Electrical storm

Background

Risk factors [1]

  • CAD
  • HFrEF
  • Long QT
  • DM2 is protective

Causes

Clinical Features

Differential Diagnosis

Wide-complex tachycardia

Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)

^Fixed or rate-related

ICD malfunction

Evaluation

  • ECG or clinical history for those with ICDs

Management

Emergency Department

  • Follow current ACLS guidelines if pulseless
  • Analgesia / Sedation for all patients
  • ACC recommends repletion of K to 4.5 in all cases [2]
  • Amiodarone 1st line antiarrhythmic (preferred over lidocaine) for most cases[3]
    • Efficacy of lidocaine highest if actively ischemic
  • Beta blockade: Minimize epinephrine use as much as possible
    • Consider sympathetic blockade as first line over ACLS antiarrhythmics
      • Especially in patients that are high risk CAD
      • 67% vs. 5% survival in 49 patient study, respectively for esmolol/propranolol vs. ACLS antiarrhythmic[4]
      • Patients who survived initial ES event did well over 1 yr follow up
    • Metoprolol 2.5-5mg IV q2-5 min to max of 15mg
    • Propranolol 0.15mg/kg IV over 10 minutes followed by 3-5mg q6h; may be effective even if metoprolol fails
      • More efficacious than metoprolol, terminated VT at 3 hours vs. 18 hours with metoprolol [5]
    • Esmolol 300-500 mcg/kg load over 1 minutes follwed by infusion at 25-50 mcg/kg/min initial dose
  • Exceptions to above are:
    • Torsades with known long QT
      • Magnesium sulfate 1-2 grams IV over 1-2 minutes
      • Potassium repletion
      • If bradycardic between episodes, pace at 90-120 or start Isoproterenol 2 mcg/min and titrate to HR 90-100
      • Consider bolus dose 0.02-0.06mg isoproterenol, then infusion
    • Brugada syndrome[6]
      • Isoproterenol infusion is 1st line
      • Quinidine may be of benefit[7]
        • Due to it's Ito channel blockade
        • Sodium channel blockade may be harmful, however (avoid other Class I antiarrhythmics)
  • Consider isoproterenol in electrical storm in the following situations:
    • Recalcitrant idiopathic ventricular fibrillation, not associated with structural heart, electrical, coronary heart disease
    • Benign early repolarization with J waves[8]
    • Idiopathic ventricular fibrillation with complete right bundle branch block
    • Consider isoproterenol carefully as it has been used to induce ventricular tachycardia by EPs[9]

Inpatient

  • Emergent revascularization if ischemic
  • Ablation
  • Left sympathetic ganglionic blockade
  • Deep sedation / general anesthesia
  • IABP / ECMO
  • Palliative care as this could represent impending terminal failure

Disposition

  • CCU or cath lab

See Also

External Links

References

  1. Brigadeau F et al. Clinical predictors and prognostic significance of electrical storm in patients with implantable cardioverter defibrillators. Eur Heart J 2006;27:700-7.
  2. Zipes DP et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. J Am Coll Card 2006;48(5):e247-346.
  3. Eifling M, Ravazi M, Massumi A. The Evaluation and Management of Electrical Storm. Tex Heart Inst J 2011;38(2):111-21
  4. Nademanee K et al. Treating Electrical Storm: Sympathetic Blockade Versus Advanced Cardiac Life Support–Guided Therapy. Circulation. 2000; 102: 742-747.
  5. Chatzidou, S., Kontogiannis, C., Tsilimigras, D. I., Georgiopoulos, G., Kosmopoulos, M., Papadopoulou, E., … Rokas, S. (2018). Propranolol Versus Metoprolol for Treatment of Electrical Storm in Patients With Implantable Cardioverter-Defibrillator. Journal of the American College of Cardiology, 71(17), 1897–1906.
  6. Jongman JK et al. Electrical storms in Brugada syndrome successfully treated with isoproterenol infusion and quinidine orally. Neth Heart J. 2007 Apr; 15(4): 151–155.
  7. Belhassen B et al. Efficacy of Quinidine in High-Risk Patients With Brugada Syndrome. Circulation. 2004; 110: 1731-1737.
  8. Aizawa Y et al. Electrical storm in idiopathic ventricular fibrillation is associated with early repolarization. J of Am Coll of Card. Vol 62, No 11, 2013.
  9. de Meester A et al. Usefulness of isoproterenol in the induction of clinical sustained ventricular tachycardia during electrophysiological study. Acta Cardiol. 1997;52(1):67-74.