AMC cardiologist Ruud Koster already CPR Pioneer for decades


Qualitatively it is quite far, now is the time to improve the quantity’


In case of an alert via HeartsafeLiving about ten to thirty volunteers are alerted and one or two AEDs come to the incident. “That is not enough,” says CPR pioneer and cardiologist at the Academic Medical Center Ruud Koster. “To really add something to the system, you should have availabe three to four AEDs per square kilometer. Qualitatively, it is quite far, now is the time to improve the quantity.”

Chance of survival

When you have the luck in a cardiac arrest to get resuscitated and defibrillated within two to three minutes, has fifty to sixty percent chance of survival. And someone who has to wait for help for more than ten minutes, the chances of survival are below fifteen percent. “Time is all-important,” says Koster.


Twenty years ago there were only defibrillators on ambulances. Koster began in 1990 with his Amsterdam Resuscitation Studies (ARREST) research. Researchers analyzed results of resuscitation at that time: only nine percent after a cardiac arrest left the hospital alive. Also, the researchers analysed factors that determined these results and how to influence them.


In my opinion there are two all determining factors,” says Koster. “In the first place, do bystanders respond immediately with CPR. And secondly, is there quick a defibrillator present.” The Dutch Heart Foundation has been working for half a century with heart and soul to teach as many people to provide CPR. And with success, according to Koster: “There are many people in the Netherlands who can do this.” Yet by far the most victims died of a cardiac arrest: “For with resuscitation alone you will not solve the problem. Without defibrillator you don’t bring a heart back to the normal rhythm permanently so the patient will die almost for sure.

Arrest research

The Arrest research has as topic ‘the neighborly assistant with an AED, controlled by the dispatch center: a new and necessary link in the chain of survival’. HeartsafeLiving is one of two organizations that facilitate this neighborly assistance via the dispatch centers by providing specific software. Furthermore HeartsafeLiving contributes actively to this research showing that neighborly assistance actually saves lives. Koster: “We hope to fix this which conditions a local organization must meet in order to be effective; the 6 minute zone. Which includes about numbers and density of volunteers and AEDs.


To retain more lives, we needed a solution for defibrillation. In the United States there was already a ‘mobile defibrillator for lay people’ developed, the AED. Koster knew this and introduced this product in 2000 in the Netherlands. That did not go without a fight. Koster found that the Dutch Heart Foundation was willing to finance a large trial, on which the police regions Kennemerland and Zaanstreek-Waterland and the fire department of Amsterdam cooperated. This study lasted two years and yielded three important conclusions: the AED is safe to use, the device is efficient and easy to operate by lay people and targeted use shortened the average time to defibrillation with about three minutes. Three very, very precious minutes on a very fragile human life.

Resuscitation course

The next step was to make the Dutch people the use of the AED their own. The Dutch Resuscitation Council developed a special, short course – which has now been integrated into a complete resuscitation course – and the Heart Foundation stimulated the AED. “The device was quickly popular, the Dutch were particularly willing to take care,” says Koster. The acclaim he received from the cardiologist Ton Gurgles from Maastricht actively contributed to the oil slick effect.

Effect measurement

The first effect measurement took place in 2008. The results were highly encouraging: the sharp increase in the use of AEDs greatly reduced the time between a cardiac arrest and assistance. The chance of survival increased up to fifty percent, in particular in the use of public AEDs where the AED already was near the victim. The chance of survival in a cardiac arrest increased from 9 to 23 percent in the last fifteen years. And this increase is according to Koster for the most part due to the increased use of the AED. “Every year hundreds of lives are saved additionally,” says Koster.

Neighborly assistants

Currently, in approximately half of the cases there is already an AED in use upon the arrival of the ambulance. “That’s a lot, a huge improvement. But this can be even better. We aim for a hundred percent,” says the cardiologist. “The closer, the faster the AED is being used, the greater the chance of survival. You can get a heart attack much better in a busy shopping center than for example at home.” Therefore Koster would prefer to have on the corner of every street a public AED: “Especially at a time when the number of fire departments and ambulance stations decrease and there are fewer patrolling police cars driving on the street. For three quarters of the cardiac arrests occur in the home. And then as victim you are often dependent on these neighborly assistants.


Therefore Koster strongly supports ‘crowdsourcing of resuscitators’, as he describes HeartsafeLiving. “To ensure that people who can resuscitate are actually alerted, there are now very nice tools like text message and apps on smartphones,” he says. “Still, it takes a lot of energy to build such a system. You must reach resuscitators and find them willing to be with their mobile number in a database and go with an alert to a situation that could have significant impact. Dispatch centers need to know who they should and should not alert, and there must be an overview of accessible AEDs. These both should be accessible and well protected from bad influences.

Resuscitation opportunities

If the cardiologist compares the Dutch numbers with those of other countries, he notes that the Netherlands – along with Sweden, Norway, Denmark and Germany – is one of the forerunners in the world. In his department operates a ten-person research team fulltime to optimize resuscitation capabilities. The design and deployment of HeartsafeLiving finds Koster a very good thing: “But it is certainly not finished. The quality of assistants and AEDs is fine, now it is important to work on the quantity. We need more volunteers to be quickly at the victim. And on an average village that takes about five to six public AEDs for an optimal functioning assistance system. The AED density is our next challenge.