Advanced Cardiovascular Life Support (ACLS) certification is issued primarily by the American Heart Association (AHA) and is required for healthcare professionals who respond to cardiac arrest and other cardiovascular emergencies — including physicians, nurses (RNs and APRNs), respiratory therapists, paramedics, and other advanced providers working in emergency medicine, critical care, and perioperative settings.
ACLS certification is required or strongly recommended for: registered nurses working in emergency departments, intensive care units, cardiac care units, and operating rooms; physicians and advanced practice providers in emergency, critical care, and hospitalist roles; paramedics and flight nurses in pre-hospital emergency care; respiratory therapists in ICU and emergency settings; and any healthcare professional who may be a first or second responder to in-hospital cardiac arrest. Specific requirements vary by employer and state — check with your hospital's education or compliance department for applicable requirements for your role and unit.
The AHA ACLS provider course is a 2-day, hands-on course that includes didactic content (lectures, videos), skills stations (megacode practice, rhythm interpretation, airway management, IV/IO access), and a final skills assessment and written exam. The course can be taken at AHA Training Centers (hospitals, colleges, healthcare training organizations) or through AHA's HeartCode ACLS, which uses online self-directed learning followed by a hands-on skills session with an AHA instructor. ACLS certification is valid for 2 years. Renewal is completed via a shorter renewal/recertification course.
The ACLS written exam is a 50-question multiple-choice test. A minimum score of 84% (42 out of 50 correct) is required to pass. The exam covers ACLS algorithms, pharmacology, rhythm recognition, and management of cardiac arrest, post-cardiac arrest care, and acute cardiovascular emergencies. The written exam must be passed in addition to the skills assessment — both components must be passed to receive ACLS certification.
The AHA ACLS algorithms are systematic step-by-step protocols for managing specific cardiovascular emergencies. Memorizing and being able to apply these algorithms is the core of ACLS certification. The written exam heavily tests algorithm knowledge.
The cardiac arrest algorithm applies to pulseless arrest regardless of rhythm. Key sequence: start high-quality CPR immediately (100–120 compressions/minute, 2–2.4 inch depth, allow full chest recoil, minimize interruptions); establish IV/IO access; administer epinephrine 1 mg IV/IO every 3–5 minutes; analyze rhythm every 2 minutes. For shockable rhythms (VF or pulseless VT): deliver defibrillation (biphasic 120–200 J or manufacturer's recommendation), resume CPR immediately, reassess in 2 minutes. For non-shockable rhythms (PEA or asystole): continue CPR, give epinephrine, search for and treat reversible causes (the Hs and Ts). Amiodarone (300 mg IV first dose, 150 mg second dose) is given for refractory VF/pVT.
Bradycardia management applies when heart rate is less than 50 bpm AND the patient has signs and symptoms related to the rate (hypotension, altered mental status, chest pain, acute heart failure, syncope). Treat symptomatic bradycardia with: Atropine 1 mg IV first (repeat every 3–5 minutes to maximum 3 mg total); if atropine is ineffective, prepare for transcutaneous pacing while considering dopamine infusion (2–20 mcg/kg/min) or epinephrine infusion (2–10 mcg/min). Transcutaneous pacing is the definitive bridge treatment for unstable bradycardia that does not respond to atropine.
Tachycardia management depends on whether the patient is stable or unstable and whether the QRS is narrow or wide. Unstable tachycardia with serious signs (hypotension, altered mental status, chest pain) → synchronized cardioversion immediately. Stable narrow-complex tachycardia (regular SVT): attempt vagal maneuvers first, then adenosine 6 mg rapid IV push (may repeat 12 mg × 2). Stable wide-complex tachycardia (regular): if presumed SVT with aberrancy, adenosine; if presumed VT, amiodarone 150 mg IV over 10 minutes, then amiodarone infusion. Expert consultation should be obtained for irregular rhythms.
After return of spontaneous circulation (ROSC), post-arrest care focuses on: targeted temperature management (TTM) — maintaining body temperature at 32–36°C for 24 hours in comatose survivors; hemodynamic optimization (MAP ≥ 65 mmHg, avoiding hypotension); oxygenation (SpO2 94–99%, avoiding hyperoxia); ventilation (targeting PaCO2 35–45 mmHg, avoiding hyperventilation); 12-lead EKG to evaluate for ST elevation myocardial infarction (STEMI) requiring emergent PCI; and transfer to an appropriate ICU for ongoing monitoring and care.
ACLS pharmacology focuses on a small core set of medications that are used in the ACLS algorithms. Knowing the dose, indication, route, and key considerations for each medication is essential for both the written exam and megacode performance.
Epinephrine 1 mg IV/IO every 3–5 minutes: the primary vasopressor in cardiac arrest. Used in all pulseless arrest rhythms. Causes vasoconstriction to improve coronary and cerebral perfusion pressure during CPR. Amiodarone 300 mg IV/IO (first dose), 150 mg IV/IO (second dose): antiarrhythmic for VF or pulseless VT refractory to defibrillation. For stable wide-complex tachycardia: 150 mg IV over 10 minutes. Atropine 1 mg IV every 3–5 minutes (max 3 mg): first-line medication for symptomatic bradycardia. Blocks vagal tone to increase heart rate. Not effective for infranodal (Mobitz type II or complete heart block) bradycardia. Adenosine 6 mg rapid IV push (first dose), 12 mg (subsequent doses): converts regular narrow-complex SVT to sinus rhythm. Must be administered as a rapid push followed immediately by a saline flush due to its ultra-short half-life. Dopamine 2–20 mcg/kg/min infusion: used for bradycardia refractory to atropine while awaiting pacemaker. Epinephrine infusion 2–10 mcg/min: alternative to dopamine for symptomatic bradycardia. Sodium bicarbonate: used for cardiac arrest associated with hyperkalemia or tricyclic antidepressant overdose.
Rhythm recognition is a core skill tested throughout the ACLS course and on the written exam. The algorithms hinge on correctly identifying the presenting rhythm and determining whether it is shockable or non-shockable, fast or slow, narrow or wide.
In cardiac arrest, the first rhythm analysis determines whether defibrillation is indicated: Shockable rhythms: Ventricular Fibrillation (VF) — chaotic, irregular waveform with no discernible QRS complexes; and Pulseless Ventricular Tachycardia (pVT) — regular wide-complex tachycardia at rate greater than 100 bpm with no palpable pulse. Both receive immediate defibrillation in the algorithm. Non-shockable rhythms: Pulseless Electrical Activity (PEA) — organized electrical activity on monitor but no palpable pulse; and Asystole — flat line (confirm in two leads). Both receive continued CPR and epinephrine with search for reversible causes.
ACLS tachyarrhythmias: Supraventricular Tachycardia (SVT) — regular, narrow-complex tachycardia at 150–250 bpm; P waves may not be visible. Atrial Fibrillation — irregularly irregular rhythm, absent P waves, fibrillatory baseline; can be narrow or wide complex. Atrial Flutter — sawtooth pattern at atrial rate approximately 300 bpm, ventricular rate depends on block ratio (2:1 flutter = ventricular rate ≈ 150 bpm). Ventricular Tachycardia (VT) — regular wide-complex tachycardia; can be stable or unstable. Wide complex tachycardia of uncertain origin should be treated as VT until proven otherwise.
Key bradyarrhythmias for ACLS: Sinus Bradycardia — regular, normal P wave before each QRS, rate less than 60 bpm. First-degree AV block — prolonged PR interval (greater than 0.20 seconds), every P wave followed by a QRS. Second-degree Mobitz type I (Wenckebach) — PR interval progressively lengthens until a beat is dropped; responds to atropine. Second-degree Mobitz type II — PR interval constant, then sudden dropped QRS without warning; does NOT reliably respond to atropine — prepare for pacing. Third-degree (complete) AV block — P waves and QRS complexes are dissociated, each at their own rate; requires pacing.
Using the right study resources makes ACLS preparation significantly more efficient. ACLS tests a specific, well-defined set of content — algorithms, pharmacology, and rhythm recognition — and resources that directly target this content are more effective than broad cardiovascular textbooks.
The American Heart Association ACLS Provider Manual is the official reference for ACLS content. It contains all the algorithms, pharmacology tables, and skill stations in a condensed reference format. The manual is included with AHA ACLS courses; it can also be purchased separately. Read the manual cover-to-cover before your course, paying particular attention to the algorithm flowcharts. Having the manual physically or digitally available as you study allows you to reference the exact AHA language used on the exam.
AHA publishes pocket reference cards (also called quick reference cards or laminated algorithm cards) that display the core ACLS algorithms in condensed format. These cards are useful for quick review sessions — carry them and quiz yourself on algorithm sequences and drug doses during any available study time. Many healthcare training stores and online retailers carry laminated ACLS algorithm card sets.
Online ACLS practice tests are among the most valuable preparation tools because the written exam is scenario-based and question-heavy. Free and paid ACLS practice resources are available from ACLS Medical Training (acls.com), ACLS Certification Institute (aclscert.com), and PracticeTestGeeks. When using practice tests, focus on understanding why each correct answer is correct (which algorithm step, which drug dose) rather than just memorizing the right answer. ACLS algorithm drill tools — flashcard or click-through versions of the algorithms — help build the automatic recall needed during megacode performance.