Although 40 years have passed since the advent of advanced cardiac life support, out-of-hospital cardiac arrest still carries an ultimate failure rate of 95%. This review reinforces the importance of public education, optimization of the local chain of survival, early bystander access and bystander basic life support, and early defibrillation. It emphasizes the role of simplified basic life support algorithms and demonstrates the low incremental benefit of complex skillful protocols employed in ACLS. The impact of automatic external defibrillators and new medications incorporated into ACLS algorithms is evaluated in the light of contemporary research. The persistent, discouraging, low functional survival rate (less than 5% of out-of-hospital cardiac arrest victims) mandates reassessment of current strategies and guidelines.