North Carolina RACE-CARS Trial Fails to Raise Survival After Out-of-Hospital Cardiac Arrest
A five-year community intervention aimed at improving cardiac arrest recognition, bystander CPR and early defibrillation did not increase survival with favorable brain function after out-of-hospital cardiac arrest across North Carolina counties. The result matters because the program reached large numbers of residents and tried to attack the problem from both sides of the emergency response chain: the person who calls 9-1-1 and the people closest to the patient when the arrest happens.
Across 60 counties that represented nearly 80% of the state population, the intervention changed training, dispatcher readiness and first-responder response. Yet the main clinical endpoint did not move in a meaningful way. Survival to hospital discharge with favorable brain function was about 9% in intervention counties and 9.4% in comparison counties.
A single number captures the difficulty of the problem: the emergency starts long before the ambulance arrives.
A Wide Community Strategy Met a Stubborn Clinical Endpoint
The trial enrolled 22,459 adults 18 years and older who experienced out-of-hospital cardiac arrest between July 1, 2021, and June 30, 2026. The median age was 64 years, 37% of patients were women, 33% were Black adults, and 29% lived in rural areas. Counties were randomly assigned to receive the RACE-CARS intervention or continue their existing cardiac arrest response practices, which gave the study a strong real-world framework for testing whether a population-level program could shift outcomes.
The intervention itself was broad. Community partners held CPR training events in schools, workplaces, county government and other organizations. EMS-related components included dispatcher training to recognize cardiac arrest quickly and coach callers through CPR, along with efforts to improve early defibrillation before EMS arrival. In all, community partners conducted 5,724 CPR training events and reached 201,586 people, equal to 4.8% of residents in the intervention counties.
Coverage was uneven. Four counties reached more than 10% of residents, while eight counties reached fewer than 3%. This variation likely blunted the overall effect, because mass training programs depend not just on curriculum quality but on density, repetition and local buy-in. A community with a few concentrated champions can move faster than one with scattered participation and uneven institutional support.
Bystander CPR Rose Late, But Not Enough to Change the Primary Endpoint
Bystander CPR occurred in 44.8% of cardiac arrests in intervention counties compared with 42.3% in comparison counties. Defibrillation before EMS arrival occurred in 13.5% of intervention county arrests and 15.3% of comparison county arrests. On the surface, those figures suggest a program that struggled to translate education into immediate front-line action, especially for the earliest and most decisive steps in the chain of survival.
Still, the final year of the study revealed a different pattern. People who experienced out-of-hospital cardiac arrest in communities with the education program had 33% higher odds of receiving bystander CPR than those in counties outside the intervention. That delayed signal fits the way community emergency readiness often evolves: habits, recognition and confidence build slowly, and the benefit may emerge only after enough residents have been reached, retrained or exposed to repeated messaging.
The physiology behind this is straightforward. Every minute without CPR allows the heart and brain to drift farther from reversibility, and the window for meaningful neurologic recovery closes quickly when circulation is not restored. If a program does not create immediate, widespread action at the scene, survival is unlikely to improve even if knowledge gains eventually accumulate.
Why a Large Trial Still Missed Its Main Goal
The study used the Cardiac Arrest Registry to Enhance Survival, a national database drawing from 9-1-1, EMS and hospital records. County leaders, including commissioners and church leaders, were recruited to help with community engagement, and surveys were completed every six months to track CPR training, AED deployment and other implementation details. Thirty-one counties received 405 trial-provided defibrillators, and 26 of those counties deployed the devices. Nineteen counties placed them in publicly accessible locations, while 18 deployed them with first responders such as fire departments and law-enforcement agencies.
Even with that infrastructure, real-world implementation remained inconsistent. Staffing shortages and turnover at 9-1-1 centers complicated training and data collection. The COVID-19 pandemic and Hurricane Helene also disrupted operations in western North Carolina, adding pressure to a program that depended on regular training, stable personnel and local coordination.
Those barriers matter because CPR education is not a one-time intervention. The first responder system needs refreshers, dispatch coaching, device placement and sustained public awareness. Without those layers working together, the benefit can fragment before it reaches a patient in arrest.
The Bedside Lesson Remains Simple Even When the Trial Result Is Not
Christopher Granger said the increase in bystander CPR toward the end of the study suggests that sustained outreach may be needed before survival shifts. Carolina Malta Hansen framed the public message in direct terms: learn CPR, recognize cardiac arrest, call 9-1-1 immediately and follow dispatcher instructions.
That advice aligns with the broader public health reality. The American Heart Association’s statistics place the annual U.S. burden of out-of-hospital cardiac arrest at about 350,000 cases, with only about 1 in 10 people surviving. Immediate CPR can double or triple the chance of survival. Yet only about 40% of people with out-of-hospital cardiac arrest receive bystander CPR, and only 10% have an AED applied before EMS arrives.
The numbers explain why the intervention was attractive and why the negative primary result is sobering. A population-based program can improve infrastructure, training and readiness, but survival still depends on what happens in the first few minutes after collapse. Rural areas, volunteer-first-responder systems and uneven county-level participation make that challenge even harder.
What This Trial Adds to the Cardiac Arrest Field
The value of the study lies in its size, its inclusion of urban and rural communities and its ability to test a realistic community response model across nearly 8.5 million residents. The lack of improvement in survival with favorable brain function should not be read as proof that community CPR education is futile. It shows that broad outreach alone may not be enough, at least over five years, to move the hardest outcome in cardiac arrest care.
The late rise in bystander CPR suggests the program was beginning to change behavior, but the effect was not yet strong enough to shift the primary endpoint. A slower, more durable approach may be needed, especially in counties where participation was sparse or implementation lagged. The pending challenge is practical and measurable: identify which elements of community training, dispatcher coaching and AED placement can be intensified enough to turn early response gains into better neurologic survival.