How to manage ventricular tachycardia (VTach) in a patient with multiple sclerosis (MS) who has undergone percutaneous endoscopic gastrostomy (PEG) placement?

Management of Ventricular Tachycardia in MS Patient After PEG Placement

Immediate treatment with amiodarone is recommended for ventricular tachycardia in a patient with multiple sclerosis who has undergone PEG placement, as ventricular arrhythmias can lead to hemodynamic instability and end-organ dysfunction despite being generally well-tolerated in most patients. 1, 2

Initial Assessment and Management

• Evaluate hemodynamic stability immediately, as prolonged ventricular tachycardia can contribute to low flow and ultimately end-organ dysfunction, requiring prompt intervention 2
• Initiate amiodarone treatment with an initial rapid loading infusion, followed by a slower 6-hour loading infusion, and then an 18-hour maintenance infusion for acute management of ventricular tachycardia 1
• Monitor for hypotension during amiodarone administration, as treatment-emergent hypotension occurs in approximately 16% of patients treated with amiodarone injection 1
• Consider the possibility that the VT may be related to cardiovascular autonomic dysfunction, which is common in MS patients and can manifest as impaired heart rate variability with increased sympathetic cardiovascular tone 3

Special Considerations for MS Patients

• Be vigilant for fever which can worsen MS symptoms and may be mistaken for an MS relapse (pseudo-relapse); maintain controlled normothermia (targeting core temperature 36.0-37.5°C) 4
• Use antipyretics promptly if fever develops, as temperature elevation can exacerbate existing MS symptoms 4
• Consider that cardiovascular dysfunction in MS may be caused by brainstem lesions affecting autonomic pathways, overall plaque burden, or clinical severity of the disease 5
• Recognize that MS patients may have underlying cardiovascular dysautonomia that could complicate the arrhythmia management 3

Post-PEG Placement Considerations

• Monitor for potential post-PEG complications such as infection, which is the most common postoperative complication and could trigger arrhythmias if systemic infection develops 6
• Ensure prophylactic antibiotics were administered during PEG placement to reduce risk of peristomal wound infection that could lead to systemic complications 6, 7
• Be aware that PEG placement under non-invasive ventilation has been shown to be safe and effective in patients with neurological conditions and severe ventilatory impairment, which may be relevant if the MS patient has respiratory compromise 8

Ongoing Management

• After acute stabilization with IV amiodarone, transition to oral amiodarone for continued management as indicated by the FDA label 1
• Consider electrophysiology consultation as part of a multidisciplinary management approach for ventricular arrhythmias 2
• Monitor for potential cardiovascular side effects of MS therapies that may contribute to arrhythmias, such as fingolimod which can cause bradycardia or mitoxantrone which may cause cardiomyopathy 5
• Perform cardiac monitoring during the acute phase and follow-up to assess response to treatment and detect any recurrence of arrhythmias 2

Potential Pitfalls and Caveats

• Be cautious with sedative medications in MS patients with respiratory compromise, as they may worsen respiratory function 8
• Monitor for amiodarone-related adverse effects, particularly hypotension during the initial infusion period 1
• Recognize that MS patients may have altered autonomic function that could affect their response to antiarrhythmic medications 3
• Consider that the stress of the recent PEG procedure may have contributed to the development of ventricular tachycardia, and address any procedural complications promptly 6, 7