The Cardiovascular Side Effects of Electroconvulsive Therapy and Their Management

Venlafaxine During Electroconvulsive Therapy Is Associated With the Postictal Administration of Antihypertensive Medication

INTRODUCTION

Electroconvulsive therapy (ECT) is a highly effective treatment for severe depression and commonly administered with concomitant antidepressant medication. ECT is associated with short-lived and self-limiting changes in blood pressure. Thus, additional medications that potentially elevate blood pressure, such as antidepressants with noradrenergic effects, might be of special concern during ECT.

METHODS

We retrospectively analyzed data from patients in which the same patient received some ECT sessions with and some without concomitant venlafaxine medication. To assess whether concomitant venlafaxine medication increased the likelihood that patients required antihypertensive medication after ECT, we used mixed-effects logistic regression. We restricted our analysis to high-risk patients with at least 1 recorded systolic blood pressure >200 mmHg during their ECT series.

RESULTS

We identified 56 patients who received some of their ECT sessions with and some without concomitant venlafaxine, in total 1173 ECT treatments. Among these, 40 patients had at least 1 systolic blood pressure measurement >200 mmHg. The 396 ECT treatments of these 40 patients were further analyzed. The odds for postictal administration of antihypertensive medication in the treatment room were significantly higher when patients received concomitant venlafaxine medication (odds ratio, 5.46; P = 0.015) and in older patients (OR, 3.28; P = 0.019).

CONCLUSIONS

Concomitant venlafaxine medication could increase the likelihood that patients need antihypertensive medication during ECT treatment, especially patients at high risk for hypertension. Clinicians should be aware of this association and consider either adjusting the venlafaxine dose or adapting the timing of its administration during an ECT series.

Raised Intracranial Pressure in Seizures Induced by Electroconvulsive Therapy

BACKGROUND

Increased intracranial pressure (ICP) can be observed immediately upon seizure activity in craniotomized patients in neurosurgical practice. However, it is not commonly included in models of pathomechanisms contributing to morbidity and mortality in epilepsy. A main contributor to this may be the fact that measuring ICP noninvasively during a seizure is technically challenging. The optic nerve sheath diameter (ONSD) represents a promising, noninvasive option to monitor relative ICP changes. We therefore measured ONSD in patients undergoing electroconvulsive therapy (ECT).

METHODS

Twenty-seven ECT-induced seizures from nine consecutive patients underwent ONSD measurement at baseline after induction of anesthesia (t0), during injection of suxamethonium (sux) (t1), after injection of sux (t2), during the electrically induced seizure (t3), and after the electrically induced seizure (t4). A linear mixed model was applied.

RESULTS

An increase in ONSD of > 0.2 mm from t0 to t3 was observed in all patients and in all ECT-induced seizures except one. ONSD increased significantly during the succinylcholine-induced fasciculations, T1, (β = 0.535 mm, p < 0.001) and during the electrically induced seizure, T3, (β = 1.02 mm, p < 0.001). ONSD returned to baseline after the fasciculations, T2, (β = 0.091 mm, p = 0.443) and after the seizure, T4, (β = 0.103 mm, p = 0.379).

CONCLUSIONS

This investigation shows generalized convulsive seizures are associated with a transient but pronounced increase in ONSD, suggesting a temporary increase in ICP.

Use of Electroconvulsive Therapy in a University Psychiatric Hospital in Brazil

OBJECTIVES

The aim of the study were to describe the practice of electroconvulsive therapy (ECT) at the Institute of Psychiatry (IPUB) of the Federal University of Rio de Janeiro (UFRJ) from 2015 to 2019 and to compare it with previous years at the same institute and with international practices.

METHODS

Sociodemographic and epidemiological data, along with information on ECT and anesthetic techniques, were collected from the medical records of all patients who received ECT at IPUB-UFRJ between 2015 and 2019.

RESULTS

A total of 238 patients underwent 4110 ECT sessions during the study period. A slight predominance of female patients (55.9%) was observed. Most patients were aged between 21 and 40 years (46.2%). Over half of the patients were outpatients (63.4%), with bipolar affective disorder being the most common diagnosis, accounting for 35.7% of ECT indications. Consent for ECT was obtained from all patients. Most treatments (85.2%) were conducted during the acute phase of illness. The average number of ECT sessions per patient was 5.4. All patients received anesthesia, and no deaths or severe complications related to ECT occurred. Monitoring cognitive effects and discharge criteria were the responsibility of the attending physician.

CONCLUSIONS

The practice of ECT at IPUB-UFRJ adhered to both local and international guidelines. There has been a notable shift in the utilization patterns of ECT at the institute compared to previous years. Standardized monitoring of cognitive effects and discharge criteria remains essential.

Safety of electroconvulsive therapy in the context of physiological and medical complexity: A state-of-the art review

Medical contraindications and complications pose challenges for electroconvulsive therapy (ECT). Most published reports are scattered across various physiological systems and individual disease conditions. This review aimed to evaluate the literature on physiological and medical complexities during ECT and discuss risk mitigation strategies in a comprehensive review. We searched PubMed and Embase for contraindications and precautions during ECT with relevant MeSH terms and appraised previous reviews on the same topic. The results suggest that mortality directly attributed to ECT is extremely rare. Instances of fatalities, including fetal deaths, have been reported after ECT in the presence of recent myocardial infarction, deep vein thrombosis, intracranial aneurysm and tumors, pheochromocytoma, sepsis, and pregnancy. However, there are no definite conclusions or consensus on attributions of the outcomes to ECT in all cases because of the time lag between the treatment and deaths and confounding factors. The risks can be mitigated with safety protocols, adequate stakeholder communication, collaboration with anesthetists and specialists, consultation-liaison services, and ECT education. Overall, ECT remains a relatively safe treatment even in the presence of medical and physiological complexities. In rare instances, certain medical conditions may indicate a high risk for ECT, where practitioners avoid the treatment or administer it with precautions if the risk-benefit ratio favors its use.

The acute effect of bitemporal electroconvulsive therapy on synchronous changes in heart rate variability and heart rate in patients with depression

Objective.The transient autonomic nervous system responses induced by electroconvulsive therapy (ECT) may serve as critical indicators of treatment efficacy and potential side effects; however, their precise characteristics remains unclear. Considering that the intense stimulation of ECT may disrupt the typical antagonistic relationship between the sympathetic and parasympathetic branches, this study aims to conduct a meticulous analysis of the rapid changes in heart rate variability (HRV) and HR during ECT, with a particular focus on their synchronized interplay.Methods.Pulse interval sequences were collected from 50 sessions of bitemporal ECT administered to 27 patients diagnosed with major depressive disorder. The average HR and ultra-short term HRV indices RMSSD and SDNN, as well as the Poincaré indices SD1, SD2 and SD2/SD1, were calculated using a 10 s sliding window with a step size of 1 s. In particular, the synchronous changes between SD1, SD2, SD2/SD1 and HR were analyzed.Results.The synchronous changes of the indices showed different characteristics over time. In particular, SD1, SD2 and HR increased significantly by 41.50 ± 11.45 ms, 33.97 ± 10.98 ms and 9.68 ± 2.00 bpm respectively between 8 and 20 s, whereas they decreased significantly by 19.89 ± 9.07 ms, 17.54 ± 8.54 ms and 3.80 ± 1.33 bpm respectively between 45 and 53 s after ECT stimulus onset. SD1 and SD2 both had highly significant positive correlations with HR in the above phases.Conclusion.The results suggest that bitemporal ECT induces the sympathetic and parasympathetic co-activation during the early ictal period and brief co-inhibition approximately 45 s after stimulus. Our findings may provide new insights comprehending the mechanisms of ECT and its associated cardiovascular risks.

Exploring the use of electroconvulsive therapy in the anticoagulated population: A systematic review

BACKGROUND

Electroconvulsive therapy is an effective treatment for several psychiatric conditions. There are theoretical risks associated with electroconvulsive therapy in patients who are anticoagulated. However, there is no review investigating these adverse effects.

AIM

This systematic review explored the literature on using electroconvulsive therapy in anticoagulated patients, including adverse effects associated with continuation or cessation of anticoagulation during electroconvulsive therapy.

METHODS

The study was registered on PROSPERO (registration CRD42023432178). A search was conducted across CENTRAL, Embase, Medline and PsychINFO databases, with title and abstract screening, full-text review and data extraction by two independent reviewers. Patients planned for electroconvulsive therapy and on anticoagulation prior to electroconvulsive therapy were included. Papers not related to electroconvulsive therapy or anticoagulation were excluded. Data were recorded in Microsoft Excel, presented in tables.

RESULTS

The studies comprised 108 patients and over 700 sessions of electroconvulsive therapy. 64.81% patients were on warfarin, 22.22% on a direct-acting oral anticoagulant, 5.55% on heparin and the rest on enoxaparin, dalteparin, acenocoumarol or bemiparin. There were two reports of both nonfatal non-central nervous system bleeding and pulmonary embolism in patients with anticoagulation. There were no intracranial haemorrhages or deaths. Bridging or substitution with an anticoagulant with a shorter half-life had no additional benefit.

CONCLUSION

This review showed tolerability of anticoagulants continued throughout electroconvulsive therapy, with most patients reporting no adverse effects. Given limitations including few studies and medical comorbidities influencing patient risk profile, further studies are required to guide practice recommendations and review long-term outcomes.

Exploring Brain and Heart Interactions during Electroconvulsive Therapy with Point-of-Care Ultrasound

BACKGROUND

Electroconvulsive therapy (ECT) is a procedure commonly used to treat a number of severe psychiatric disorders, including pharmacologic refractory depression, mania, and catatonia by purposefully inducing a generalized seizure that results in significant hemodynamic changes as a result of an initial transient parasympathetic response that is followed by a marked sympathetic response from a surge in catecholamine release. While the physiologic response of ECT on classic hemodynamic parameters such as heart rate and blood pressure has been described in the literature, real-time visualization of cardiac function using point-of-care ultrasound (POCUS) during ECT has never been reported. This study utilizes POCUS to examine cardiac function in two patients with different ages and cardiovascular risk profiles undergoing ECT.

METHODS

Two patients, a 74-year-old male with significant cardiovascular risks and a 23-year-old female with no significant cardiovascular risks presenting for ECT treatment, were included in this study. A portable ultrasound device was used to obtain apical four-chamber images of the heart before ECT stimulation, after seizure induction, and 2 min after seizure resolution to assess qualitative cardiac function. Two physicians with expertise in echocardiography reviewed the studies. Hemodynamic parameters, ECT settings, and seizure duration were recorded.

RESULTS

Cardiac standstill was observed in both patients during ECT stimulation. The 74-year-old patient with a significant cardiovascular risk profile exhibited a transient decline in cardiac function during ECT, while the 23-year-old patient showed no substantial worsening of cardiac function. These findings suggest that age and pre-existing cardiovascular conditions may influence the cardiac response to ECT. Other potential contributing factors to the cardiac effects of ECT include the parasympathetic and sympathetic responses, medication regimen, and seizure duration with ECT. This study also demonstrates the feasibility of using portable POCUS for real-time cardiac monitoring during ECT.

CONCLUSION

This study reports for the first time cardiac standstill during ECT stimulation visualized using POCUS imaging. In addition, it reports on the potential differential impact of ECT on cardiac function based on patient-specific factors such as age and cardiovascular risks that may have implications for ECT and perioperative anesthetic management and optimization.

Electroconvulsive Therapy in Heart Transplant Patients: To Avoid or Embrace?

ABSTRACT

Patients with heart disease are at an increased risk of depression. Electroconvulsive therapy (ECT) is a highly effective treatment for severe depressive episodes. However, ECT may increase the risk for adverse outcomes in certain patients because of changes in blood pressure and heart rate secondary to an initial parasympathetic surge followed by a sympathetic surge and peripheral catecholamine release. In post-cardiac transplant patients, these acute hemodynamic changes on a denervated heart may bring clinical challenges. The available data on ECT in heart transplant patients are limited. The authors of this article present a summary of the available literature relating to ECT in heart transplant patients.The authors performed a literature search of 6 online databases yielding 6 English-language case reports of ECT in cardiac transplant patients. All patients experienced changes in hemodynamic variables during and immediately after ECT, ranging from moderate decrease in blood pressure to extreme hypertension. The cases did not report any serious cardiac complications during the course of ECT. In the 5 patients whose psychiatric responses to treatment were detailed, all had improvement in their depressive symptoms. Electroconvulsive therapy may be considered for severe cases of depression in patients with a history of cardiac transplant, but the potential benefit of ECT needs to be weighed against risks. In the limited number of cases reported in the literature, ECT seems to have been relatively safe and effective.