR.2022.15.51.3007

Table 1 . Occurrence of sudden cardiac arrest in paramedic transfera) and surveyb).

Year20062007200820092010201120122013
119 Paramedic transferHospitals812757708742757739712661
Persons19,48020,35321,90524,44225,90926,38227,82329,356
Survey of medical recordCompleted hospitals616619634623644585593575
Rate of completion (%)75.981.889.584.085.179.283.387.0
Completed persons16,34818,06020,09122,66724,47924,90226,53128,170
Rate of completion (%)83.988.791.792.794.594.495.496.0
Year20062007200820092010201120122013
Year20142015201620172018201920202021
119 Paramedic transferHospitals644590556536492476454440
Persons30,30930,77129,83229,26230,53930,78231,65233,235
Survey of medical recordCompleted hospitals566547505514477458446433
Rate of completion (%)87.992.790.895.997.096.298.298.4
Completed persons29,28229,95928,96328,62930,17930,27931,41733,041
Rate of completion (%)96.697.497.197.898.898.499.399.4

a)Based on the first aid activity log, cases with ‘cardiac arrest’ or ‘respiratory arrest’ as the main symptoms, or with ‘resuscitation’ or ‘use of an automated external defibrillator’ in treatment. b)Among the cases of 119 paramedic transfers of sudden cardiac arrest, cases completed with the survey of medical record in transfered hospitals..


Table 2 . Cases of sudden cardiac arrest by gender and age in 2021.

Gender‧ageCasesProportion (%)Cases per 100,000 populationa)
Total33,235(100.0)64.7
GenderMen21,077(63.4)82.4
Women12,156(36.6)47.2
Unknown-b)
Age (yr)0–9265(0.8)6.9
10–19390(1.2)8.2
20–29913(2.7)13.6
30–391,206(3.6)17.9
40–492,402(7.2)29.5
50–594,409(13.3)51.6
60–695,946(17.9)86.4
70–797,317(22.0)199.2
80 and over10,387(31.3)513.5
Unknown-

a)Estimated population in 2021, Commissioner of Statistics Korea. b)Not presented under 10 cases..


Table 3 . Cases of sudden cardiac arrest by city and province in 2021.

Cities and provincesCasesProportion (%)Cases per 100,000 populationa)
Total33,235(100.0)64.7
Seoulb)4,576(13.8)48.4
Busan2,419(7.3)72.4
Daegu1,254(3.8)52.5
Incheon1,796(5.4)61.5
Gwangju680(2.0)47.3
Daejeon824(2.5)56.8
Ulsan676(2.0)60.1
Sejong161(0.5)44.4
Gyeonggi7,638(23.0)57.0
Gangwon1,466(4.4)95.8
Chungbuk1,395(4.2)87.7
Chungnam1,882(5.7)89.2
Jeonbuk1,509(4.5)84.5
Jeonnam1,649(5.0)90.0
Gyeongbuk2,193(6.6)83.7
Gyeongnam2,434(7.3)73.5
Jeju683(2.1)101.8

a)Estimated population in 2021, Commissioner of Statistics Korea. b)Based on the location of the occurrence..


Table 4 . Survival ratesa) of sudden cardiac arrest according to cardiopulmonary resuscitation by bystandersb) in 2016–2021 (unit: %).

Cardiopulmonary resuscitation by bystanders201620172018201920202021
Total6.98.07.88.06.76.5
Yes15.516.514.315.011.911.6
No4.77.97.46.24.95.3

a)Discharged alive. b)Cardiopulmonary resuscitation performed by a bystander excluding paramedics and medical staff before arriving at the hospital..


Table 5 . The rate of cardiopulmonary resuscitation by bystandersa), by city and province in 2016–2021 (unit: %).

Cities and provinces201620172018201920202021
Total16.821.023.524.726.428.8
Seoulb)29.635.837.038.440.744.0
Busan13.316.517.118.719.720.8
Daegu23.633.434.335.035.135.6
Incheon16.614.717.823.227.231.2
Gwangju8.111.414.612.212.817.2
Daejeon20.823.826.832.728.931.2
Ulsan20.718.715.014.816.820.0
Sejong13.413.722.825.817.840.9
Gyeonggi18.925.328.929.931.836.0
Gangwon16.218.518.322.425.524.2
Chungbuk13.913.120.222.422.332.1
Chungnam12.118.117.617.615.720.1
Jeonbuk9.716.318.418.817.823.8
Jeonnam6.18.912.612.520.510.4
Gyeongbuk8.010.013.616.815.520.7
Gyeongnam11.515.118.115.923.721.1
Jeju17.016.619.619.120.917.7

a)Cardiopulmonary resuscitation performed by a bystander excluding paramedics and medical staff before arriving at the hospital. b)Based on the location of the occurrence..


References

  1. Korea Disease Control and Prevention AgencyNational Fire Agency. 2021 sudden cardiac arrest survey statistics. Cheongju: Korea Disease Control and Prevention Agency; 2022.
  2. Korea Disease Control and Prevention Agency. 2022 sudden cardiac arrest survey manual. Cheongju: Korea Disease Control and Prevention Agency; 2022.
  3. National Fire Agency. 2022 national fire agency statistical yearbook. Sejong: National Fire Agency; 2022.
  4. myCARES.net. CARES Annual Report 2020 [Internet]. myCARES.net; 2020 [[cited 2022 Nov 7]. Available from: https://mycares.net/
  5. Warwick Clinical Trials Unit. Out-of-hospital Cardiac Arrest Overview [Internet]. Warwick Clinical Trials Unit; 2020 [cited 2022 Nov 7]. Available from: https://warwick.ac.uk/fac/sci/med/research/ctu/trials/ohcao/
  6. Ministry of Health and Welfare. The 5th national health plan. Sejong: Ministry of Health and Welfare; 2022.
  7. Korea Disease Control and Prevention AgencyKorean Association of Cardiopulmonary Resuscitation. 2020 Korean Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Cheongju: Korea Disease Control and Prevention Agency; 2021.

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