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Background   The conversion from a nonshockable rhythm (asystole or pulseless electrical activity (PEA)) to a shockable rhythm (pulseless ventricular tachycardia or ventricular fibrillation) may be associated with better out-of-hospital cardiac arrest (OHCA) outcomes. There are insufficient data on the prognostic significance of such conversions by initial heart rhythm and different rhythm conversion time.Methods   Among 24,849 adult OHCA patients of presumed cardiac etiology with initial asystole or PEA in the Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry (version 3, 2011–2015), we examined the association of shockable rhythm conversion with prehospital return of spontaneous circulation (ROSC), survival, and favorable functional outcome (modified Rankin Scale score ≤3) at hospital discharge by initial rhythm and rhythm conversion time (time from cardiopulmonary resuscitation (CPR) initiation by emergency medical providers to first shock delivery), using logistic regression adjusting for key clinical characteristics.Results   Of 16,516 patients with initial asystole and 8,333 patients with initial PEA, 16% and 20% underwent shockable rhythm conversions; the median rhythm conversion time was 12.0 (IQR: 6.7–18.7) and 13.2 (IQR: 7.0–20.5) min, respectively. No difference was found in odds of prehospital ROSC across rhythm conversion time, regardless of initial heart rhythm. Shockable rhythm conversion was associated with survival and favorable functional outcome at hospital discharge only when occurred during the first 15 min of CPR, for those with initial asystole, or the first 10 min of CPR, for those with initial PEA. The associations between shockable rhythm conversion and outcomes were stronger among those with initial asystole compared with those with initial PEA.Conclusions   The conversion from a nonshockable rhythm to a shockable rhythm was associated with better outcomes only when occurred early in initial nonshockable rhythm OHCA, and it has greater prognostic significance when the initial rhythm was asystole.

Conversion from Nonshockable to Shockable Rhythms and Out-of-Hospital Cardiac Arrest Outcomes by Initial Heart Rhythm and Rhythm Conversion Time