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cardio.stemi.with-electrical-storm.v1

STEMI complicated by ventricular electrical storm (≥3 sustained VT/VF/24 h)

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E adjacent-disease overlay of cardio.stemi.core.v1 — STEMI complicated by ventricular electrical storm (≥3 sustained VT/VF in 24 h). Inherits reperfusion + antiplatelet + statin regimen from parent via routing; specializes for the multi-modal AAD + deep sedation + stellate ganglion block + ablation + ECPR pathway. Storm management hierarchy per AHA 2017 VA consensus (PMID 29084731): IV beta-blocker → amiodarone → lidocaine → magnesium → deep sedation → stellate ganglion block → catheter ablation (VANISH PMID 27149033) → ECPR (ARREST PMID 33308475) for refractory VF. ICD secondary-prevention per AVID PMID 9411221 once acute reversible causes addressed. Mental health follow-up critical — PTSD risk substantial after recurrent shocks. Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (overlay-specific differences documented inline in this dossier). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E recursive-depth wave 7 overlay.

Entry points (3)

  • symptom
    ≥3 episodes sustained VT/VF (or appropriate ICD therapies) within 24 h post-MI = electrical storm
    three_or_more_sustained_vt_vf_in_24h_post_mi
  • imaging
    Recurrent polymorphic VT on telemetry post-MI — peri-infarct ischemia until proven otherwise
    recurrent_polymorphic_vt_post_mi_on_telemetry
  • history
    Recurrent appropriate ICD shocks in post-MI patient (≥3 in 24 h) → ICD storm
    recurrent_icd_therapies_in_post_mi_patient

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Older patients have higher all-cause mortality with electrical storm; informs sedation tolerance + ablation candidacy
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic stability during storm dictates immediate cardioversion vs medical management; SCAI staging if shock develops
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    STEMI ECG + characterization of storm rhythm (monomorphic VT vs polymorphic VT vs VF; QT prolongation suggests torsades; QRS morphology suggests substrate location)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Goal K ≥4.5 in post-MI storm; hypokalemia + hypomagnesemia precipitate; replete aggressively
  • magnesiumrequired
    lab • used at INITIAL_WORKUP
    Goal Mg ≥2; empiric 2 g IV bolus regardless of level if torsades or polymorphic VT
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Trajectory informs reperfusion success + ongoing ischemia as storm trigger
  • creatininerequired
    lab • used at CONTEXT
    eGFR for sotalol/dofetilide dosing if used; lidocaine accumulates in renal/hepatic failure
  • echo_post_pcirequired
    imaging • used at MONITORING
    LVEF + scar burden — informs ICD eligibility (MADIT-II EF ≤30) + ablation substrate planning
  • cor_angiorequired
    imaging • used at TREATMENT
    Confirm patent culprit + complete revasc; ongoing ischemia is dominant reversible cause of post-MI storm

12-phase flow (10)

  1. 1FRAME
    Electrical storm = ≥3 sustained VT/VF in 24 h post-MI; high mortality without aggressive multi-modal management; route to cardio.stemi.core.v1 for the reperfusion arc; storm management is the dominant clinical problem
    inputs: ecg
    advance: storm criteria met
  2. 2ENTRY
    Cath lab activation if not yet reperfused; EP team activation; anesthesia consult for stellate ganglion block + deep sedation; MCS team standby for refractory storm with shock
    inputs: age, sbp
    advance: EP + anesthesia + cath lab + MCS team alerted
  3. 3CONTEXT
    Electrolytes (K, Mg), recent antiarrhythmic exposure, QT interval, prior ICD status, hepatic/renal function for AAD dosing
    inputs: potassium, magnesium, creatinine
    advance: metabolic + drug context complete
  4. 4RED_FLAGS
    Hemodynamic instability during storm → STAT cardioversion / defibrillation; refractory VF → ECPR per ARREST PMID 33308475; shock + storm → MCS bridge
    inputs: sbp
    actions: wide_complex_tach, cardiogenic_shock
    advance: shock + airway + sedation plan documented
  5. 5INITIAL_WORKUP
    ECG + telemetry rhythm strip review; electrolytes + Mg + troponin + BMP; characterize storm rhythm (monomorphic VT vs polymorphic VT vs VF; QT length)
    inputs: ecg, potassium, magnesium, troponin, creatinine
    actions: acs_pathway, wide_complex_tach, panel.cardiac, panel.renal
    advance: rhythm characterized + reversible causes screened
  6. 6BRANCHING_WORKUP
    Confirm patent culprit on cor_angio (treat ongoing ischemia); echo for LVEF + scar; consider STAT EP electrophysiology study + acute catheter ablation if storm refractory to AAD per VANISH
    inputs: cor_angio
    advance: reversible causes addressed + ablation candidacy assessed
  7. 7TREATMENT
    Multi-modal storm management: (1) IV beta-blocker (esmolol or metoprolol IV — Class I per AHA 2017); (2) amiodarone 150 mg IV bolus → 1 mg/min × 6 h then 0.5 mg/min (Class IIa); (3) lidocaine 1-1.5 mg/kg if amiodarone refractory; (4) magnesium 2 g IV (especially torsades); (5) deep sedation with propofol if recurrent shocks (intubate); (6) stellate ganglion block (anesthesia) for refractory; (7) catheter ablation per VANISH; (8) ECPR for refractory VF per ARREST
    inputs: sbp, creatinine
    actions: protocol.stemi
    advance: storm controlled or escalation pathway delivered
  8. 8DISPOSITION
    CICU mandatory; longer monitoring than uncomplicated STEMI; arterial line + telemetry continuous; deep sedation if intubated
    advance: unit assigned + sedation + AAD plan documented
  9. 9MONITORING
    Continuous telemetry; arterial line; serial K + Mg q6h with replacement to keep K ≥4.5 + Mg ≥2; daily QT interval; echo at 5-7 d for LVEF + scar reassessment
    inputs: echo_post_pci
    actions: panel.cardiac
    advance: storm-free × 24 h + AAD plan + ICD pathway documented
  10. 10FOLLOWUP
    Cardiology + EP follow-up; ICD secondary-prevention per AVID PMID 9411221 (any sustained VT/VF post-acute period not from reversible cause); WCD bridge during peri-MI window if EF <35; cardiac rehab; mental health (PTSD risk after recurrent shocks)
    advance: ICD implant scheduled + cardiac rehab booked + mental health follow-up arranged