Major Adverse Cardiac Events and Mortality Associated with Electroconvulsive Therapy

Abstract

EDITOR’S PERSPECTIVE What We Already Know about This Topic The incidence of major adverse cardiac events after electroconvulsive therapy is not known What This Article Tells Us That Is New Major adverse cardiac events and death after electroconvulsive therapy are infrequent and occur in about 1 of 50 patients and after about 1 of 200 to 500 electroconvulsive therapy treatments Background Cardiac events after electroconvulsive therapy have been reported sporadically, but a systematic assessment of the risk is missing. The goal of this study was to obtain a robust estimate of the incidence of major adverse cardiac events in adult patients undergoing electroconvulsive therapy. Methods Systematic review and meta-analysis of studies that investigated electroconvulsive therapy and reported major adverse cardiac events and/or mortality. Endpoints were incidence rates of major adverse cardiac events, including myocardial infarction, arrhythmia, pulmonary edema, pulmonary embolism, acute heart failure, and cardiac arrest. Additional endpoints were all-cause and cardiac mortality. The pooled estimated incidence rates and 95% CIs of individual major adverse cardiac events and mortality per 1,000 patients and per 1,000 electroconvulsive therapy treatments were calculated. Results After screening of 2,641 publications and full-text assessment of 284 studies, the data of 82 studies were extracted (total n = 106,569 patients; n = 786,995 electroconvulsive therapy treatments). The most commonly reported major adverse cardiac events were acute heart failure, arrhythmia, and acute pulmonary edema with an incidence (95% CI) of 24 (12.48 to 46.13), 25.83 (14.83 to 45.00), and 4.92 (0.85 to 28.60) per 1,000 patients or 2.44 (1.27 to 4.69), 4.66 (2.15 to 10.09), and 1.50 (0.71 to 3.14) per 1,000 electroconvulsive therapy treatments. All-cause mortality was 0.42 (0.11 to 1.52) deaths per 1,000 patients and 0.06 (0.02 to 0.23) deaths per 1,000 electroconvulsive therapy treatments. Cardiac death accounted for 29% (23 of 79) of deaths. Conclusions Major adverse cardiac events and death after electroconvulsive therapy are infrequent and occur in about 1 of 50 patients and after about 1 of 200 to 500 electroconvulsive therapy treatments.

Electroconvulsive therapy, depression severity and mortality: Data from the Danish National Patient Registry

“…A large study of case records of patients who died from natural causes within a month of ECT showed no association with ECT treatment (total n = 99,728 treatments) (Ostergaard et al, 2014). Two meta-analyses (Duma et al, 2019; Torring et al, 2017) and recent cohort studies (Blumberger et al, 2017; Dennis et al, 2017) have shown that ECT is associated with a low likelihood of immediate or short-term death, and the few available studies have indicated that patients treated with ECT compared to other patients have decreased long-term mortality from all, and natural, causes (Avery and Winokur, 1976; Munk-Olsen et al, 2007; Philibert et al, 1995). However, no studies have examined whether depression severity influences the effect of ECT on health outcomes.…”

Electroconvulsive therapy (ECT) versus sham ECT for depression: do study limitations invalidate the evidence (and mean we should stop using ECT)?

“…In discussing the mortality rate after ECT the authors of this review dismiss a recent meta-analysis of 15 studies finding low rates as a ‘study’ (not acknowledged as a meta-analysis) ‘based on medical records (relying on staff recording that [ECT treatments] had caused a death)’. One has to then ask why they did not instead report a meta-analysis of all-cause mortality after ECT based on data from 43 studies (Duma 2019). This found a mortality rate of 0.42/1000 patients and 6/100 000 ECT treatments, not all of which would be due to ECT, as depression itself is associated with a 1.5–2 times higher risk of death than in the general population.…”

A second independent audit of electroconvulsive therapy in England, 2019: Usage, demographics, consent, and adherence to guidelines and legislation

“…There is reasonable agreement, however, that the leading cause of death is cardiovascular failure. A recent review of 82 studies found that one in 50 patients experience ‘major adverse cardiac events’ (Duma et al, 2019).…”