Multidisciplinary Critical Care Management of Electrical Storm: Key Points

Jentzer JC, Noseworthy PA, Kashou AH, et al., on behalf of the American College of Cardiology Critical Care Cardiology and Electrophysiology Sections.
Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review. J Am Coll Cardiol 2023;81:2189-2206.

The following are key points to remember from a state-of-the-art review on multidisciplinary critical care management of electrical storm:

  1. Development of electrical storm usually requires both an arrhythmic substrate and a proarrhythmic trigger. Most electrical storms develop due to either structural heart disease or pathogenic ion channel defects.
  2. A 12-lead electrocardiogram should be obtained during both the native rhythm and ventricular tachycardia (VT).
  3. Reversible triggers are myocardial ischemia, worsening heart failure (HF), or volume overload causing myocardial stretch, infection, medication changes causing drug toxicity or QT prolongation, imbalances in autonomic activity, noncardiac organ failure, thyrotoxicosis, and electrolyte abnormalities.
  4. A coronary angiogram is often indicated to identify obstructive coronary artery disease even for patients without clear evidence of acute myocardial infarction (AMI).
  5. Echocardiography should be done to identify structural heart disease and perform noninvasive hemodynamic assessment. Cardiac magnetic resonance imaging or positron emission tomography can identify occult structural heart disease or active myocardial inflammation.
  6. New, worsening, or severe ventricular dysfunction should raise suspicion for progressive cardiomyopathy, and evidence of advanced HF should be investigated.
  7. Patients with implantable cardioverter-defibrillators (ICDs) are at reduced risk for sudden death. ICDs should be interrogated and adjustments can be made to the devices to reduce the number of shocks.
  8. The most effective intervention for acute termination of ventricular arrhythmia (VA) is synchronized electrical cardioversion or unsynchronized defibrillation, either externally or using an existing ICD.
  9. The acute efficacy for VT termination appears to be greatest for procainamide, intermediate for amiodarone and sotalol, and lowest for lidocaine.
  10. Procainamide is contraindicated in severe structural heart disease, decompensated HF, AMI, and advanced kidney disease. Therefore, intravenous (IV) amiodarone is frequently used to treat VT.
  11. Sotalol and amiodarone (particularly IV amiodarone) have beta-blocking properties, but adding another beta-blocker can enhance their efficacy. Adding or up-titrating a guideline-directed medical therapy beta-blocker (e.g., metoprolol succinate, bisoprolol, carvedilol) can be considered, although the alpha-1 blockade produced by carvedilol often causes dose-limiting hypotension.
  12. Catheter ablation is essential to consider for patients with electrical storm to either terminate incessant VA or prevent recurrent VA after medical stabilization.
  13. Peri-ablation acute hemodynamic decompensation is associated with a higher likelihood of procedural failure, more VT recurrence, and increased in-hospital and long-term mortality. Preprocedural optimization of hemodynamics, avoidance of general anesthesia if possible, and choosing substrate modification over VT induction in higher-risk patients can reduce harm.
  14. Electrical storm occurs in up to 10% of patients after left ventricular assist device and is associated with high 1-year mortality.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Adrenergic beta-Antagonists, Arrhythmias, Cardiac, Cardiomyopathies, Catheter Ablation, Coronary Angiography, Death, Sudden, Defibrillators, Implantable, Diagnostic Imaging, Drug-Related Side Effects and Adverse Reactions, Echocardiography, Electrocardiography, Electric Countershock, Heart Failure, Hemodynamics, Inflammation, Kidney Diseases, Long QT Syndrome, Magnetic Resonance Imaging, Myocardial Infarction, Myocardial Ischemia, Patient Care Team, Tachycardia, Ventricular, Thyrotoxicosis, Ventricular Dysfunction

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