Electrical storm: Clinical management

Abstract

Electrical storm (ES) is defined as three or more sustained episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter-defibrillator (ICD) therapies during a period of 24 h. Electrical storm is a life-threatening situation presenting during the acute phase of myocardial infarction or in patients with various forms of ischemic or nonischemic cardiomyopathy. It requires hospitalization to ensure management of hemodynamically unstable patients and optimization of pharmacologic or non-pharmacologic therapy. Certain triggers or risk factors have been identified for patients presenting with ES, and, in general, ES has been associated with increased mortality and might be an independent risk factor for cardiac death. The cornerstone of ES treatment is the reduction of elevated sympathetic tone by maximizing the dose of beta-blockers, usually in combination with amiodarone and other antiarrhythmic drugs or invasive adrenergic blockade and implantation of an intra-aortic balloon pump. The implantation of ICDs for primary and secondary prevention reduces mortality in patients at high risk for arrhythmic death, yet the rate of ES recurrences is high during follow-up, probably due to advanced structural heart disease. Advances in technology and in our understanding of ventricular tachycardia substrates have led to suppression of malignant arrhythmias by catheter ablation therapy and resynchronization therapy, with acceptable efficacy and safety.