VT storm

#Electrical storm
Admitted with electrical storm as defined by >= 3x *** [ symptoms or shocks ] within 24 hours with confirmed VT on *** [tele, device interrogation ]. Considered triggers include QT-prolonging drugs or substances, electrolyte disturbance, heart failure, ACS, thyrotoxicosis.
## Dx:
- [ ] BMP/Mg, UDS, BNP, TFTs
- [ ] EKG/trop
- [ ] CXR
- [ ] TTE (if c/f CHF)
- [ ] Med review (for QT prolonging medications)
- [ ] Device interrogation (if s/p PPM, CRT)

## Initial tx
- HDUS —> ACLS (electrical cardioversion!); if successful, initiate antiarrhythmic therapy with amio as below
- HDS —> IV amio (150 mg  x 10 min f/b 1 mg/min x 6h f/b 0.5 mg/min x 18 h)  + propranolol (PO 40 mg Q6H x 48 h); Amio preferred over lido, procainamide given superior efficacy for VT termination; Beta blockade reduces adrenergic surge associated with VT and defibrillator shocks (which contributes to VT via increased sympathetic output); Propranolol, a non-selective beta-blocker, is more efficacious than B1-selective agents (eg metop)
- If component of ischemia, urgent revascularization indicated

## Long-term arrhythmia control:
- Catheter ablation: recommended for patients with persistence of electrical storm or incessant VT despite medical rx with amio and beta blocker
- Maintenance oral antiarrhythmic therapy indicated for recurrence of VT after catheter ablation
- If component of heart failure, initiate or uptitrate GDMT
- Initiate appropriate GDMT