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ECT is often administered to patients with severe medical illness (see Chapter 4.1). In fact, it commonly is the treatment of choice in medically ill patients because of its speed of action and safety profile. There are no absolute medical contraindications to ECT. Instead, it is more pertinent to think in terms of degree of risk relative to the potential benefits of ECT.
Some conditions substantially increase the risk of treatment. For each patient, the attending physician and treating psychiatrist must undertake a risk-benefit analysis, including consideration of the seventy and duration of the illness and its threat to life; the likelihood of therapeutic success with ECT; the medical risks of ECT; and the benefits and risks of alternative treatments and of no treatment. After such an analysis, a choice can be made regarding the optimal intervention for an individual patient. In treating "high risk" patients with ECT, attempts should be made to improve and stabilize risk-related medical conditions (see Chapter 4.1). Careful medical evaluation is an essential component of this process and may include consultations with internists, cardiologists, neurologists, and other specialists (see Chapter 6).
The two organ systems of most importance when considering the medical risks of ECT are the cardiovascular system and the central nervous system. Most of the medical complications and mortality associated with ECT are referable to the heart. Recent myocardial infarction is believed to represent a risk for re-infarction during ECT (Applegate 1997). The concept of "recency" as it applies to this condition is difficult to define in the absence of relevant supporting data. The risks at six weeks following a mild myocardial infarction without adverse sequelae may be less than those present at six months following a severe, complicated infarction. In many cases of pre-existing cardiac disease the risks of ECT may be reduced by the use of short-acting intravenous antihypertensive agents (McCall et at. 1991) that diminish the hemodynamic changes that occur during the treatment or that exert other cardioprotective effects (set Chapter. 4.1).
Although there are little data to tie other specific cardiac disorders to substantially elevated morbidity and mortality with ECT, perioperative risk in general is believed to be greatly elevated in the presence of either uncompensated congestive heart failure or severe valvular heart disease (Dovinsky and Zyara 1997; Rayburn 1997). Again, pharmacologic means to diminish such risk exists (see Chapter 4.1). A similar situation can be said to exist with respect to vascular aneurysms. Here, lesions that are at increased risk of rupture with transient elevations in blood pressure are of particular concern, although, once more, data are lacking and the degree of risk can once more be minimized by appropriate acute antihypertensive prophylaxis (see Chapter 4.1).
Regarding the central nervous system, conditions associated with increased intracranial pressure, such as some brain tumors, are theoretically of great concern (Krystal and Coffey 1997). In the presence of these conditions, the rise in intracranial pressure that occurs with ECT could lead to brain herniation. However, such events are rare in practice (Kellner 1996). Most of the reports of dire outcomes are from the distant past when ECT technique was far less sophisticated (Maltbie 1980). The type and size of brain tumor also correlate with the degree of danger, smaller and slow-growing neoplasms posing less risk. For example, there are now several case reports of successful ECT in the presence of meningiomas (Fried and Mann 1988,- Greenberg et al. 1988: Hsiao 1984: Kellner and Rames, 1990; Malek-Ahmadi and Sedler 1989; Zwil et al. 1990). Clearly, clinical judgement needs to be exercised in determining the risk-benefit ratio in each individual case. Only rarely would one treat a patient with a known, large brain tumor, and likewise, only rarely would one need to avoid ECT in a patient with a small, stable meningioma. There is little information about the safety of ECT in other conditions associated with increased intracranial pressure, such as hydrocephalus or normal pressure hydrocephalus.
ECT may pose additional risks in patients who have recently suffered a cerebral infarct. Reports of stroke (either hemorrhagic or ischemic) during or shortly after ECT are surprisingly rare. Given the magnitude of hemodynamic changes, that occur during the treatment and the number of patients with cerebrovascular disease who receive ECT (Miller and Isenberg 1998; Zwil et al. 1992). This finding may be due to the brief duration of blood pressure and heart rate changes that are associated with ECT. Maintenance of blood pressure within a fairly narrow range is generally thought to be prudent, in order to avoid the potential risk of cerebral bleeding with severe hypertension or cerebral ischemia with hypotension (see Chapter 4.1).
Severe pulmonary conditions may lead to difficulties in airway management during and after the procedure. Consultation with anesthesiology or other staff regarding management (e.g. pre-ECT use of bronchodilators, attention to pre-treatment oxygenation) will often be indicated.
Patients with severe cardiopulmonary or other organ system disease that renders them high anesthesia risks (ASA level 4 or 5) also represents potentially high risk situations with ECT. Specialty consultations before ECT are often indicated to optimize the patient's medical status (see Chapter 4.1 ).
In addition to medical conditions that increase the risks of ECT, certain medication regimens may also contribute to risk (see, Chapter 7).
RECOMMENDATIONS
1) There are no "absolute" medical contraindications to ECT.
2) Situations exist in which ECT is associated with an increased likelihood of serious morbidity or mortality. For such patients, the decision to administer ECT should be based upon the premise that their psychiatric condition is grave and that ECT is the safest treatment available.
3) Careful medical evaluation of risk factors should be carried out prior to ECT, with specific attention to modifications of the patient's management and the administration of ECT which may diminish the level of risk (see Section 4.1).
4) Specific conditions that may be associated with substantially increased risk include the following:
a) unstable or severe cardiovascular conditions such as recent myocardial infarction, poorly compensated congestive heart failure, and severe valvular cardiac disease.
b) aneurysm or vascular malformation that might be susceptible to rupture with increased blood pressure.
c) increased intracranial pressure, as may occur with some brain tumors or other space-occupying cerebral lesions.
d) recent cerebral infarction.
e) pulmonary conditions such as severe chronic obstructive pulmonary disease, asthma, or pneumonia.
f) anesthetic risk rated as ASA level 4 or 5.
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