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European Heart Journal Advance Access published online on October 18, 2006
European Heart Journal, doi:10.1093/eurheartj/ehl276
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European Heart Journal © The European Society of Cardiology 2006; all rights reserved
Received March 7, 2006
Revised July 25, 2006
Accepted September 11, 2006

Clinical research

Electrical storm in patients with an implantable defibrillator: incidence, features, and preventive therapy: insights from a randomized trial

Stefan H. Hohnloser 1 *, Hussein R. Al-Khalidi 2, Craig M. Pratt 3, Jose M. Brum 2, Daljit S. Tatla 2, Patrick Tchou 4, and Paul Dorian 5, on behalf of the SHock Inhibition Evaluation with AzimiLiDe (SHIELD) Investigators

1 Division of Electrophysiology, Department of Cardiology, J.W. Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
2 Procter & Gamble Pharmaceuticals, Health Care Research Center, Cincinnati, OH, USA
3 The Methodist DeBakey Heart Center, Houston, TX, USA
4 Cleveland Clinic Foundation, Cardiology Department, Cleveland, OH, USA
5 Division of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada

* To whom correspondence should be addressed.
Stefan H. Hohnloser, E-mail: hohnloser{at}em.uni-frankfurt.de


  Abstract

Aims The purpose of this study was to assess the incidence, features, and clinical sequelae of ‘electrical storm’ (ES).

Methods and results This study is a prospectively designed secondary analysis of SHIELD; a randomized trial of azimilide for suppression of ventricular tachycardia/fibrillation (VT/VF) leading to implanted cardioverter defibrillator (ICD) therapies. Systematic and rigorous follow-up and blinded adjudication of ICD therapy allowed identification of all ESs (≥3 separate VT/VF episodes leading to ICD therapies within 24 h). Of 633 ICD recipients, 148 (23%) experienced at least one ES over 1-year follow-up. No clinical predictors of ES were identified. Frequent VT episodes accounted for 91% of all ESs, with the remaining being VF alone or both VT plus VF. ES led to a 3.1-fold increase in arrhythmia-related hospitalization (95% CI 2.3-4.3; P < 0.0001) compared with patients with isolated VT/VF, and to a 10.2-fold increase (95% CI 6.4-16.3; P < 0.0001) compared with patients without VT/VF. Compared with placebo, azimilide (75 and 125 mg/day) reduced the risk of recurrent ES by 37% (HR=0.63, 95% CI 0.35-1.11, P = 0.11) and 55% (HR=0.45, 95% CI 0.23-0.87, P = 0.018), respectively. However, the reduction in time-to-first ES did not reach statistical significance by both doses (75 and 125 mg) of azimilide (HR=0.82, 95% CI 0.56-1.19, P = 0.29 and HR=0.69, 95% CI 0.46-1.04, P = 0.07), respectively.

Conclusion ES is common and unpredictable in ICD recipients and it is a strong predictor of hospitalization.

Keywords: Azimilide dihydrochloride; Implantable cardioverter defibrillator; Antiarrhythmic therapy; Ventricular tachycardia storms.
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