The Safety of Anticoagulation Continuation in Electroconvulsive Therapy A Systematic Review and Proportional Meta-Analysis
Main Article Content
Keywords
ECT, Anticoagulation
Abstract
Background: Physiologic changes during electroconvulsive therapy (ECT) raise concern for intracranial bleeding, particularly in patients on anticoagulation. We conducted a systematic review and proportional meta-analysis on bleeding and thromboembolic outcomes in this patient population.
Methods: Ovid MEDLINE, Embase, Cochrane Library, and APA PsycInfo were searched to identify relevant studies. A proportional meta-analysis was conducted on the incidence of intracerebral hemorrhage (ICH), thromboembolic events, and bleeding.
Results: Nine studies were included: one retrospective cohort study and eight case series. 772 ECT sessions were reported. No ICH event was reported. The pooled incidence was 0.21% (95% CI 0.01-0.66), 0.83% (95% CI 0.32-1.59), and 1.44% (95% CI 0.33-3.20) for ICH, bleeding, and thromboembolic events respectively. Conclusion: Although the evidence regarding the safety of continuing anticoagulation during ECTs is of low quality, primarily from case series, the pooled ICH incidence of less than 1% (0.21%) is a valuable reference for informed healthcare decisions.
Résumé
Contexte: Les changements physiologiques survenant au cours de l’électrochoc soulèvent des inquiétudes quant aux hémorragies intracrâniennes, en particulier chez les patients recevant une anticoagulothérapie. Nous avons réalisé une revue systématique et une méta-analyse proportionnelle sur les conséquences hémor-ragiques et thromboemboliques chez cette population de patients.
Méthodologie: Une recherche a été effectuée dans les bases de données Ovid MEDLINE, Embase, Cochrane Library et APA PsycInfo pour relever les études pertinentes. La méta-analyse proportionnelle a été réalisée sur la fréquence des hémorragies cérébrales, des événements thromboemboliques et des saignements.
Résultats: Neuf études ont été retenues, soit une étude de cohorte rétrospective et huit séries de cas. On rapporte 772 séances d’électrochoc. Aucune hémorragie cérébrale n’est signalée. La fréquence regroupée est de 0,21 % (intervalle de confiance [IC] à 95 % de 0,01 à 0,66) pour l’hémorragie cérébrale, de 0,83 % (IC à 95 % de 0,32 à 1,59) pour le saignement et de 1,44 % (IC à 95 % de 0,33 à 3,20) pour les événements thromboemboliques.
Conclusion: Bien que les données probantes concernant les risques liés à la poursuite de l’anticoagulothérapie pendant les électrochocs soient de faible qualité, surtout celles des séries de cas, la fréquence regroupée de l’hémorragie cérébrale inférieure à 1 % (0,21 %) constitue un point de référence précieux pour prendre des décisions éclairées en matière de soins.
References
2. Ross EL, Zivin K, Maixner DF. Cost-effectiveness of Electroconvulsive Therapy vs Pharmacotherapy/Psychotherapy for Treatment-Resistant Depression in the United States. JAMA Psychiatry. Jul 1 2018;75(7):713–722. https://doi.org/10.1001/jamapsychiatry.2018.0768
3. Park L. Neurostimulation: ECT, VNA, rTMS and DBS. In: Fogel BS, Greenberg, D.B., ed. Psychiatric care of the medical patient. 3rd ed. Oxford University Press; 2015:501–503.
4. Abrams R. Electroconvulsive therapy. 4th ed. The medical physiology of electroconvulsive therapy. Oxford University Press; 2002.
5. McNally KA, Blumenfeld H. Focal network involvement in generalized seizures: new insights from electroconvulsive therapy. Epilepsy Behav. Feb 2004;5(1):3–12. https://doi.org/10.1016/j.yebeh.2003.10.020
6. Cocito L, Nizzo R, Bisio N, Favale E. Epileptic seizures heralding intracerebral hemorrhage. Stroke. Nov 1994;25(11):2292–3. https://doi.org/10.1161/01.STR.25.11.2292
7. Jaychandran R, Chaitanya G, Satishchandra P, Bharath RD, Thennarasu K, Sinha S. Monitoring peri-ictal changes in heart rate variability, oxygen saturation and blood pressure in epilepsy monitoring unit. Epilepsy Res. Sep 2016;125:10–8. https://doi.org/10.1016/j.eplepsyres.2016.05.013
8. Nass RD, Hampel KG, Elger CE, Surges R. Blood Pressure in Seizures and Epilepsy. Front Neurol. 2019;10:501. https://doi.org/10.3389/fneur.2019.00501
9. Higgins TJ, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 63 (updated February 2022). Cochrane; 2022.
10. Page MJ, Moher D, Bossuyt PM, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. Mar 29 2021;372:n160. https://doi.org/10.1136/bmj.n160
11. Wells GA SB, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2000;
12. Barker TH, Migliavaca CB, Stein C, et al. Conducting proportional meta-analysis in different types of systematic reviews: a guide for synthesisers of evidence. BMC Med Res Methodol. Sep 20 2021;21(1):189. https://doi.org/10.1186/s12874-021-01381-z
13. Khan S. Meta-analysis on One Proportion. In: Khan S, ed. Meta-Analysis: Methods for Health and Experimental Studies. Springer Singapore; 2020:119–137. https://doi.org/10.1007/978-981-15-5032-4_6
14. Deeks JJ HJ, Altman DG (editors). Chapter 10: Analysing data and undertaking meta-analyses. Cochrane Handbook for Systematic Reviews of Interventions version 63 (updated February 2022). Cochrane; 2022.
15. Centanni NR, Craig WY, Whitesell DL, Zemrak WR, Nichols SD. Safety of ECT in patients receiving an oral anticoagulant. Ment. Jul 2021;11(4):254–258. https://doi.org/10.9740/mhc.2021.07.254
16. Hirata T, Yasuda K, Uemura T, et al. Electroconvulsive Therapy While Receiving OralAnticoagulation for Deep Venous Thrombosis:Report on Eight Cases and a Review of theLiterature. Psychosomatics. July - August 2019;60(4):402–409. https://doi.org/10.1016/j.psym.2018.10.007
17. Hirata T, Yasuda K, Uemura T, et al. Electroconvulsive therapy in patients with cerebral aneurysms taking an anticoagulant or antiplatelet-report on three cases and review of the literature. Letter. Psychiatry Research. June 2020;288 (no pagination)113022. https://doi.org/10.1016/j.psychres.2020.113022
18. Inagawa Y, Saito S, Okada T, Inoue K, Suda S. Electroconvulsive therapy for catatonia With deep venous thrombosis: A case series. Primary Care Companion to the Journal of Clinical Psychiatry. 2018;20(4) (no pagination)18m02286. https://doi.org/10.1016/j.psychres.2020.113022
19. Mehta V, Mueller PS, Gonzalez-Arriaza HL, Pankratz VS, Rummans TA. Safety of electroconvulsive therapy in patients receiving long-term warfarin therapy. Mayo Clinic Proceedings. November 2004;79(11):1396–1401. https://doi.org/10.4065/79.11.1396
20. Petrides G, Fink M. Atrial fibrillation, anticoagulation, and electroconvulsive therapy. Convulsive Therapy. 1996;12(2):91–98.
21. Schmidt ST, Lapid MI, Sundsted KK, Cunningham JL, Ryan DA, Caroline Burton M. Safety of Electroconvulsive Therapy in Patients Receiving Dabigatran Therapy. Psychosomatics. July 2014;55(4):400–403. https://doi.org/10.1016/j.psym.2013.06.010
22. Suzuki K, Takamatsu K, Takano T, Tanabe Y, Fujiyama K, Matsuoka H. Safety of electroconvulsive therapy in psychiatric patients shortly after the occurrence of pulmonary embolism. Journal of ECT. December 2008;24(4):286–288. https://doi.org/10.1097/YCT.0b013e31816c434a
23. Tancer ME, Evans DL. Electroconvulsive therapy in geriatric patients undergoing anticoagulation therapy. Convulsive Therapy. 1989;5(1):102–109.
24. Gokcek A, Celik O, Cil C, Ozlek B, Biteker M. Electroconvulsive Therapy and Anticoagulation. Letter. Psychosomatics. July - August 2019;60(4):433. https://doi.org/10.1016/j.psym.2018.11.004
25. Warriach ZI, Shamim SA, Saeed A, Kashif S, Malik BH. Association of the Thrombo-embolic Phenomenon with Electroconvulsive Therapy Treatment in Schizophrenia with Catatonia Patient. Review. Cureus. Sep 14 2019;11(9):e5656. https://doi.org/10.7759/cureus.5656
26. Yacoub A, Mormando C. Electroconvulsive therapy in a patient with chronic deep vein thrombosis receiving dabigatran therapy: Case report and literature review. Conference Abstract. Journal of ECT. September 2017;33(3):214. https://doi.org/10.1097/YCT.0000000000000429
27. Hermida AP, Glass OM, Shafi H, McDonald WM. Electroconvulsive Therapy in Depression: Current Practice and Future Direction. Psychiatr Clin North Am. Sep 2018;41(3):341–353. https://doi.org/10.1016/j.psc.2018.04.001
28. Group UER. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet. Mar 8 2003;361(9360):799–808. https://doi.org/10.1016/S0140-6736(03)12705-5
29. Matthew JR, Constan E. Complications Following Ect over a Three-Year Period in a State Institution. Am J Psychiatry. May 1964;120:1119–20. https://doi.org/10.1176/ajp.120.11.1119
30. Weisberg LA, Elliott D, Mielke D. Intracerebral hemorrhage following electroconvulsive therapy. Neurology. Nov 1991;41(11):1849. https://doi.org/10.1212/WNL.41.11.1849
31. Carlson EWJ, Weeks H, Couldwell WT, Kalani MYS. Intraparenchymal hemorrhage after electroconvulsive therapy. Interdisciplinary Neurosurgery. 2017/09/01/ 2017;9:89–91. https://doi.org/10.1016/j.inat.2017.07.012
32. Ishida T, Sakurai H, Watanabe K, Iwashita S, Mimura M, Uchida H. Incidence of deep vein thrombosis in catatonic patients: A chart review. Psychiatry Res. Jul 30 2016;241:61–5. https://doi.org/10.1016/j.psychres.2016.04.105
33. Kunutsor SK, Seidu S, Khunti K. Depression, antidepressant use, and risk of venous thromboembolism: systematic review and meta-analysis of published observational evidence. Ann Med. Sep 2018;50(6):529–537. https://doi.org/10.1080/07853890.2018.1500703
34. Di X, Chen M, Shen S, Cui X. Antipsychotic use and Risk of Venous Thromboembolism: A Meta-Analysis. Psychiatry Res. Feb 2021;296:113691. https://doi.org/10.1016/j.psychres.2020.113691
35. Gelenberg AJ, Freeman MP, Markowitz JC, et al. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. October 2010
36. Mamah D, Lammle M, Isenberg KE. Pulmonary embolism after ECT. J ECT. Mar 2005;21(1):39–40. https://doi.org/10.1097/01.yct.0000152572.27344.f5
37. Hamdieh M, Safaie N, Abbasinejad M. A psychiatric patient with catatonia and pulmonary thromboemboli. J Neuropsychiatry Clin Neurosci. Winter 2014;26(1):E19–20. https://doi.org/10.1176/appi.neuropsych.13010004
38. Gordis L. Epidemiology. 3rd ed. Saunders; 2004.
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Articles are published under a Creative Commons Attribution - Non Commercial 4.0 International License. Authors and users are free to copy and redistribute the material in any medium or format, with proper attribution, for non-commercial purposes. Authors retain copyright to their article.