Therapeutic Temperature Management Following Cardiac Arrest: Evolving Evidence and Clinical Practice

Abstract Background: Temperature management remains a cornerstone intervention in postcardiac arrest care. However, optimal temperature targets and implementation strategies continue to be the subjects of debate following recent trials challenging established paradigms. Objective: To critically review current evidence on temperature management following cardiac arrest, focusing on recent high-quality studies and their implications for clinical practice. Methods: A systematic literature search was conducted across PubMed, Embase, Cochrane Library, and Web of Science for studies published between 2010 and 2025, focusing on randomized controlled trials (RCTs), meta-analyses, and systematic reviews examining temperature management strategies after cardiac arrest. Results: Evidence from 27 studies was analyzed, including 8 RCTs (sample sizes 54–1900), 12 meta-analyses, 5 systematic reviews, and 2 Cochrane reviews. Recent large-scale trials have questioned the superiority of hypothermia (33°C) over controlled normothermia (36–37.5°C), suggesting noninferiority for neurological outcomes. The targeted temperature management (TTM) trial (939 patients) found no significant difference in mortality between 33°C and 36°C groups (hazard ratio [HR] 1.06, 95% confidence interval [CI] 0.89–1.28, P = 0.51). The TTM2 trial (1900 patients) showed no benefits of hypothermia over normothermia with fever control (HR 1.08, 95% CI 0.93–1.25, P = 0.37). The Therapeutic Hypothermia after Cardiac Arrest in Nonshockable Rhythm (HYPERION) trial (584 patients) demonstrated benefit specifically in nonshockable rhythms (10.2% vs. 5.7% favorable neurological outcome, P = 0.04). Implementation timing, duration, and rewarming strategies demonstrate significant variability in clinical outcomes. Conclusions: The current evidence favors individualized approaches to temperature management following cardiac arrest. While TTM remains essential, strict hypothermia protocols may not benefit all patients. Prevention of fever, maintenance of hemodynamic stability, and integration with other neuroprotective strategies appear to be key factors in improving outcomes, with effectiveness varying significantly across patient subgroups.