Can Electroconvulsive Therapy (ECT) cause elevated D-dimer (D-dimer) levels?

Electroconvulsive Therapy (ECT) and D-dimer Elevation

There is no direct evidence that ECT procedures cause D-dimer elevation, but this is plausible given that D-dimer can be elevated by many conditions including inflammation, which ECT temporarily induces.

Relationship Between ECT and D-dimer

D-dimer is a fibrin degradation product that forms when cross-linked fibrin is broken down by plasmin. While no studies directly examine the relationship between ECT and D-dimer levels, several relevant factors should be considered:

Physiological Changes During ECT

• ECT induces a generalized seizure that triggers various physiological responses including:

  • Temporary inflammatory response 1
  • Neurobiological function modifications 2
  • Endocrine changes including hypothalamus-hypophysis-adrenal axis activation 2

• Research has demonstrated that inflammatory markers like C-reactive protein (CRP) and interleukin-6 (IL-6) increase from baseline to the second ECT session and then return to baseline levels by the end of treatment 1

D-dimer Elevation Mechanisms

According to guidelines, D-dimer can be elevated in numerous conditions:

• The American Heart Association/American Stroke Association notes that D-dimer has "poor specificity, because there are many causes of elevated D-dimer" 3
• The European Society of Cardiology states that "fibrin is also produced in a wide variety of conditions such as cancer, inflammation, bleeding, trauma, surgery and necrosis" 3

Clinical Implications

Interpreting D-dimer Results After ECT

• If D-dimer is elevated after ECT, clinicians should:

  1. Consider that the elevation may be related to the inflammatory response induced by ECT
  2. Evaluate for other more common causes of D-dimer elevation
  3. Assess for clinical signs of venous thromboembolism (VTE)

• The European Society of Cardiology guidelines emphasize that D-dimer testing has high negative predictive value but low specificity 3

When to Pursue Further Testing

• According to the American Heart Association/American Stroke Association, "If there is a strong clinical suspicion of CVT, a normal D-dimer level should not preclude further evaluation" 3

• For patients with elevated D-dimer after ECT:

  • Assess clinical probability using validated tools like Wells score or Geneva score 4
  • Consider age-adjusted D-dimer cutoffs for patients over 50 years 4
  • Pursue standard-of-care objective testing (CTPA, V/Q scan, ultrasonography) if clinical suspicion of VTE exists 4

Common Pitfalls

• Misattribution: Attributing D-dimer elevation solely to ECT without considering other common causes

• Overreaction: Initiating anticoagulation based solely on elevated D-dimer without clinical signs of VTE

• Underreaction: Dismissing elevated D-dimer in a patient with clinical signs of VTE

• A prospective study found that nearly half of all emergency department patients had elevated D-dimer levels, associated with various conditions including VTE, infection, cancer, heart failure, and anemia 5

Conclusion for Clinical Practice

When evaluating D-dimer elevation in a patient who has undergone ECT:

1. Consider the timing relative to the ECT procedure (inflammatory markers peak after the second session) 1
2. Evaluate for clinical signs and symptoms of VTE
3. Consider other common causes of D-dimer elevation
4. Use clinical prediction rules to guide further diagnostic testing
5. Remember that D-dimer has high negative predictive value but poor specificity 3