Arrhythmic
Storm (AS) in general is defined as an occurrence of more than two
episodes of malignant ventricular tachycardia in 24 hours. In patients
with ICD AS causes several shocks of defibrillator. Incidence of AS is
almost 11% of ICD patients and mortality is most 25% (Krivan '99). Acute
myocardial ischemia, worsening heart failure, pro arrhythmic effect of
drugs, electrolytic disorders
are main causes of AS. Sedative drugs,
correction of the destabilizing factors and mainly VVI
stimulation 80/90 b/m to reduce in the number of premature ventricular
beats, as trigger of VT are more common therapy.
CASE
REPORT
C.A.,
man 66 years old, is affect from CHD, previous myocardial infarction
and dilatative myocardiopatie with several episodes of Sustained
Ventricular Tachycardia (SVT), symptomatic for
syncope and collapse. Seven month ago we implanted on him AICD
Philax 06 Biotronik. The patient on follow up was treated by amiodarone,
furosemide, ramipril, without evident heath failure. ICD efficaciously
shocked him only one time on previous two months. The patient came in
hospital for SVT and severe collapse. In day after he's affected 29
episodes by TV-FV stopped every time by AICD. After sedative drugs,
xylocaina, beta blocker, and reprogram of AICD 90 b/m, the emodinamic
balance of patient return
to normal condition. The patient discharged after five days.
DISCUSSION
The
main causes of AS in literature is worsening of chronic heart failure
(37%) and ischemia (25%). In 37% of cases the main cause remained
unknown. (Krivan '99).
We
not found evident cause of arrhythmic storm as myocardial ischemia,
electrolytic disorder, hearth failure, but only a severe psychic
depression for the recent
death of her wife. Several studies in literature reported the dangerous
cardiac effect of mental stress. Lampert (2000), recently reported that
mental stress alters VT cycle length and termination without evidence of
ischemia in ICD patients. This suggests that mental stress may lead to
sudden death trough the facilitation of lethal ventricular arrhythmias.
Hoeper reported, in USA, that major depression causes cardiac events the
18-25% of patients with coronaric heart diseases. The mechanism from
psychic depression to cardiac events is hyperactivity of cortico-hypothalamic- hypofisar system
and increased release of ACTH, hypertension,
hypercholesterolemia (Raadasheer).
Psychic
depression strongly actives hadrenergyc system (Cripps), and increases
noradrenaline (Roy) and consequent ventricular arrhythmias hearth attack
and sudden death (Cripps). The subjects with pshycic depression have
higher hearth rate at rest and stress than control (Raadasheer). Frasure
- Smith (2000) showed that depression after myocardial infarction is a
significant predictor of long term cardiac mortality and the risk
associated with depression is greatest among
patient with >10 PVB/hour. This result is compatible with the
literature suggesting an arrhythmic mechanism as the link between
psycological factors and sudden death.
Probably
severe and acute psychic depression in our patient did play an important
role for arrhythmic storm .
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