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Original Article

An Observational Study of Out‑of‑Hospital Cardiac Arrests

Reported in Indian Print Media
Srinivas Ramaka, Vemuri S. Murthy1, Navin C. Nanda2, Vasudeva Murthy Sindgi3, Adil Sarvar Mohammed4
Consultant Cardiologist, Srinivasa Heart Centre,Warangal,Telangana, India, 1Department of Emergency Medicine, University of Illinois at Chicago College of Medicine,
Chicago, IL, 2Division of Cardiology, University of Alabama, School of Medicine, Birmingham, Alabama, USA, 3Department of Pharmacology, Jayamukhi College of
Pharmacy, Warangal,Telangana, 4Medical Student, Mamata Medical College, Khammam, Telangana, India

Abstract
Background: Newspapers in India often report incidents of cardiac arrest. Media reports are a source for raising awareness of cardiac
arrest and cardiopulmonary resuscitation (CPR) among the public. This study is aimed at evaluating the reports of cardiac arrest published
in Indian newspapers. Materials and Methods: This is an observational study of cardiac arrests reported in Indian newspapers between
January 2001 and June 2019. The study included reports containing the word “cardiac arrest” referring to a cardiac arrest event in
India. Data of demographics, location, time, clinical characteristics, performance of CPR, and survival using the Utstein template were
extracted from the newspapers. Reports of out-of-hospital cardiac arrest (OHCA) were selected for analysis. Results: One thousand seven
hundred seventy-nine reports of cardiac arrest were reviewed and 1703 reports were selected after excluding 76. Of these, 279 reports did
not specify whether it was an in-hospital cardiac arrest (IHCA) or OHCA. Of the remaining 1424 reports, 377 reports were IHCA and 1047
were OHCA. One thousand forty-seven OHCA cases were selected for analysis. The study noted male preponderance and a median age
of 51–60 years. OHCA commonly occurred in residential locations, followed by public buildings, other places, and street/highways.
Prior risk factors, heart disease, and symptoms were reported in some reports. Of 15 subjects who received CPR, 11 were reported to
have survived. Although demographic data are reported in the majority, there is poor reporting of clinical and resuscitation details.
Conclusions: The study gives a glimpse of OHCA in India and emphasizes the need for elaborate reporting of data on cardiac arrest.
The crucial role of media is recognized.

Keywords: Cardiac arrest, cardiopulmonary resuscitation, newspaper reports, out‑of‑hospital cardiac arrest, survival from out‑of‑hospital
cardiac arrest and India, Utstein template

Introduction cardiopulmonary resuscitation (CPR) skills and contribute to

Mass media are an important source to improve health literacy
in the country.[1] The most common platforms for mass media
are newspapers, magazines, radio, television, and the Internet.
Newspapers serve as a valuable source of health‑related
information to the lay public. One such example of health
literacy which impacts community participation is knowledge
of cardiovascular disease (CVD).[2] Reports of cardiac arrest
are often reported in the lay press. Being an important public
health problem, they generate immense interest among
the readers. Dissemination of accurate information by
the newspapers and other media will influence the public
perception of cardiac arrest, resuscitation, and outcomes.[3]
Such newspaper reports serve to motivate the lay public to learn
resuscitation quality outcomes. There are evidence‑based data
to prove that immediate bystander CPR increases survivals in
out‑of‑hospital cardiac arrest (OHCA).[4]
The burden of CVD in India is increasing. Reports of sudden
cardiac arrest are often reported in Indian media. The Indian
Readership Survey data released for the first quarter of
2019 reveal that the overall readership of newspapers is
Address for correspondence: Dr. Srinivas Ramaka,
Consultant Cardiologist, Srinivasa Heart Centre,
Warangal, Telangana, India.
E‑mail: srinivasaheartcentre@outlook.com

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DOI: How to cite this article: Ramaka S, Murthy VS, Nanda NC, Sindgi VM,
10.4103/JICC.JICC_52_19 Mohammed AS. An observational study of out-of-hospital cardiac arrests
reported in Indian print media. J Indian coll cardiol 2019;9:223-9.

© 2020 Journal of Indian College of Cardiology | Published by Wolters Kluwer - Medknow 223
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Ramaka, et al.: Reports of out‑of‑hospital cardiac arrest in Indian print media
increasing (Media Research Council). While there is an overall
increasing readership of newspapers in all languages, English
newspaper readership has been increasing more.[5]
Currently, the data on cardiac arrest, especially OHCA,
are limited in India. There have been few studies
published,[6,7] including a recently completed regional study
Warangal Area Out-of-Hospital Cardiac Arrest Registry-
WACAR (unpublished data). Comprehensive national data
on OHCA are lacking. The data from media reports provide
a glimpse of OHCA in India. A  study published from the
United  Kingdom reviewed the details of cardiac arrests
reported in the lay press adopting the Utstein template.[8]
However, there have been no reported studies so far from
Indian media based on an internationally accepted Utstein
template.[9,10]
Aims and objectives
The study aims at evaluating the reports of OHCA as reported
in print media (particularly newspapers in India) with Utstein
template  –  portrayal of cardiac arrest, demographics, and
patient and resuscitation characteristics.
Materials and Methods
Study design
This is an observational study of a cohort of cardiac arrests
reported in selected Indian English newspapers.
Setting
There has been an attempt in securing national data on OHCA.
There is no single source or agency in India through which all
media reports can be collected. Only English newspapers with
websites and data available for public domain were accessed
for reports of cardiac arrest.
Participants
Subjects from reports of cardiac arrest in various locations in
India were included in the study.
Sources of data
Newspaper reports from Indian newspapers in English
language with a wide circulation. They were retrieved from the
archives during 2001–2019 from the websites of The Hindu,
The New Indian Express, The Times of India, The Hans India,
and The Pioneer.
All the articles are screened for eligibility. Initially, those
reports with a search word “cardiac arrest” were retrieved.
Articles eligible for inclusion included persons sustaining
cardiac arrest at several Indian locations. Reports with no
reference to a possible cardiac arrest were excluded. Articles
in different newspapers of the same cardiac arrest victim
were searched for any additional information, and only the
best report was included. Those due to obvious possible
noncardiac causes such as trauma were excluded. Data related
to Utstein variables were extracted from these reports. Data
of OHCA subjects were selected for analysis.
224 Journal of Indian College of Cardiology  ¦  Volume 9  ¦  Issue 4  ¦  October-December 2019
Variables
Demographics
1. Gender: Male, female, or unknown
2. Age range: 0–20, 21–30, 31–40, 41‑50, 51–60, 61–70,
71–80, 81–90, and 91–100. Coronary artery disease (CAD)
is the common cause for OHCA. CAD in <45 years of age
of subjects is labeled as “young CAD.” CAD in <55 years
in males and <65 years in females is labeled as “premature
CAD”[11]
3. Location: Whether the arrest location is in‑hospital or
out‑of‑hospital.If OHCA, the categories of location
noted: residence/home, public building, street, place
of recreation/ground, transport center, educational
institution, health‑care facility, industrial or workplace,
and others
4. Witnessed: By a layperson or health‑care professional
5. Etiology/clinical characteristics: Based on the Utstein
definition, the cause of cardiac arrest is presumed to be of
cardiac origin unless it is known to be caused by trauma,
drowning, respiratory, or other causes as determined by
the rescuers
6. Performance of CPR: Whether CPR was performed
or not and details of the arrival of emergency medical
services (EMS)
7. Defibrillation: Details of availability and utilization
of an automated external defibrillator (AED) and EMS
8. Outcomes: Details of survival and management.
Statistical analysis
Data entry was done using MS Excel. Statistical analysis
was done using MedCalc Statistical Software version
19.1.5 (MedCalc Software bv, Ostend, Belgium; https://
www.medcalc.org;2019). Frequencies were calculated for
descriptive data.
Results
A total of 1779 reports of cardiac arrest were reviewed
from January 2001 to June 2019. Of these, 76 reports which
reported more than once in different newspapers and those
which did not meet the inclusion criteria were excluded. Of
the 1703 reports, only 1424 had in‑hospital or out‑of‑hospital
information. After excluding 377 reports of in‑hospital
cardiac arrest (IHCA), 1047 reports of OHCA were selected
for analysis.
In 37 subjects, the identity of the subject was not reported. They
were labeled as “unknown name” [Flow Chart 1 and Table 1].
Demographics
The study noted male preponderance with a median age group
being 51–60  years  (27.78%) [Figures 1 and 2]. The mean
age was 54.1 years. The mean age of OHCA was higher in
females compared to males.
Of the 889 subjects (males – 782 and females – 107) in whom
age was reported, 225 (25.3%) are <45 years and 664 (74.7%)
were above 45 years.
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Ramaka, et al.: Reports of out‑of‑hospital cardiac arrest in Indian print media

Of 782 males, 398 (44.8%) were <55 years and 384 (43.2%) Clinical details

were above 55 years. Of 107 females, 65 (7.3%) were <65 years Clinical details were reported in 32 media reports. Of these,
and 42 (4.7%) were above 65 years. 19 media reports contained details of prior heart disease and
interventions such as previous heart ailments including heart
Location of out‑of‑hospital cardiac arrest
attacks, angioplasty, and coronary artery bypass graft (CABG)
Common locations of OHCA were residential areas
procedures. There were very few reports which mentioned
followed by public buildings, other places, and street/
risk factors. There was a report of a heart attack as a cause of
highways.
cardiac arrest in some (7).
Prior symptoms were reported in 58 subjects. Chest pain
is the most common symptom reported  (24), followed by
collapse  (20). Other symptoms reported were as follows:
Newspaper unconsciousness, fainting, and uneasiness.
articles
reviewed
n = 1779
Witnessed status
In 87 subjects, the OHCA was unwitnessed. In all others,
the OHCA was witnessed. Time of the unwitnessed arrest:
morning – 22, afternoon – 4, night – 13, and early hours of the
Cardiac arrest events
morning – 5.  In 43 subjects, the time of unwitnessed OHCA
articles excluded
n = 76 n = 1703 was unknown.
Cardiopulmonary resuscitation and survival
Fifteen reports indicated CPR: 11 survivals and 4 nonsurvivals.
In those who have survived, there is a mention of undergoing
IHCA and OHCA Location (IHCA OR percutaneous coronary intervention and CABG  (two).
n = 1424 OHCA) not specified Among those who received CPR, it was performed by an
n = 279
anesthesiologist  (1), “doctor”  (1), Central Reserve Police
Force jawan  (1), and Central Industrial Security Force
IHCA person (1). The survival rate of OHCA in this study is 1.05%.
n = 377 One hundred seventeen subjects were reported to have been
brought dead and six subjects were reported to have died in
hospital. Follow‑up data of those who have survived are not
reported.
OHCA Details regarding EMS ambulance arrival were not mentioned
n = 1047
(Taken for analysis) in the majority of the reports. There are no reports of the use
of an AED.

Flow Chart 1: Flow of newspaper articles through the selection process
resulting in 1047 out‑of‑hospital cardiac arrest subjects for data analysis
Terms used in the newspaper reports
Certain terms are often used in the media reports. The term
“massive cardiac arrest” has been used in 47 reports and
“severe cardiac arrest” in 1 report. Although these terms are
not used clinically by the physicians, they probably convey the
intensity of the event and generate interest to the lay reader.

Figure 1: Age range versus the number of subjects of out‑of‑hospital

cardiac arrest Figure 2: Age range and number of males versus females

Journal of Indian College of Cardiology  ¦  Volume 9  ¦  Issue 4  ¦  October-December 2019 225

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Ramaka, et al.: Reports of out‑of‑hospital cardiac arrest in Indian print media

Table 1: Baseline data of out‑of‑hospital cardiac arrest subjects

Demographics n (%)
Males 926 (88.7)
Females 118 (11.3)
Total 1044
Age (years)
0-20 30 (3.37)
21-30 58 (6.52)
31-40 99 (11.14)
41-50 162 (18.22)
51-60 247 (27.78)
61-70 155 (17.44)
71-80 80 (9.01)
81-90 49 (5.51)
91-100 9 (1.01)
Total 889 (100.00)
Location of OHCA
Residence 343 (32.76)
Public building 308 (29.42)
Street/highway 124 (11.84)
Place of recreation 63 (6.02)
Transport center 25 (2.39)
Educational institution 5 (0.48)
Health‑care facility 4 (0.38)
Industrial/workplace 1 (0.1)
Other 174 (16.61)
Time of OHCA
Day 231 (55.8)
Night 183 (44.2)
By stander CPR initiated
CPR done 15 (1.43)
Survived 11 (1.05)
No survival 4 (0.38)
Age criteria (years) Both, n (%) Males, n (%) Females, n (%)
<45 225 (25.3) 205 (23.1) 20 (2.2)
>45 664 (74.7) 577 (64.9) 87 (9.8)
<55 398 (44.8)
>55 384 (43.2)
<65 65 (7.3)
>65 42 (4.7)
Age characteristics n Age range (minimum-maximum) Mean SD SEM 95% CI of mean
Male 782 0.6-99 53.79 16.61 0.594 52.63-54.96
Female 107 10-87 56.57 18.8 1.818 52.97-60.17
Total 889 0.6-99 54.1 16.91 0.566 52.99-55.21
OHCA: Out‑of‑hospital cardiac arrest, SD: Standard deviation, CI: Confidence interval, SEM: Standard deviation, CPR: Cardiopulmonary resuscitation

The terms mentioning “brought dead or declared brought dead,”
“died at the hospital,” and “died while undergoing treatment”
which were commonly used in the media reports convey to the
lay reader that the cardiac arrest has occurred in an out‑of‑hospital
setting and attempts were made to revive at the hospital of arrival.
Discussion
To the best of our knowledge, this is the first study covering
reports of cardiac arrest, particularly OHCA in Indian print
media. The study gives insight into OHCAs in India. The
study also points to the role of newspapers in contributing
to the health literacy of the lay reader about CVD, cardiac
arrest, and CPR.
The study data based on Utstein reporting are also compared with
international data from the USA, Europe, and Asian nations.[12‑14]
Demographics
The study provides important data on demographics – gender
and age. Male preponderance is similar to the reports in some
international studies. The mean and median ages of OHCA are
lower than those reported in these studies.

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Ramaka, et al.: Reports of out‑of‑hospital cardiac arrest in Indian print media
Location of out‑of‑hospital cardiac arrest
The common location of OHCA is residential. Predominance
of OHCA in residential locations points to the need to train
family members in CPR. Reducing EMS arrival times will
improve survival outcomes of OHCA.[15] Individually, the
predominant location of OHCA reported in this study is in
residential areas. However, relatively, a majority of the OHCA
reported by newspapers occurred in nonresidential locations.
This might be because a OHCA in a nonresidential location
attracts more media and public attention.
The various locations of OHCA in diverse situations (educational
institutions, health‑care facilities, places of recreation, transport
centers, places of worship, polling stations, and other outdoor
sites) across the country noted in this study help in identifying
high‑risk areas for OHCA and the need for public health
measures.[16]
Time of out‑of‑hospital cardiac arrest
The study shows a significant number of OHCAs occurring
during the day time. Previous studies have shown big temporal
variability in the incidence and survival after OHCA.[17]
Data on clinical characteristics
Data on medical history are less reported in the media. Studies
have demonstrated that classical risk factors for CAD such as
previous heart attacks have increased risk for OHCA.[18] In our
study, there is poor reporting of risk factors.
Symptoms
Studies have shown that chest pain and shortness of breath are
the common symptoms preceding OHCA which usually point
to CAD as the etiology.[19] Reporting of chest pain followed
by sudden collapse as common symptoms will educate the
lay reader about the possibility of OHCA. Those patients
with prodromal symptoms before cardiac arrest are likely to
receive early EMS help and may have better outcomes than
those without symptoms.[20] Increasing awareness of warning
symptoms of OHCA among the public may lead to seeking
medical help sooner and may improve survivals.[21]
Resuscitation characteristics
Bystander CPR enhances the survival of OHCA victims. The
2017 Heart Disease and Stroke Statistics show that among the
356,000 OHCA that occurred, 45.7% received bystander CPR.
Studies have also shown an increase in the number of victims
receiving bystander CPR from 40.8% to 68.2% gradually.[22]
The poor bystander CPR response in this study (1.43%) may
be probably due to relative lack of awareness of cardiac arrests
and <1% of bystander hands‑only CPR training among Indian
population.[23]
The use of AEDs/defibrillators was not reported in this study.
AEDs are not routinely available in major public locations.
Public access defibrillators should be available to improve
outcomes from OHCA. Barriers to the availability and use of
AEDs should be overcome.[24]
Journal of Indian College of Cardiology  ¦  Volume 9  ¦  Issue 4  ¦  October-December 2019
Survival from out‑of‑hospital cardiac arrest
While the international data suggest a survival varying
from 6% to 10%,[25] this study from India shows a survival
of 1.05%.
Strategies to enhance bystander CPR, delivering early
defibrillation with AED, and restoring the circulation
soon (return of spontaneous circulation) before transporting
to a hospital may improve aggregate rates of survival of
OHCA.[26] Ninety‑two percent with OHCA do not survive to
hospital discharge. This can be improved with improving the
links in the chain of survival.[27]
Role of media
Health literacy is important in health‑related outcomes
nationally. In general, sudden cardiac arrests are underreported
in the media. A report of OHCA and its detailed portrayal will
encourage the lay public to learn CPR.
Public education initiatives of the “chain of survival” are also
possible through the use of digital tools and digital strategies
such as mobile devices, social media, and crowdsourcing.[28]
Need for action
As majority of OHCA occurred in residential locations, there
is a dire need to train family members in CPR. It is also
important to conduct regular training programs in bystander
CPR for staff at public buildings, places of worship, polling
stations, workplaces, transport centers, recreation places, and
educational institutions. Availability and access to AEDs at
public places will improve outcomes significantly.
The reporting of chest pain, collapse, breathlessness, and other
symptoms creates awareness among the lay readers about the
prior symptoms of cardiac arrest. There is a need to educate
the public about the circumstances of cardiac arrest. Reports of
survivors of the OHCA encourage the lay public to learn CPR.
The international evidence‑based recommendations regarding
the cardiac resuscitation systems of care will improve survival
from OHCA.[29,30]
Limitations of the study
The number of OHCA in the study is not the accurate total
number as only limited information from select newspapers
was available for review. There was no single agency with all
needed data. Accessing the information from newspapers in
different languages from different states was also a limiting
factor. Considering these limitations, the study may not reflect
the total burden of sudden cardiac arrests in general and OHCA
in particular. The level of medical knowledge of the media
personnel is another limiting factor in accurate reporting of
data on OHCA which needs to be addressed.
Conclusions
With an increasing number of newspaper readers, a detailed
reporting of cardiac arrests is important. With 384 million
Internet users which include 50% of rural population in India,
there is a vast scope for the digital media to improve health
227
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Ramaka, et al.: Reports of out‑of‑hospital cardiac arrest in Indian print media
literacy in enhancing cardiac arrest awareness and bystander
CPR.
There needs to be an official source for capturing health‑related
information. Making OHCA a reportable event in India would
increase the number of cardiac arrests reported. In the absence
of National Data Bank, any reported study of cardiac arrests
will be incomplete. There needs to be a consistent contribution
from all media sources, print, audiovisual, and digital. All
stakeholders involved in the delivery of health care such as
the medical professionals and governmental agencies need to
coordinate and combine their resources for pooling the data.
This pilot study recognizes the need to have systems in place
at the local, regional, state, and national levels contributing to
a comprehensive national cardiac arrest data pool (National
OHCA Registry). All governmental and nongovernmental
organizations involved with health care need to combine their
resources. The authors recognize the challenges involved in
initiating and maintaining such a system in India. However,
these crucial data will help in developing and implementing a
national program of OHCA awareness with bystander CPR and
AED training to improve outcomes. The Government of India
needs to address this major health‑care issue soon to prevent
lakhs of preventable sudden deaths every year.
Dataset
Ramaka, Srinivas; Murthy, Vemuri; Nanda, Navin; Sindgi,
Vasudeva Murthy; Sarvar Mohammed, Adil (2020), “Data
of “An Observational Study of Out-of-Hospital Cardiac
Arrests Reported In Indian Print Media””, Mendeley Data,
V1, doi: 10.17632/ckjrch6bxg.1. http://dx.doi.org/10.17632/
ckjrch6bxg.1.
Key messages
*What is already known about this subject?
There is paucity of data on OHCA in India.
*What this study adds?
In the absence of national representative data on OHCA,this
study on newspaper reports of OHCA provides a glimpse of
OHCA in India.
*What is the likely impact?
This study is likely to generate interest among various
stakeholders in prevention of cardiac arrest and focus on
measures to improve outcomes from OHCA ,an important
public health problem.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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