View all AHA 2026 trials
RACE-CARSAcute Cardiac CareNew England Journal of Medicine
Community and EMS Interventions to Improve Survival in Cardiac Arrest
Carolina Malta HansenKonstantin A. KrychtiukMonique A. StarksHussein R. Al-KhalidiDaniel B. MarkLisa MonkLisa KaltenbachJames G. JollisSana M. Al-KhatibHayden B. BosworthKimberly WardSarah SmithTyler CopeSteve VandeventerJyotsna GargAudrey L. BlewerEdward SharpeThomas D. ReaR. Darrell NelsonBryan McNallyChristopher B. Granger
What happened
Community and EMS educational intervention fails to improve favorable neurological survival over standard care.
- OR 0.97
- 95% CI 0.75-1.26
- P=0.80
- n=22,459
Key points
- Context & question: Although early cardiopulmonary resuscitation and defibrillation are known to improve survival after out-of-hospital cardiac arrest, randomized trial evidence is lacking on whether community-based implementation strategies improve patient outcomes. The RACE-CARS trial was conducted to evaluate the effectiveness of a multifaceted community and emergency medical services intervention compared with usual care.
- Methods & population: Study design, patient population, and sample size are not yet reported.
- Finding & limits: In adults with out-of-hospital cardiac arrest across 60 North Carolina counties, a comprehensive EMS and community-based educational intervention did not significantly improve survival to hospital discharge with favorable brain function compared with standard care (approximately 9% vs. 9.4%).
Discussion
Expert perspectives 3
Expert perspective
Lisa Monk14h ago
Cross-Cutting Cardiology · Duke University
We want to gather information about how people do over the next year. We are following up with survivors at three and 12 months to assess their health status and quality of life.
RACE-CARS co-authorExpert perspective
Carolina Malta Hansen14h ago
Cross-Cutting Cardiology · Institut polytechnique de Grenoble
Changing how an entire community responds to cardiac arrest takes time, and our findings show just how challenging that can be. In the meantime, the message to the public remains simple: learn CPR, recognize the signs of cardiac arrest, call 9-1-1 immediately and follow the dispatcher's instructions. Everyone has the potential to save a life.
RACE-CARS co-authorExpert perspective
Christopher B. Granger14h ago
General Cardiology
The increase in bystander CPR toward the end of the study shows there was some effect and suggests that a sustained community outreach may be needed to show an improvement in survival. We have established an efficient, high-quality clinical trial network to continue this work.
RACE-CARS co-authorAsk about this paper
Answers are grounded in this paper and cite their sources.
Full evidence
Why the trial, tables, limitations, PICO, abstract, media & sources
Full evidence
Why the trial, tables, limitations, PICO, abstract, media & sources
Why the trial?
Although early cardiopulmonary resuscitation and defibrillation are known to improve survival after out-of-hospital cardiac arrest, randomized trial evidence is lacking on whether community-based implementation strategies improve patient outcomes. The RACE-CARS trial was conducted to evaluate the effectiveness of a multifaceted community and emergency medical services intervention compared with usual care.
Does a multifaceted community and EMS intervention improve survival to hospital discharge with a good neurologic outcome in adults with out-of-hospital cardiac arrest?
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Structured PICO
Does a multifaceted community and EMS intervention improve survival to hospital discharge with a good neurologic outcome in adults with out-of-hospital cardiac arrest?
Population
22,459 adults with out-of-hospital cardiac arrest treated by EMS in 55 North Carolina county clusters (median age 64.0 years, 36.7% women) followed to hospital discharge.
Intervention
Multifaceted community and EMS intervention including four components: training of 911 telecommunicators to improve rapid recognition of cardiac arrest, training of 911 telecommunicators to improve delivery of CPR instructions to bystanders, community CPR training, and enhanced use of automated external defibrillators (AEDs) by first responders or bystanders before EMS arrival (implemented from July 1, 2022, to June 30, 2026).
Comparator
Usual care
Outcome
Survival to hospital discharge with a good neurologic outcomehard clinical endpoint
Main Result
Odds Ratio0.97 (95% CI 0.75–1.26)
Absolute Event Rate9% vs 9.4%
p-valuep=0.80
Implementing a multifaceted community and EMS strategy for out-of-hospital cardiac arrest did not improve neurologically favorable survival to hospital discharge compared with usual care.
Expert reaction
What experts said about RACE-CARS
New England Journal of Medicine · AHA Scientific Sessions 2026
2 experts have reacted so far. We show the split once 3 have.
Expert labels are toward RACE-CARS's result, from named public quotes (n=2). As of Nov 8, 2026.
Implication
No benefit on neurologically favorable survival with EMS-community education in OHCA; informs guidelines against implementation and directs future resuscitation trials.
Abstract
Background Early cardiopulmonary resuscitation (CPR) and defibrillation improve survival after out-of-hospital cardiac arrest, but evidence from randomized trials about whether community-based implementation strategies improve outcomes is lacking. Methods We conducted a registry-based, cluster-randomized trial involving adults with out-of-hospital cardiac arrest treated by emergency medical services (EMS) in North Carolina counties. The counties were grouped into clusters, which were then randomly assigned in a 1:1 ratio to implement a multifaceted intervention or administer usual care. The intervention included four components: training of 911 telecommunicators to improve rapid recognition of cardiac arrest, training of 911 telecommunicators to improve delivery of CPR instructions from telecommunicators to bystanders, community CPR training, and enhanced use of automated external defibrillators by first responders or bystanders before EMS arrival. Results From July 1, 2022, to June 30, 2026, a total of 28 clusters comprising 11,615 patients were assigned to the intervention group, and 27 clusters comprising 10,844 patients were assigned to the usual-care group. The median age of the patients was 64.0 years, and 36.7% were women. The percentage of patients who survived to hospital discharge with a good neurologic outcome was 9.0% (1048 of 11,608 patients) in the intervention group and 9.4% (1017 of 10,839 patients) in the usual-care group (adjusted odds ratio, 0.97; 95% confidence interval, 0.75 to 1.26; P=0.80). Conclusions Among adults with out-of-hospital cardiac arrest, implementation of a multifaceted strategy involving the community and EMS did not result in a greater percentage of patients who survived to hospital discharge with a favorable neurologic outcome than usual care.
Cite This Study
Hansen et al. (2026) conducted an RCT in Out-of-hospital cardiac arrest (n=22,459). Multifaceted community and EMS intervention (911 telecommunicator training, community CPR training, enhanced AED use) vs. Usual care was evaluated on Survival to hospital discharge with a good neurologic outcome (OR 0.97, 95% CI 0.75-1.26, p=0.80). A multifaceted community and EMS strategy did not increase survival to discharge with good neurologic outcome vs usual care (9.0% vs 9.4%; aOR 0.97; 95% CI 0.75-1.26; P=0.80).