Version October 2024
| Condition | Recommendations | Rationale |
| Stable chronic hypertension with blood pressure ≤140/90 mmHg | Continue usual antihypertensive medication through the morning of procedure | Blood pressure increases during the postictal phase of ECT; systolic pressure increases from 29 to 48% during ECT, and diastolic pressure from 24 to 60% |
| Chronic or new-onset hypertension with blood pressure >140/90 mmHg | Start antihypertensive medications; delay ECT until blood pressure is <140/90 mmHg; avoid beta blockers | Beta blockers may shorten the seizure duration and reduce the efficacy of ECT |
| Asymptomatic or stable coronary artery disease | Continue medications such as aspirin, statins, antihypertensive agents, and antianginal medications, including nitrates for chronic cardiac conditions; continue aspirin and clopidogrel in patients with coronary stents | Discontinuation of long-term cardiac medications on the morning of the procedure increases the risk of cardiac ischemia |
| Aortic stenosis | Perform echocardiography to assess severity if it has not been performed within the past year or if there is a change in symptoms; consult cardiologist and reassess indication for ECT if stenosis is moderate or severe | Limited data suggest that ECT is safe with the use of short-acting intravenous beta blockers to minimize procedure-related hypertension and tachycardia[1] |
| Implanted pacemaker | Test the pacemaker before and after ECT; place magnet at the patient's bedside in the event that electrical interference leads to pacemaker inhibition and bradycardia | In a study involving 26 patients with pacemakers who were undergoing ECT, 1 patient had postprocedural supraventricular tachycardia, but no clinically significant arrhythmias occurred; all pacemakers functioned normally after ECT[2] |
| ICD | Turn off detection mode of ICD during ECT; perform continuous ECG monitoring throughout treatment with careful attention to grounding; place resuscitative equipment by the patient’s bedside in the event that external defibrillation is necessary | ECT appears to be safe in patients on direct anticoagulants and warfarin[4,5] |
| Atrial fibrillation | Continue outpatient medications for control of heart rate; control heart rate with calcium-channel blockers if needed; manage anticoagulation as described below | Few data exist, but ECT appears to be safe in patients with atrial fibrillation[3]; patients may have conversion to and from sinus rhythm during ECT; the effect of spontaneous rate conversion on embolization rates is unknown |
| Need for long-term anticoagulation | Continue anticoagulation. For patients on warfarin, maintain an international normalized ratio of up to 3.5, unless there is an increased risk of intracranial hemorrhage (eg, intracranial mass or aneurysm) | In a study involving 33 patients with an international normalized ratio of ≤3.5, there were no complications from ECT[6] |
| Asthma or chronic obstructive pulmonary disease | Discontinue theophylline by tapering the dose if possible; continue outpatient regimen of bronchodilators and inhaled corticosteroids; if an exacerbation is present on evaluation, provide standard treatment–inhaled beta agonists and, if necessary, corticosteroids–before proceeding with ECT | Theophylline increases the risk of status epilepticus after ECT; in a study involving 34 patients with asthma, 12% of the patients had an exacerbation, all of whom had a response to standard therapy and were able to complete ECT[7] |
| Diabetes | Measure blood glucose levels before and after ECT treatment; give half the usual amount of longacting insulin the morning of the procedure; withhold oral agents until patient can eat; provide short-acting insulin to treat elevations in blood glucose level; perform ECT early in the morning if possible | The effect of ECT on blood glucose is unpredictable because of changes in diet, appetite, and energy level that may result from ECT; individual ECT treatments raise blood glucose levels in patients with diabetes to the same degree as in patients without diabetes |
| Pregnancy | The informed-consent and risk-stratification process should include an obstetrician and an anesthesiologist; in addition to standard monitoring of the patient, noninvasive fetal monitoring should be used after 14 to 16 weeks; after 24 weeks, a nonstress test with a tocometer should be performed before and after treatments | Pregnancy would require modification of the anesthetic technique, positioning of the patient, and monitoring requirements |
From: Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med 2009; 360:1437. Copyright © 2009 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.
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