Balancing Seizure Quality and Cardiovascular Safety in Anesthetic Selection During ECT
V. Patel, J. D. White, J. D. Hagan, B. R. CarrIntroduction
Electroconvulsive therapy (ECT) is a cornerstone of treatment for severe depression, suicidality, and catatonia. Anesthetic choice directly influences seizure threshold, seizure quality, hemodynamic stability, and ultimately therapeutic efficacy. Cardiovascular comorbidity amplifies these challenges. For psychiatrists, acquiring fluency in anesthetic principles contributes to safety, tolerability, and quality outcomes.
Objectives
To review anesthetic agents used in ECT and clarify how pharmacological selection intersects with treatment efficacy and patient safety.
Methods
Narrative educational review of psychiatric, anesthetic, pharmacologic literature (2010–2025), focus on four mainstay agents showcasing the effect on hemodynamics, cardiac function, and therapeutic seizure characteristics.
Results
ECT anesthetics differ substantially in both neuropsychiatric and cardiovascular profiles (Table 1):
Methohexital is the gold standard: it lowers seizure threshold, sustains adequate seizure duration, and provides remarkable hemodynamic stability in the majority of patients. However, its dose-dependent negative inotropy can become significant in patients with advanced heart failure.
Etomidate preserves cardiac output and reliably produces long seizure durations, often yielding higher efficacy in treatment-resistant depression. Downsides include temporary adrenal suppression, especially in the context of frequent treatments and limited availability outside North America.
Propofol blunts hypertensive surges and provides rapid emergence, though slower than methohexital. It raises seizure threshold and shortens seizure duration. Hemodynamic effects include vasodilation leading to lower systemic vascular resistance and some negative inotropy, making it less suitable in patients with heart failure.
Ketamine prolongs seizure duration and augments sympathetic tone, occasionally improving mood acutely. Yet its indirect sympathetic activation may be destabilizing in patients with arrhythmias or advanced coronary disease.
Table 1. Long description.