A CASE OF BIGEMINY AND SUCCESSFUL COMPLETION OF ACUTE ELECTROCONVULSIVE THERAPY COURSE

Abstract

Introduction Electroconvulsive therapy (ECT) remains stigmatized in the broader medical community due to misunderstandings about treatment procedures, mortality rates, and cardiovascular complications. Several concerns have risen regarding the safety of ECT on the cardiovascular system. ECT causes periprocedural hemodynamic variability due to the surges in parasympathetic and sympathetic nervous systems following the administration of the electric current.1 Patients experience an increase in cardiac workload and oxygen demand, which is potentially dangerous for patients with preexisting heart disease. Several findings suggest the incidence of cardiac complications is relatively rare and occurs most frequently in patients with underlying cardiovascular disease. Methods We describe a case report of a 53 year old female with history of bipolar I disorder current episode depressed, hyperlipidemia undergoing ECT who developed cardiovascular complications after her seventh brief pulse right unilateral (BRUL) treatment. Electrocardiogram (EKG) monitoring revealed bigeminy for two to three minutes (heart rate in 80s) during post-anesthesia care. Results The cardiovascular system undergoes various changes during ECT including events secondary to the parasympathetic release such as asystole, hypotension, bradycardia, and events secondary to sympathetic release such as hypertension and tachycardia. Other complications include arrhythmias, ST elevation, and Takotsubo Cardiomyopathy. The patient was seen by cardiology for further work-up. EKG, 2-D cardiac echocardiogram, 48-hour Holter monitoring, and coronary CT calcium scan were performed. She was found to have rare premature atrial contractions (PACs) (8 in 48 hours). Her bigeminy resolved spontaneously. The patient was able to complete the acute course of BRUL ECT and continued onto maintenance ECT with good effect. We also present a table with the common cardiovascular side effects from ECT and the most recent evidence-based treatment strategies to manage them. Conclusions Generally, ECT is a safe procedure; complications are minor and manageable. Most major complications caused by ECT are related to the cardiovascular system; however, with an appropriate pre-ECT evaluation and a comprehensive multidisciplinary-team approach the cardiovascular complications can be well managed and minimized. Our case highlights the benefits of a multidisciplinary care model between psychiatry, anesthesia, and cardiology. Providing proper cardiac clearance can prevent cardiac complications and provide timely care to treatment-resistant populations who are at risk for excessive morbidity and suicide. This research was funded by None.