Home > Resources > Blog > Chain of Survival

Chain of Survival

Sudden cardiac arrest happens when the heart stops functioning and is one of the leading causes of death in the United States. An electrical malfunction in the heart throws off the heart’s normal rhythm and causes a cardiac arrest. 

Sudden cardiac arrest victims must receive a series of life-saving measures quickly to improve their survival chances. To make the public aware of these life-saving steps, and to stress the importance of each step of a well-orchestrated rescue, health professionals have devised the phrase “cardiac chain of survival.”

What is the Chain of Survival?

The cardiac chain of survival includes a series of steps that bystanders and first responders must take to improve a victim’s survival chances following cardiac arrest. These steps can help keep the victim’s heart artificially beating and blood flowing to their brain until medical professionals can intervene and restore a healthy heart rhythm. 

Chain of Survival Graphic

The chain of survival reinforces the concept that a chain is only as strong as its weakest link. The chances of the victim’s survival decrease if any steps in the chain of survival are missed or done poorly. While all links in the chain are important, recognizing cardiac arrest is essential for beginning CPR, administering defibrillation,and activating more advanced emergency response.

What are the Steps in the Chain of Survival?

Some steps have been added over time. 

Since cardiac arrest usually occurs suddenly, often the first people to help are bystanders with no medical training. Even without medical training, laypeople can help save lives from cardiac arrest (and several studies have shown that children can safely and effectively use AEDs)! In fact, laypeople who witness and respond to a cardiac arrest emergency can make the biggest difference in whether a person survives or not. To help empower people to take action, health professionals and cardiac arrest advocates have simplified the beginning of the chain of survival into Call-Push-Shock. The Call-Push-Shock concept can help bystanders more easily remember the three essential steps to save a life: 

Call-Push-Shock consists of just three steps: 

  1. Call 911
  2. Perform hands-only CPR
  3. Use an AED to shock the heart
Call, Push & Shock Small

Currently, between 70-90% of cardiac arrest victims die before they reach the hospital. However, a cardiac arrest does not have to be lethal if bystanders can take the right steps immediately. 

Everyone should become familiar with the chain of survival, which lays out the steps that bystanders need to take to help a cardiac arrest victim survive. Anyone can take these simple steps and help save a life.

Why is the Chain of Survival Important?

Time is of the essence when a cardiac arrest occurs and a cardiac arrest victim’s chances of survival decrease with every passing minute. Three minutes after the onset of cardiac arrest, a lack of blood flow starts to damage the brain, and 10 minutes after, the chances of survival are low.

Therefore, bystanders have only a few minutes to act to optimize a victim’s chances of survival and recovery. The chain of survival lays out how someone can take immediate action in quick, easy-to-remember steps.

The chain of survival stresses that bystanders do not need any medical training to take these steps. Anyone can initiate the chain of survival and save a life.

Why is Defibrillation Important?

Rapid defibrillation is considered the most important link in the chain of survival. Rapid defibrillation outside of the hospital improves the chances of survival by as much as 30%. 

Rapid defibrillation involves using an automated external defibrillator (AED) to shock the victim’s heart. 

While CPR keeps blood flowing artificially, rapid defibrillation is the only way to restart the heart and reset it back to a healthy rhythm. The chances of the victim’s survival decrease by as much as 10% with every minute that they do not receive rapid defibrillation. 

AEDs are becoming more common in businesses, schools, and even the home as the public becomes more aware of the importance of rapid defibrillation. AEDs come with pre-recorded instructions and are easy to use.  

If an AED is not available, bystanders will need to continue CPR until emergency responders arrive with a defibrillator, which is why it is important to recognize cardiac arrest and call for help quickly. 

History of the Chain of Survival

The American Heart Association introduced the chain of survival in the late 1980s. Emergency response and public health professionals helped publicize the chain of survival throughout the 1980s and 1990s. 

The American Heart Association officially incorporated the chain of survival into its guidelines for cardiac arrest in 1992 and has adjusted it to include additional steps since then. However, the key three steps of calling 911, CPR, and rapid defibrillation have always remained a part of the chain.

Mary Newman on Her Role in Developing the Chain of Survival

Avive Solutions

Read the Podcast Transcript

Avive: (00:03)

Mary Newman has an extensive background in Sudden Cardiac Arrest, research and advocacy.

Mary Newman: (00:09)

My name is Mary Newman and I’m President and CEO of the Sudden Cardiac Arrest Foundation, which is a national non-profit organization that works to raise awareness about Sudden Cardiac Arrest and help save lives. I’ve been in this industry for many years. I began in 1980, working for the Advanced Coronary Treatment Foundation and JEMS, Journal of EMS magazine. And after that, I worked for a while as a consultant to Laerdal Medical, I worked with the Chronic Institute of Cardiology. I was actually recruited to work at the University of Pittsburgh. And during the time I was there, we started a national survivor network and also a national champions network. Subsequently, I started the Sudden Cardiac Arrest Foundation along with several colleagues, continuing with the goal to simply try to raise awareness about cardiac arrest and the fact that it’s a leading cause of death in the U.S., that it’s a crisis and it’s a crisis that can be treated. If more people only knew about the importance of immediate bystander intervention, with CPR and AED.


Avive: (01:22)

During her career, Mary Newman also developed the idea of the chain of survival.


Mary Newman: (01:27)

The chain of survival originated in the late eighties. There is a researcher by the name of Kenneth Stults, and he was advocating for something called “phone first”. At the time, the paradigm for teaching the public what to do in a case of out-of-hospital cardiac arrest was to start CPR and then call 911, who would bring the AED or defibrillator. So we were having lunch talking about this and I said, “Well, why don’t we just call it the chain of survival and try to teach people to first call, then start CPR and then use the defibrillator?” And he said, “That that’s really a great idea! And why don’t you write it up?” So I wrote an article about it that was published in JEMS in 1989. And then I wrote an article that was published in Current and Emergency Cardiac Care on the same topic about the chain of survival. That was published in 1990. Then we eventually talked about adding advanced care. So we had developed the chain that would include call 911, start CPR, use the defibrillator, and then early advanced care was EMS coming in and helping. I also worked with Dr. Raymond Bahr and he and I wrote an article that focused on the importance of early recognition of the event. So we developed a second article related to the chain of survival which included early recognition.


Mary Newman: (03:16)

Very rewarding to see how the chain of survival has taken off over all these years. And that it seems to make a difference as far as educating people about what to do. I have to say that my kids eventually had to learn it in school. And they’re like, “Did you really come up with that?” I’m like, “I did!” So it’s kind of nice on that front too.

Changes to the AHA Chain of Survival Over Time

The American Heart Association has revised the chain of survival since it was first introduced in the 1980s to address medical and technological developments.

For instance, in 2020, the American Heart Association updated its guidelines to add a sixth step, recovery, to the chain of survival. This change stresses the importance of recovery to cardiac arrest survival.

Also, in 2020 the American Heart Association issued a new pediatric chain of survival for infants, children, and adolescents.  

Adult Chain of Survival versus Pediatric Chain of Survival

Pediatric Chain of Survival Graphic

Although the majority of cardiac arrest victims are adults, children and infants suffer from cardiac arrest too. In fact, cardiac arrest is the leading cause of death in student athletes. 

The steps in a pediatric chain of survival are slightly different from the adult cardiac chain of survival to account for the size and physiological distinctions. 

The pediatric chain of survival includes prevention as the first step since cardiac arrest in children and infants typically occurs due to preventable problems. In addition to heart problems, some of the common causes of cardiac arrest in children are respiratory issues, infections, and trauma. 

There are also some differences in the proper way to administer CPR in infants and children compared to adults. 

Stroke Chain of Survival

While the chain of survival focuses on treating cardiac arrest, its success in raising public awareness has prompted the metaphor of a chain to be adapted to treating strokes.

The American Heart Association’s stroke chain of survival includes five steps to help improve the chances of stroke survival and recovery:

  • Recognize stroke symptoms and call 911
  • Timely EMS response 
  • Transport and notify stroke center 
  • Stroke care 
  • Post-stroke care

Contact Us

We would love to hear from you!