Immediate angiography and PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows (Level of Evidence: B) See Online Data Supplement 2 for additional data on PCI for cardiac arrest. Almost 70% of the coronary heart disease deaths annually in the United States occur out of hospital, usually presenting as sudden death due to cardiac arrest.175 Resuscitation is attempted by EMS personnel in approximately 60% of these out-of-hospital cardiac arrest cases; the remaining patients are deceased on arrival of the EMS team.175 177 Although only 23% of out-of-hospital cardiac arrest cases have a shockable initial rhythm (primarily VF), the majority of neurologically intact survivors come from this subgroup.175,176 The median rate of survival to hospital discharge with any first recorded rhythm is only 7.9%175 ; the rate of survival in patients who are in VF initially is much higher (median 22%, range 8% to 40%), as documented in 10 US and Canadian regions participating in the National Institutes of Health sponsored Resuscitation Survival from out-of-hospital cardiac arrest is optimal when both CPR and defibrillation are initiated early.178 Survival from VF specifically is inversely related to the time interval between its onset and termination, with the odds of survival decreasing 7% to 10% for each minute of delay from onset to The percentage of patients who are found in VF and the likelihood of survival are higher if the patient s collapse is witnessed, if bystander CPR is performed, and if a monitor/defibrillator can be applied quickly.181 Community strategies that improve the delivery of early defibrillation to out-of-hospital cardiac arrest victims include training and equipping first responders (fire and law enforce- ment), EMS personnel, and paramedics to defibrillate, as well as placing automated external defibrillators in highly popu- lated locations such as airports, commercial aircraft, and gam- bling casinos ( public access defibrillation ).182 193 The latter strategy has been shown to approximately double the number of neurologically intact out-of-hospital cardiac arrest sur- vivors when laypersons are trained and equipped to provide early CPR and defibrillation with automated external defibril- lators, compared with providing CPR alone while awaiting arrival of EMS personnel.183 Two RCTs have reported improved rates of neurologi- cally intact survival to hospital discharge when comatose patients with out-of-hospital VF or nonperfusing VT car- diac arrest were cooled to 32 C to 34 C for 12 or 24 hours beginning minutes to hours after the return of spontaneous Additional studies with historical control groups also have shown improved neurological outcomes after therapeutic hypothermia for comatose survivors of VF Accordingly, therapeutic hypothermia should be initiated in patients with STEMI and out-of-hospital cardiac arrest. 