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asystole, identified as a flatline in all ECG leads, is a nonshockable rhythm that is associated with high mortality. Patients with coronary artery disease who suffer a sudden occlusion may progress to asystole through a sequence of events initiated at the onset of the occlusion: local ischemia, ventricular tachycardia (VT), ventricular fibrillation (VF), global ischemia, and asystole. Defibrillation has the highest efficacy when applied during VF, well before asystole. Prognosis is dim for patients suffering from out-of-hospital cardiac arrest (OHCA) who are found in asystole. An analysis of the Swedish OHCA registry has shown that patients who were found in a nonshockable rhythm had an average one-month survival rate of 1.3% (8).

Racing to the flatline: heart rate and β-adrenergic stimulation quicken the pace