Electrical Storm with Structural Heart Disease: What to Do When Amiodarone and Beta-Blocker Therapy Has Not Suppressed the Arrhythmia

Clinical Scenario

Electrical storm is defined as three or more episodes of sustained ventricular arrhythmia occurring within 24 hours. This protocol addresses patients with sustained monomorphic ventricular tachycardia causing electrical storm in the setting of structural heart disease, where the arrhythmia has not been controlled by first-line therapy.

Previous Treatment — Escalation Required

First-Line Insufficient

Standard first-line management combines mild to moderate sedation with a non-selective beta-blocker (propranolol) and intravenous amiodarone, along with correction of reversible contributing conditions. When this regimen fails to achieve suppression of ventricular arrhythmia with no recurrent sustained ventricular tachycardia, a next-line approach becomes necessary.

Prior therapy (name only)

Mild to moderate sedation · non-selective beta-blocker (propranolol) · intravenous amiodarone

Next-Step Approach (Partial — Full Protocol Below)

When recurrent, haemodynamically poorly tolerated ventricular tachycardia persists despite amiodarone-based combination therapy, an ultra-short-acting β₁-selective intravenous agent has demonstrated effectiveness for arrhythmia suppression in this refractory setting.

Complete dosing, titration, and monitoring parameters are available in the full structured protocol.

Treatment Goals

Suppression of the ventricular arrhythmia
No recurrent ventricular tachycardia

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehac262

An electrical storm is common in ICD patients and has been defined as three or more episodes of sustained VA occurring within 24 h, requiring either anti-tachycardia pacing (ATP) or cardioversion/defibrillation, with each event separated by at least 5 min.
Antiarrhythmic therapy with beta-blockers (non-selective preferred) in combination with intravenous amiodarone is recommended in patients with SHD and electrical storm unless contraindicated.
In patients with recurrent haemodynamically not-tolerated VTs resistant to amiodarone, landiolol (ultra-short-acting β1-selective blocker) was found to be effective for arrhythmia suppression in two smaller studies.

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