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ICD Electrical Storm — RACP Adult Medicine MCQ

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HardCardiologyICD Electrical StormRACP Adult Medicine

A 55-year-old man with an ICD for ischaemic cardiomyopathy (LVEF 28%) receives 3 ICD shocks in 1 hour. He is haemodynamically stable. Telemetry shows the shocks were appropriate (for sustained monomorphic VT). He is on amiodarone 200 mg daily and metoprolol 100 mg BD. Electrolytes are normal. What is the most appropriate acute management?

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Correct answer: D — IV amiodarone loading + optimise beta-blocker + catheter ablation referral

Electrical storm (≥3 appropriate ICD shocks in 24 hours) is a medical emergency. Management: (1) IV amiodarone loading (300 mg then 900 mg/24h), (2) optimise beta-blocker (IV esmolol or increase metoprolol), (3) correct reversible causes (electrolytes, ischaemia), (4) sedation for patient comfort, (5) urgent referral for catheter ablation (definitive treatment for recurrent VT). If refractory: general anaesthesia ± neuraxial blockade (stellate ganglion block/thoracic epidural). Do NOT deactivate ICD unless comfort care decision.

Reference: CSANZ – 2024 – VT Management; ESC 2022 VA/SCD; HRS 2024