CASE REPORT

Ventricular Tachycardia Storm and Unstable Ventricular Tachycardia in A 48-

years-old Man Following a Non-ST Elevation Myocardial Infarction: A Case Report
Marliau, R. J.1, Supit, A. I.2, Ketaren, I.2
1. General Practitioner at Kharitas Bhakti Hospital, Pontianak, Indonesia
2. Cardiologist at Kharitas Bhakti Hospital, Pontianak, Indonesia
INTRODUCTION:
Ventricular tachycardia (VT) is associated with an increased risk of sudden death. The most common cause is myocardial infarction
(MI), whereas myocardial scar from prior infarct can lead to arrhythmia. VT storm is a presentation of VT in patients with structural
heart disease. It is defined as three or more episodes of sustained VT within 24 hours, which requires intervention in the form of
antiarrhythmic drugs, cardiac pacing, or cardioversion.

CASE DESCRIPTION:
• A 48-years-old man with a history of untreated CAD came to hospital with vomiting and dyspnea. Vital signs: BP 110/70mmHg,
HR 69bpm, RR 24x/m, SpO2 98%. Physical examinations were unremarkable. Blood examinations were within normal limit,
Troponin-I was negative. Chest x-ray showed cardiomegaly. ECG showed trigeminy ventricular extrasystoles.
• The patients suddenly develop severe bradycardia followed by cardiac arrest. In ICCU, the patient had several episodes of
unstable VT and hypotension. Echocardiography showed reduced ejection fraction (LVEF 38%), Troponin-I re-examination was
positive.
• The patient was given IV amiodarone and dobutamine, and electrical cardioversion to treat the unstable VT. Percutaneous
coronary intervention (PCI) was performed, coronary arteriography showed stenosis in the first diagonal branch and chronic
total occlusion in left anterior descendent below the first diagonal branch, PCI to LAD failed due to the hardness of the lesion,
and balloon angioplasty was performed to the diagonal branch.
• After the procedure, the patient becomes stable, heart rhythm returned to normal sinus rhythm with no episode of recurrent
VT. The patient then referred to referral central hospital for further management.

Patient’s ECG during hospitalization Patient’s ECG in ICCU post cardiac arrest Patient’s ECG post PCI
ECG shows trigeminy ventricular extrasytoles ECG return to normal sinus rhythm

DISCUSSION:
• Arrhythmia after MI is a common clinical problem requiring prompt
recognition and treatment. Arrhythmias are more common in patients
who do not undergo timely reperfusion, particularly those with resulting
LVEF depression.1
• The most prevalent form of electrical storm is monomorphic VT storms
linked with structural heart disease, in particular scar tissue following
MI.2
• DC cardioversion is recommended as first-line treatment. Optimal
medical treatment including ACE-I/ARB/ARNIs, MRAs, beta-blockers, and
SGLT2 inhibitors in all heart failure patients with reduced EF.3
• Chronic total occlusion (CTO) can lead to a number of clinical sequelae.
Reports have documented a higher incidence of left ventricular
dysfunction, ventricular arrhythmia, and cardiac death among patients
with a CTO.4
• Percutaneous treatment of CTOs may lead not only to relief of
symptoms, but also to resolution of ventricular arrhythmia by minimizing
underlying ischemia.4

Scheme of drivers for arrhythmias in acute coronary syndromes5

CONCLUSION:
Prior ischemia and infarction scar have an important role in the development of VT in patients with MI. Early recognition and
prompt treatment for VT can prevent the patient from failing into hemodynamic instability dan reduce mortality. PCI may also lead
to resolution of VT by minimizing underlying ischemia.
References:
1. Frampton J, Ortengren AR, Zeitler EP. Arrhythmias After Acute Myocardial Infarction. Yale J Biol Med. 2023 Mar 31;96(1):83-94.
2. Lestari, Puspa et al. Ventricular Tachycardia Storm Management in Acute Cardiac Care: Prompt response to life-threatening conditions. Heart Science Journal, [S.l.], v. 4, n. 1, p. 40-43, jan. 2023.
3. Katja Zeppenfeld, et al, 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death, European Heart Journal, Volume 43, Issue 40, 21 October 2022, Pages 3997–4126.
4. Mixon TA. Ventricular tachycardic storm with a chronic total coronary artery occlusion treated with percutaneous coronary intervention. Proc (Bayl Univ Med Cent). 2015;28(2):196-199.
5. Gorenek B, Blomström Lundqvist C, Brugada Terradellas J, et al. Cardiac arrhythmias in acute coronary syndromes: position paper from the joint EHRA, ACCA, and EAPCI task force. EuroIntervention. 2015;10(9):1095-1108.