[Electrical storm : Recognition and management]

The electrical storm (ES) defined as ≥3 sustained episodes of ventricular tachycardia within a 24 h period comprises a wide spectrum of clinical entities. Mostly patients suffer from severe heart insufficiency and comorbidities making an immediate transfer into a heart center with multidisciplinary expertise in the treatment of ES mandatory. As these patients are often traumatized by ongoing tachycardia despite multiple cardioversions, early deep sedation and β‑blockade to break the vicious circle of sympathico-adrenergic hyperactivation is very effective. Multiple ICD discharges suggesting the diagnosis of ES are inadequate in one third of cases. Pharmacological suppression, frequency control or ablation of supraventricular tachycardias (SVT) help in most cases. In some cases "oversensing" demands optimization of ICD programming. Even so not all adequate ICD discharges, however, are necessary. Since every ICD discharge worsens the patient's prognosis, any kind of ICD discharge should be prevented as far as hemodynamically feasible. After clinical stabilization of the patient with simultaneous acquisition of ECG and testing for reversible causes of ES, ES should be terminated by external or internal cardioversion followed by urgent but elective therapy. Some cases of ES, however, may require immediate escalation of therapy with emergency ablation or revascularization sometimes with circulatory support systems. If ES still persists, a further step in escalation may be taken by cardiac sympathetic denervation. Due to the poor prognosis of patients after ES, close monitoring of the patient, preferably with telemedicine, is indicated.