The Journal of ECT
19(1):22–25 © 2003 Lippincott Williams & Wilkins, Inc., Philadelphia
Cardiac Arrhythmias Induced by ECT in Elderly Psychiatric
Patients: Experience with 48-Hour Holter Monitoring
*Martti J. Huuhka, M.D., †Lauri Seinelä, M.D., ‡Pekka Reinikainen, M.D., and §Esa V. J. Leinonen, M.D.
*Department of Psychogeriatrics and ‡Department of Clinical Physiology, Tampere University Hospital; †Department of Geriatrics,
University of Tampere Medical School; and §Department of Psychogeriatrics, Tampere University Hospital, Tampere, Finland
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Summary: Serious adverse events associated with electroconvul-
sive therapy (ECT) are uncommon and consist mostly of cardio-
vascular complications, mainly arrhythmias. The risk of compli-
cations is increased in elderly and physically ill patients. In
the current study, a 24-hour pre-ECT and 24-hour post-ECT
Holter recording was performed on 26 elderly patients during
their first ECT treatment. ECT caused a significant increase in
bigeminy/trigeminy and supraventricular tachycardia, but did not
increase other arrhythmias. Pre-ECT arrhythmias correlated with
post-ECT arrhythmias. All patients in the current study completed
the ECT course. Thus, the clinical significance of arrhythmias
remains uncertain. The present findings support the usual practice
of continuous electrocardiogram monitoring during ECT and re-
covery.
Key Words: Electroconvulsive therapy—Cardiac arrhythmias—
Elderly patients.
INTRODUCTION
Electroconvulsive therapy (ECT) is widely used in the
treatment of affective disorders in the elderly (1,2). It is
considered to be an effective and safe treatment, even in the
older age group and in physically ill patients (3–8). Modern
techniques and brief-pulse devices have increased the safety
of ECT. Both morbidity and mortality are rare, with one to
two deaths per 10,000 patients treated with ECT reported
(9,10). Even serious complications are uncommon, but
when they occur, they are usually cardiovascular in nature
and are mostly arrhythmias (11,12).
ECT has a strong influence on the cardiovascular system
through both the parasympathetic and the sympathetic ner-
vous systems (13). Bradycardia, hypotension, and even
brief asystole occur during the initial phase of the seizure
(11,14). Vagal tone is followed by a sympathetic phase,
which is associated with hypertension and tachycardia. Car-
Received October 31, 2001; accepted December 19, 2002.
Address correspondence and reprint requests to Dr. Martti J. Huuhka,
Department of Psychogeriatrics, Tampere University Hospital, Fin-33380,
Pitkäniemi, Finland. E-mail: martti.huuhka@tays.fi
22
diac arrhythmias (sinus and ventricular tachycardia, prema-
ture atrial and ventricular contractions) are most common
during the seizure or in the immediate postictal period (15).
These are generally benign and resolve spontaneously
(15,16). The incidence of cardiovascular complications is
higher in elderly patients and in patients with pre-existing
cardiovascular diseases (11,15).
The aim of this study was to determine the influence of
ECT on the incidence of arrhythmias and ST changes in
elderly psychiatric patients using a 24-hour pre-ECT and
post-ECT Holter recording.
MATERIALS AND METHODS
Patients
Forty-eight–hour Holter monitoring was performed dur-
ing the first ECT session of 31 elderly patients referred for
ECT because of treatment-refractory depression at the De-
partment of Psychogeriatrics, Tampere University Hospital,
Tampere, Finland. Five patients were excluded because of
technical problems with the recordings. All the patients met
the DSM-IV diagnostic criteria for major depressive disor-
der (21 unipolar and five bipolar depressions), three of them
with psychotic features. Patients underwent a complete
physical examination before the ECT, a 12-lead electrocar-
diogram (ECG), a chest X-ray, and laboratory tests (includ-
ing blood count, thyroid function tests, electrolytes, creati-
nine, and blood glucose level).
The mean age of the patients was 69.3 years (SD ± 6.0;
range, 60–81 years). There were 18 women and eight men.
Twenty-one (81%) of the patients had at least one physical
disease of clinical importance, e.g., hypothyroidism treated
with thyroxine substitution (five), hypertension (four), isch-
emic or valvular heart disease (four), previous stroke (four),
Parkinson disease (two), previously treated cancer (two),
and chronic obstructive pulmonary disease (two).
All the patients used some psychotropic medications
during the treatment. All drug treatments were stabilized at
 CARDIAC ARRHYTHMIAS INDUCED BY ECT IN ELDERLY PATIENTS
least 1 week before the index ECT. Fourteen of the 26
patients used small doses of various antipsychotics: le-
vomepromazine 5 to 25 mg (seven), risperidone 0.5 to 2 mg
(four), perphenazine 4 to 10 mg (two), and chlorprothixene
50 mg (one). Eighteen patients used antidepressant medica-
tions: citalopram 20 to 30 mg (six), venlafaxine 75 mg
(four), reboxetine 2 to 6 mg (four), mirtazapine 30 to 45 mg
(two), fluoxetine 20 mg (one), and mianserin 30 mg (one).
Two patients were treated with mood stabilizers: lithium
600 mg (one) and sodium valproate 300 mg (one). Twenty-
three patients used anxiolytic-hypnotic medications—
temazepam 20 mg (sixteen), oxazepam 15 to 45 mg (seven),
lorazepam 1 to 2 mg (five), zopiclone 7.5 mg (three),
alprazolam 0.25 mg (one), and buspirone 10 mg (one)—
but did not receive these drugs the night before the treat-
ment. Fifteen of the patients received nonpsycho-
tropic medications during the treatment. Three received
ß-blockers: metoprolol 90 mg (one), sotalol 80 mg (one),
and bisoprolol 5 mg (one). Three received diuretics or an-
tihypertensives: hydrochlorothiazide 25 to 50 mg (two) and
enalapril 20 mg (one). Six patients received sex hormone
replacement, five thyroid hormone, and two antiparkinso-
nian medications.
Written informed consent was obtained from each pa-
tient before inclusion in the study, which was approved by
the Tampere University Hospital Ethics Committee.
Methods
Holter Monitoring
Automated Holter monitoring (Del Mar model 461, Del
Mar Avionics, Irvine, CA, U.S.A.) was performed for 48
hours: it was performed for 24 hours before ECT, inter-
rupted during the electrical stimulation, and resumed imme-
diately for 24 hours after the ECT. The incidence and num-
ber of ECG changes were studied throughout this 48-hour
period. The 24-hour pre-ECT recording was compared with
that of the 24 hours after ECT, with each patient serving as
his or her own control. A separate comparison was made
between the records taken in the last hour before and the
first hour after ECT. Ventricular extrasystoles (VESs) were
graded according to the classification proposed by Lown
and Wolf (17). VESs occurring less often than 1/min were
regarded as isolated (even isolated VESs were counted), and
others were regarded as frequent. Ventricular tachycardia
was defined as three or more consecutive ventricular ectopic
beats at a rate greater than 120/min, and supraventricular
tachycardia (SVT) was defined as three or more consecutive
beats at a rate greater than 130/min. ST segment changes
were analyzed 60 msec after the J-point. The Holter record-
ings were analyzed blind to the pre-ECT and post-ECT
clinical status of the patients.
23
ECT Procedure
Heart rate (HR), blood pressure (BP), and arterial oxy-
gen saturation (SpO2) were recorded before the induction of
anesthesia, immediately after ECT, and again 15 minutes
after seizure termination. Anesthesia was induced with pro-
pofol (13 patients) or methohexital (13 patients), and
muscle relaxation with succinylcholine. The initial dose was
1.5 mg/kg propofol or 1 mg/kg methohexital and 0.5 mg/kg
succinylcholine. If the seizure threshold was determined,
patients were pretreated with atropine 0.5 mg. The patients
were ventilated with 100% oxygen until resumption of
spontaneous respiration. HR, serial BP determinations,
SpO2, and three-lead ECG were monitored (Hewlett-
Packard Viridia M3 M3046A, Agilent Technologie, Böblin-
gen, Germany) continuously until the patients were trans-
ferred to the recovery room. The stimulus was administered
by a Thymatron DGx (Somatics, Lake Bluff, IL, U.S.A.)
brief-pulse device. Stimulus dosage (mC) was adjusted by
the age method in 18 patients and was approximately five
times age (18). The seizure threshold was determined for
eight patients by administering successive stimuli of in-
creasing intensity until a generalized seizure was induced.
All patients were treated with standard bilateral (bifronto-
temporal) electrode placement. Each one experienced a gen-
eralized seizure, the duration of which ranged from 21 to
136 seconds by electroencephalogram and from 9 to 57
seconds by electromyography.
Statistical Analyses
Statistical analysis was performed using the Statistical
Package for Social Sciences (SPSS for Windows 11.0.1,
SPSS, Chicago, IL, U.S.A.). Comparisons of arrhythmias
between pre-ECT and post-ECT periods were analyzed us-
ing the Wilcoxon matched-pairs signed ranks test. A non-
parametric test was used because the variables were not
normally distributed.
RESULTS
The number of ventricular arrhythmias (medians and
range) and the number and percent of patients are presented
in Table 1. There was a significant increase in the incidence
of bigeminy/trigeminy in the 24-hour post-ECT recording
when compared with the pre-ECT recording. However, this
increase was not found between 1 hour pre-ECT and post-
ECT recordings (p ⳱ 0.715) within the methohexital (p ⳱
0.180) or within the propofol (p ⳱ 0.655) group.
The differences in the other VES variables between the
24-hour pre-ECT and post-ECT Holters were not significant
(Table 1). This was also the case when the 1 hour pre-ECT
Holter analysis was compared with the 1 hour post-ECT
Holter analysis.
J ECT, Vol. 19, No. 1, 2003
24 M. HUUHKA ET AL.
TABLE 1. Number of ventricular arrhythmias
24 h before ECT
median (range)
n (%)
Bigeminy/Trigeminy 0.0 (1–142) 3 (12)
Ventricular extrasystoles 10.0 (1–7055) 22 (85)
Ventricular tachycardia 0.0 (1) 2 (8)
n, number of patients; %, percent of patients.
*p < 0.05.
The data concerning SVTs and supraventricular extra-
systoles (SVES) are shown in Table 2. SVTs were more
common in the post-ECT than in the pre-ECT 24-hour
Holter analysis. No significant difference was found, how-
ever, in the incidence of SVT between the 1 hour period
before and after the ECT (p ⳱ 0.157). Moreover, SVTs did
not differ between 1 hour pre-ECT and post-ECT analyses
using either anesthetic (methohexital, p ⳱ 0.180; propofol,
p ⳱ 0.564). No differences were found in SVES between
the pre-ECT and post-ECT recordings at either 24-hour or
1-hour intervals (Table 2).
There was a significant increase in HR immediately af-
ter ECT (p ⳱ 0.023). HR was elevated even 15 minutes
postictally when compared with the values at baseline (p ⳱
0.001). The level of SpO2 was decreased both immediately
(p < 0.001) and 15 minutes after ECT (p ⳱ 0.005).
Nine patients had an ST change of more than 1 mm, and
five of them had an ST change of more than 2 mm in the 1
hour post-ECT recording. Only two of them, however,
reached their maximal ST change during the first hour after
treatment.
DISCUSSION
Arrhythmias are common findings even in healthy el-
derly subjects. Their clinical significance depends on their
type, the underlying cardiac disease (i.e., the cause of ar-
rhythmias), and the current cardiovascular status of the pa-
tient. Some of the arrhythmias, e.g., atrial and single
ventricular extrasystoles in patients without cardiovascular
disease, may be considered benign (19,20).
In the current study, we observed the influence of ECT
on the incidence of arrhythmias and ST changes in elderly,
depressed inpatients using a 24-hour pre-ECT and post-ECT
TABLE 2. Number of supraventricular arrhythmias
24 h before ECT
median (range)
n (%)
Supraventricular extrasystoles 35.5 (3–816) 26 (100)
Supraventricular tachycardias 1.0 (1–4) 15 (58)
n, number of patients; %, percent of patients.
*p < 0.01.
J ECT, Vol. 19, No. 1, 2003
24 h after ECT 1 h before ECT 1 h after ECT
median (range) median (range) median (range)
n (%) n (%) n (%)
0.0 (1–267)* 8 (31) 0.0 (25) 1 (4) 0.0 (1–12) 4 (15)
30.5 (1–9102) 22 (85) 1.5 (0–470) 15 (58) 1.5 (1–386) 16 (62)
0.0 (1–4) 4 (15) 0.0 (1) 1 (4) 0
Holter recording. Arrhythmias associated with ECT are a
relatively common finding (12,15,21,22). In these earlier
studies, however, recordings were taken only for short time
periods during and after the ECT. To our knowledge, only
one study using a method resembling that used here has
been published (21). The major finding in our study was the
increase in bigeminy/trigeminy and SVTs after ECT. Pre-
existing arrhythmias were associated with the development
of post-ECT arrhythmias, consistent with the findings of
previous studies (15,22,23). All three patients with
bigeminy/trigeminy before ECT were included in the group
of eight patients with post-ECT bigeminy/trigeminy. Simi-
larly, 13 of the 17 patients with post-ECT SVTs had these
before the initiation of ECT. Consistent with the earlier
studies (15,24), we also found a high incidence (nine of 26
patients) of ST changes after ECT. However, only two of
these patients had pre-existing cardiovascular disease (one
hypertension and one ischemic heart disease).
Heart rate increased 4% from pre-ECT baseline, a find-
ing in line with previous reports (16,24). We recorded HR
after termination of the seizure, whereas the maximum in-
crease in this has been reported to occur during the seizure
(25,26). In our study, the HR was still elevated 15 minutes
after the treatment. Because the frequency of any arrhyth-
mias did not differ significantly between 1 hour pre-ECT
and post-ECT analyses, it is unlikely that the increase in HR
would have any influence on the present results.
Troup and et al. (21) used a protocol resembling that
described here. They found that ECT did not significantly
increase supraventricular or ventricular extrasystoles, nor
did it cause ventricular tachycardia or other complex ven-
tricular arrhythmias. However, their subjects were young
and middle-aged, physically healthy psychiatric patients.
The data of the current study are similar to those reported by
24 h after ECT 1 h before ECT 1 h after ECT
median (range) median (range) median (range)
n (%) n (%) n (%)
40.5 (3–1274) 25 (96) 1.5 (1–68) 17 (65) 2.5 (1–93) 18 (69)
2.0 (1–25)* 17 (65) 0.0 (1) 1 (4) 0.0 (1–6) 4 (15)
 CARDIAC ARRHYTHMIAS INDUCED BY ECT IN ELDERLY PATIENTS
Troup et al. (21), although our patients were older and many
of them were physically ill. Moreover, our patients contin-
ued many of their medications (including psychotropics)
during the study. Thus, all of the patients had at least one
drug during the index ECT. The drug treatments, however,
had been stabilized for at least 1 week before the ECT.
The main limitation of our study may be its relatively
small sample size. In this population, it is difficult to esti-
mate the influence of physical disease, particularly cardio-
vascular disease, on the arrhythmias, because the subgroups
are too small for reliable statistical analyses. Other limita-
tions may also be the variability in stimulus dosing strategy
(age method versus dose titration method) and the variation
in medications at the time of ECT. One half of the present
patients received methohexital and the other half propofol
as anesthetic agent (the anesthetic agent was changed during
the study because of the unavailability of methohexital at
that time). Because the patients were not randomized ac-
cording to their anesthetic drugs, the comparison between
these two anesthetic groups is not reported here.
We found that the elderly depressed inpatients in this
study exhibited arrhythmias quite frequently and that ECT
increased the occurrence of some arrhythmias. However, all
of the present patients completed the ECT course. Thus, the
clinical significance of arrhythmias remains uncertain. In
spite of that uncertainty, the present findings support the
usual practice of continuous ECG monitoring during ECT
and recovery.
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