Electrical storm is defined as a recurrent episode of hemodynamically destabilizing ventricular tachyarrhythmia that usually requires electrical cardioversion or defibrillation. We describe three cases presenting with electrical storm under differing circumstances: (1) a 57-year-old man with ST-elevation myocardial infarction within 1 week of a posterior circulation stroke who developed refractory sustained ventricular tachycardia 10 days after an acute myocardial infarction; (2) a 65-year-old man who developed polymorphic ventncular tachycardia and ventricular fibrillation following dobutamine echocardiography; and (3) a 20-year-old woman who developed intractable ventricular fibrillation following an overdose of a weight-reduction pill. The management of electrical storm is discussed, and evolving literature supporting the routine use of intravenous amiodarone and β-blockers in place of intravenous lidocaine is critically examined.
1. Dorian P, Cass D.An overview of the management of electrical storm. Can J Cardiol13(A):13A-17A, 1997
2.
2. Hine LK, Laird N, Hewitt P, et al. Meta-analytic evidence against prophylactic use of lidocaine in acute myocardial infarction. Arch Intern Med149:2694-2698, 1989
3.
3. MacMahon S, Collins, Petro R, et al. Effects of prophylactic lidocaine in suspected myocardial infarction: An overview of the results from the randomized, controlled trials. JAMA250:1910-1916, 1988
4.
4. The Cardiac Arrhythmia Suppression Trial II Investigators: Preliminary Report. Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med321:406-412, 1989
5.
5. Srivasta U, Wadhani N, Singh BN. Mechanisms of antiarrhythmic drug actions and their clinical relevance for controlling disorders of cardiac rhythm. Curr Cardiol Rep4:401-410, 2002
6.
6. Singh BN. Routine prophylactic lidocaine administration in acute myocardial infarction. An idea whose time is all but gone? Circulation86:1033-1035, 1992
7.
7. Antman EM, Berlin JA. Declining incidence of ventricular fibrillation in myocardial infarction: Implications for the prophylactic use of lidocaine. Circulation86:1085-1091, 1992
8.
8. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: An international consensus on science. Advanced cardiovascular life support. 5. Pharmacology 1: Agents for arrhythmias. Circulation102 (suppl):112-128, 2000
9.
9. Scheinman MM, Levine JH, Cannom DS, et al. Dose-ranging study of intravenous amiodarone in patients with life threatening ventricular tachyarrhythmias. Circulation92:3264-3272, 1995
10.
10. Kowey P, Levine J, Herre J, et al. Randomized doubleblind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent hemodynamically destabilizing ventricular tachycardia or fibrillation. Circulation92:3255-3263, 1995
11.
11. Levine JH, Massumi A, Scheinman MM, et al. Intravenous amiodarone for recurrent sustained hypotensive ventricular tachyarrhythmias. J Am Coll Cardiol27:67-75, 1996
12.
12. Kudenchuk PJ, Cobb L, Copass M, et al. Amiodarone for resuscitation after out of hospital cardiac arrest due to ventricular fibrillation. N Engl J Med341:871-878, 1999
13.
13. Dorian P, Cass D, Schwartz B, et al. Amiodarone as compared with lidocaine for shock resistant ventricular fibrillation. N Engl J Med346:884-890, 2002
14.
14. β-Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction. Mortality results. JAMA247:1707-1714, 1982
15.
15. Hjalmarson A, Herlitz J, Malek I, et al. Effect on mortality of metoprolol in acute myocardial infarction. A double blind randomized trial. Lancet17:823-827, 1981
16.
16. Ryden L, Ariniego R, Amman K, et al. A double blind trial of metoprolol in acute myocardial infarction. Effects on ventricular tachyarrhythmias. N Engl J Med308:614-618, 1983
17.
17. Teerlink JR, Massie BM. Beta-adrenergic blocker mortality trials in congestive heart failure. Am J Cardiol84(9A):94R-102R, 1999
18.
18. Nademanee K, Taylor R, Bailey W, et al. Treating electrical storm: Sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation102(7):742-747, 2000
19.
19. Kennedy HL, Brooks MM, Barker AH, et al for the CAST Investigators. Beta-blocker therapy in the Cardiac Arrhythmia Suppression Trial. Am J Cardiol74:674-680, 1994
20.
20. Boutitie F, Boissel JP, Connolly SJ, et al. Amiodarone interaction with beta-blockers: Analysis of the merged EMIAT and CAMIAT databases. Circulation99:2268-2275, 1999
21.
21. Ogunyankin KO, Singh BN. Mortality reduction by antiadrenergic modulation of arrhythmogenic substrate: Significance of combining beta-blockers and amiodarone. Am J Cardiol84:76R-82R, 1999
22.
22. Cairns JA, Connolly SJ, Roberts R, et al. Randomized trial of outcome after myocardial infarction in patients with frequent repetitive ventricular premature depolarizations. CAMIAT. Lancet349:672-682, 1997
23.
23. Julian DG, Camm AJ, Frangin G, et al. Randomized trial of effect of amiodarone on mortality in patients with left ventricular dysfunction after myocardial infarction: EMIAT. Lancet349:667-674, 1997
24.
24. Picano E, Mathias Jr W, Pingitore A, et al. Safety and tolerability of dobutamine-atropine stress echocardiography: A prospective multicenter study. Lancet344:1190-1192, 1994
25.
25. Poldermans D, Fioretti PM, Boersma E, et al. Safety of dobutamine-atropine stress echocardiography in patients with suspected or proven coronary artery disease. Am J Cardiol73(7):456-459, 1994
26.
26. Dharmananda, S.Synephrenine: Is chih-shih (zhishi) toxic?www.itmonline.org/arts/syneph.htm. Last accessed 12 July 2003.
27.
27. Greene HL. Interactions between pharmacologic and non pharmacologic antiarrhythmic therapy. Am J Cardiol78(suppl 4A):61-66, 1996
28.
28. Singh BN. Initial antiarrhythmic drug therapy during resuscitation from sudden cardiac death: A time for a fundamental change in strategy?J Cardiovasc Pharmacol Therapeut5:3-9, 1999
29.
29. Singh BN. Amiodarone compared with lidocaine for shock-resistant ventricular fibrillation. A clinical trial report. Curr Cardiol Rep4:399-340, 2002
