| Condition | Management | Comments |
| Aortic stenosis | Echocardiography should be performed to assess severity if not done within the past year or if there is a change in symptoms. If stenosis is severe, then consult cardiologist before proceeding with ECT. | Limited data suggest that ECT is safe with the use of short-acting intravenous beta-blockers to minimize procedure-related hypertension and tachycardia.[1] |
| Asthma or chronic obstructive pulmonary disease | Discontinue theophylline by tapering the dose, if possible. Continue outpatient regimen of bronchodilators and inhaled glucocorticoids. Provide standard treatment during an asthma exacerbation (inhaled beta-agonists and, if necessary, glucocorticoids, before proceeding with ECT). | Theophylline increases the risk of status epilepticus after ECT.[2] |
| Atrial fibrillation | Continue outpatient medications for control of heart rate. Control heart rate with calcium-channel blockers if needed. Manage anticoagulation as described below. | ECT appears to be safe in patients with atrial fibrillation. Patients may have conversion to and from sinus rhythm during ECT. The effect of spontaneous rate conversion on embolization rates is unknown. |
| Coronary artery disease (stable) | 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. |
| Diabetes | Measure blood glucose levels before and after ECT treatment. If breakfast is likely only delayed, patients may delay taking their usual morning insulin until after ECT and before eating. If ECT happens later in the morning, where breakfast and lunch are likely to be missed, then give one-half the usual total morning dose as intermediate-acting insulin. Withhold oral agents and short-acting insulin until patient can eat. 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. |
| Hypertension (poorly controlled) | Start or intensify antihypertensive medications; delay ECT until blood pressure is <140/90 mmHg. Avoid beta-blockers. | Blood pressure increases during the postictal phase of ECT. Beta-blockers may shorten the seizure duration and reduce the efficacy of ECT.[3] |
| Hypertension (well-controlled) | Continue usual antihypertensive medication(s). | |
| Implantable cardioverter-defibrillator (ICD) | Turn off detection mode of ICD during ECT. Perform continuous electrocardiographic monitoring throughout treatment. Place resuscitative equipment by the patient's bedside in the event that external defibrillation is necessary. Make sure that ICD has been interrogated routinely. | ECT appears to be safe in patients with an ICD.[4] |
| Implanted pacemaker | A magnet should be available at the patient's bedside in the event that electrical interference leads to pacemaker inhibition and bradycardia. | In rare cases, postprocedural supraventricular tachycardia can occur.[4] |
| Need for long-term anticoagulation | Continue anticoagulation to maintain an international normalized ratio of up to 3.5, unless there is an increased risk of intracranial hemorrhage (eg, intracranial mass or aneurysm). | ECT appears to be safe in patients who require long-term anticoagulation.[5] |
| 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. |
