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cardio.stemi.with-electrical-storm.v1PRODUCTION
cardio.stemi.with-electrical-storm.v1

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

cardiologyacuteadult
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Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

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

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Advance rule
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Advance when

storm criteria met

Patient inputs (9)

Older patients have higher all-cause mortality with electrical storm; informs sedation tolerance + ablation candidacy

eGFR for sotalol/dofetilide dosing if used; lidocaine accumulates in renal/hepatic failure

STEMI ECG + characterization of storm rhythm (monomorphic VT vs polymorphic VT vs VF; QT prolongation suggests torsades; QRS morphology suggests substrate location)

Goal K ≥4.5 in post-MI storm; hypokalemia + hypomagnesemia precipitate; replete aggressively

Goal Mg ≥2; empiric 2 g IV bolus regardless of level if torsades or polymorphic VT

Trajectory informs reperfusion success + ongoing ischemia as storm trigger

LVEF + scar burden — informs ICD eligibility (MADIT-II EF ≤30) + ablation substrate planning

Hemodynamic stability during storm dictates immediate cardioversion vs medical management; SCAI staging if shock develops

Confirm patent culprit + complete revasc; ongoing ischemia is dominant reversible cause of post-MI storm

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningelectrical_storm_refractory_to_amiodarone_and_beta_blocker
    Storm persists despite amiodarone load + IV beta-blocker + Mg repletion + electrolyte correction
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_vf_arrest_during_storm
    Refractory VF (>3 defibrillations + epinephrine + amiodarone failed) during storm
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningstorm_with_cardiogenic_shock
    Storm + SBP <90 + lactate ≥2 + end-organ dysfunction (SCAI C+) — usually after multiple shocks + AAD-induced hypotension
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningqt_prolongation_with_torsades
    Polymorphic VT with QT prolongation → torsades de pointes (often drug-induced — methadone, fluoroquinolones, ondansetron, AAD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_icd_shocks_post_implant
    Recurrent appropriate ICD shocks post-implant (≥3 in 24 h) → ICD storm — peri-infarct or remodeling-substrate driven
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

STEMI electrical-storm overlay — adds IV beta-blocker + amiodarone + lidocaine + magnesium + deep sedation to parent cardio.stemi.core.v1 reperfusion regimen
axis: stemi_electrical_storm_overlay
Selected axis "STEMI electrical-storm overlay — adds IV beta-blocker + amiodarone + lidocaine + magnesium + deep sedation to parent cardio.stemi.core.v1 reperfusion regimen" by default fallback (first axis)
  • aspirin
    first line
    antiplatelet_cox1
    162-325 mg chewed • PO • load + 81 mg daily
    triggers: stemi_with_electrical_storm
    ACC/AHA 2025 ACS Class I; same as parent
    rxcui 243670
  • ticagrelor
    first line
    p2y12_inhibitor
    180 mg load → 90 mg BID • PO • BID × 12 mo
    triggers: stemi_pci_planned
    PLATO PMID 19717846; same as parent
    rxcui 1116632
  • metoprolol_iv
    first line
    beta1_selective_blocker
    5 mg IV q5min × 3 doses; titrate to HR 60-80 + storm suppression • IV • q5min × 3 then PO
    triggers: electrical_storm_stable_bp, recurrent_vt_vf_post_mi
    AHA 2017 VA management Class I (PMID 29084731) — IV beta-blocker is first-line storm therapy; sympathetic surge drives storm
    rxcui 6918
  • amiodarone
    first line
    antiarrhythmic_class_iii
    150 mg IV bolus over 10 min → 1 mg/min × 6 h → 0.5 mg/min • IV • continuous infusion × 24 h
    triggers: electrical_storm, recurrent_vt_vf_post_mi, wide_complex_tachycardia
    AHA 2017 VA management Class IIa (PMID 29084731); ALIVE trial; first-line AAD for storm + post-arrest VT/VF
    rxcui 203114
  • lidocaine
    second line
    antiarrhythmic_class_ib
    1-1.5 mg/kg IV bolus → 1-4 mg/min infusion • IV • continuous infusion
    triggers: amiodarone_refractory_storm, monomorphic_vt_post_mi
    AHA 2020 ACLS Class IIb alternative when amiodarone unavailable or refractory; particularly useful in ischemic substrate
    rxcui 6387
  • magnesium_sulfate
    first line
    electrolyte_repletion
    2 g IV bolus over 5-10 min; repeat × 1-2 if torsades or persistent storm • IV • bolus
    triggers: torsades_de_pointes, polymorphic_vt, electrical_storm_with_low_or_normal_mg
    Class I for torsades; empiric repletion in storm regardless of serum level — intracellular Mg often depleted; AHA 2020 ACLS
    rxcui 6585
  • propofol
    first line
    sedative_gaba_agonist
    1-2 mg/kg IV bolus then 25-100 mcg/kg/min infusion (intubate first) • IV • continuous infusion
    triggers: recurrent_icd_shocks_or_intractable_storm, storm_requiring_deep_sedation
    Deep sedation breaks the catecholamine-driven storm cycle; propofol preferred (rapid titration); intubation required; AHA 2017 VA Class IIa
    rxcui 8782

outpatient playbook — drug actions (1)

  1. 1. continue secondary-prevention bundle
    rxcui 243670
    ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT + amiodarone 200 daily • PO • as scheduled
    trigger: post-storm
    AHA 2025 + AHA 2017 VA

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ≥3 episodes sustained VT/VF (or appropriate ICD therapies) within 24 h post-MI = electrical storm; Recurrent polymorphic VT on telemetry post-MI — peri-infarct ischemia until proven otherwise; Recurrent appropriate ICD shocks in post-MI patient (≥3 in 24 h) → ICD storm.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**STEMI complicated by ventricular electrical storm (≥3 sustained VT/VF/24 h)** (cardio.stemi.with-electrical-storm.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **STEMI electrical-storm overlay — adds IV beta-blocker + amiodarone + lidocaine + magnesium + deep sedation to parent cardio.stemi.core.v1 reperfusion regimen**.
1. aspirin 162-325 mg chewed PO load + 81 mg daily (antiplatelet_cox1, first line) — ACC/AHA 2025 ACS Class I; same as parent
2. ticagrelor 180 mg load → 90 mg BID PO BID × 12 mo (p2y12_inhibitor, first line) — PLATO PMID 19717846; same as parent
3. metoprolol_iv 5 mg IV q5min × 3 doses; titrate to HR 60-80 + storm suppression IV q5min × 3 then PO (beta1_selective_blocker, first line) — AHA 2017 VA management Class I (PMID 29084731) — IV beta-blocker is first-line storm therapy; sympathetic surge drives storm
4. amiodarone 150 mg IV bolus over 10 min → 1 mg/min × 6 h → 0.5 mg/min IV continuous infusion × 24 h (antiarrhythmic_class_iii, first line) — AHA 2017 VA management Class IIa (PMID 29084731); ALIVE trial; first-line AAD for storm + post-arrest VT/VF
5. lidocaine 1-1.5 mg/kg IV bolus → 1-4 mg/min infusion IV continuous infusion (antiarrhythmic_class_ib, second line) — AHA 2020 ACLS Class IIb alternative when amiodarone unavailable or refractory; particularly useful in ischemic substrate
6. magnesium_sulfate 2 g IV bolus over 5-10 min; repeat × 1-2 if torsades or persistent storm IV bolus (electrolyte_repletion, first line) — Class I for torsades; empiric repletion in storm regardless of serum level — intracellular Mg often depleted; AHA 2020 ACLS
7. propofol 1-2 mg/kg IV bolus then 25-100 mcg/kg/min infusion (intubate first) IV continuous infusion (sedative_gaba_agonist, first line) — Deep sedation breaks the catecholamine-driven storm cycle; propofol preferred (rapid titration); intubation required; AHA 2017 VA Class IIa

Setting playbook (outpatient) — Long-term cardiology + EP surveillance: ICD interrogation cadence, amiodarone toxicity surveillance (TSH/LFT/PFT q6mo), cardiac rehab completion, secondary-prevention bundle, mental health
8. continue secondary-prevention bundle ASA 81 + ticagrelor 90 BID × 12 mo + atorvastatin 80 + GDMT + amiodarone 200 daily PO as scheduled — post-storm (AHA 2025 + AHA 2017 VA)

Non-pharmacologic actions:
- ICD interrogation per device protocol
- Cardiac rehab maintenance phase
- Driving restriction per state law (often 6 mo after VF/VT arrest)
- PTSD therapy if post-shock anxiety

AVOID / contraindication checks:
- Metoprolol_iv_avoid_severe_bradycardia_or_high_grade_av_block
- Amiodarone_avoid_severe_qt_prolongation_or_torsades_active
- Lidocaine_dose_reduce_severe_hepatic_or_renal_failure
- Propofol_requires_intubation_and_continuous_monitoring
- Procainamide_avoid_severe_hf_or_renal_failure (alt to amiodarone)

Monitoring

Regimen monitoring:
- continuous telemetry with rhythm review q15min during storm
- arterial line continuous
- serial k mg q6h repletion to k 4.5 mg 2
- qtc pre and post aad loading
- qtc q24h during amiodarone infusion
- echo at 5-7d for lvef and substrate

Setting (outpatient) monitoring:
- Quarterly + annual EF + lipid + ICD check
- Amiodarone toxicity surveillance (TSH/LFT/PFT)

Follow-up plan: 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)
- Close-out criterion: ICD implant scheduled + cardiac rehab booked + mental health follow-up arranged

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term cardiology + EP surveillance: ICD interrogation cadence, amiodarone toxicity surveillance (TSH/LFT/PFT q6mo), cardiac rehab completion, secondary-prevention bundle, mental health

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- Amiodarone pulmonary toxicity → discontinue + alternative AAD (sotalol, dofetilide)
- Recurrent storm → ablation per VANISH

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Storm persists despite amiodarone load + IV beta-blocker + Mg repletion + electrolyte correction
- [LIFE_THREATENING] Refractory VF (>3 defibrillations + epinephrine + amiodarone failed) during storm
- [LIFE_THREATENING] Storm + SBP <90 + lactate ≥2 + end-organ dysfunction (SCAI C+) — usually after multiple shocks + AAD-induced hypotension

Citations

- 2025 ACC/AHA ACS Guideline + AHA 2017 VA Management Consensus + ESC 2022 Ventricular Arrhythmias [PMID:37622670](https://pubmed.ncbi.nlm.nih.gov/37622670/)
- Cited evidence (PMID 29084731) [PMID:29084731](https://pubmed.ncbi.nlm.nih.gov/29084731/)
- Cited evidence (PMID 27149033) [PMID:27149033](https://pubmed.ncbi.nlm.nih.gov/27149033/)
- Cited evidence (PMID 33308475) [PMID:33308475](https://pubmed.ncbi.nlm.nih.gov/33308475/)
- Cited evidence (PMID 9411221) [PMID:9411221](https://pubmed.ncbi.nlm.nih.gov/9411221/)

Last reconciled with current guidelines: 2026-05-14.
References