Can Electroconvulsive Therapy (ECT) be safely proceeded with in a patient with a new diagnosis of Atrial Fibrillation (AF)?

Can ECT Be Safely Proceeded With in New-Onset Atrial Fibrillation?

Yes, ECT can be safely proceeded with in patients with newly diagnosed atrial fibrillation, provided appropriate anticoagulation is initiated and the patient is hemodynamically stable. 1

Immediate Assessment Before Proceeding

Before proceeding with ECT in a patient with new-onset AF, you must first assess hemodynamic stability:

• Check for signs of instability: hypotension, ongoing chest pain/ischemia, altered mental status, shock, or pulmonary edema 2
• If hemodynamically unstable, the patient requires immediate cardioversion and stabilization before considering ECT 2
• If hemodynamically stable, proceed with the anticoagulation and rate control algorithm below 3, 2

Anticoagulation Is Essential Before ECT

The critical concern with AF and ECT is the high incidence of spontaneous cardioversion to normal sinus rhythm during ECT treatment, which creates embolic risk if atrial thrombus has formed. 1, 4

Initiate anticoagulation immediately based on CHA₂DS₂-VASc score:

• CHA₂DS₂-VASc ≥2: Start direct oral anticoagulant (DOAC) immediately—apixaban, rivaroxaban, edoxaban, or dabigatran preferred over warfarin 3, 5
• CHA₂DS₂-VASc = 1: Consider anticoagulation based on individual risk factors 3
• Alternative approach: Use therapeutic heparin or warfarin if DOACs are contraindicated 1

The evidence strongly supports anticoagulation because ECT frequently converts AF to normal sinus rhythm (observed in 4 of 6 patients in one case series), and this cardioversion carries embolic risk similar to electrical cardioversion. 1, 4

Rate Control Before ECT

Achieve adequate rate control targeting heart rate <110 bpm before proceeding with ECT: 2

• First-line agents (if LVEF >40%): Beta-blockers (metoprolol preferred) or non-dihydropyridine calcium channel blockers (diltiazem or verapamil) 3, 2
• Metoprolol dosing: 2.5-5 mg IV over 2 minutes, repeat every 5-10 minutes up to 15 mg total 2
• Diltiazem dosing: 0.25 mg/kg IV over 2 minutes, followed by 0.35 mg/kg if needed 2

Evidence Supporting Safety of ECT in AF

Multiple case reports and case series demonstrate that ECT can be safely administered to patients with AF:

• Published experience: 6 patients with AF successfully received ECT with anticoagulation, with 4 experiencing conversion to normal sinus rhythm 1
• Additional cases: 3 patients received ECT with AF without anticoagulation (though this is not recommended), and 3 received ECT with anticoagulation, all without embolic complications 1
• Broader experience: 18 patients received ECT while on anticoagulation for other indications without major bleeding complications 1
• Recent systematic review: Multiple patients were able to return to ECT after developing AF during treatment without further complications 6

Timing Considerations

You can proceed with ECT once anticoagulation is initiated—you do not need to wait for therapeutic levels if the AF is newly diagnosed and the patient has been anticoagulated immediately. 5, 2

However, if AF duration is >48 hours or unknown:

• Consider 3 weeks of therapeutic anticoagulation before ECT 2
• Alternative: Obtain transesophageal echocardiography to exclude left atrial thrombus before proceeding 3

Critical Pitfalls to Avoid

• Do not proceed without anticoagulation: The high rate of spontaneous cardioversion during ECT creates significant embolic risk 1, 4
• Do not delay ECT indefinitely: With appropriate anticoagulation and rate control, ECT can be safely administered and should not be withheld from patients who need this potentially life-saving treatment 1, 6
• Do not use digoxin as sole rate control agent: It is ineffective during the sympathetic surge associated with ECT 2
• Monitor for arrhythmias during ECT: Be prepared for potential conversion to sinus rhythm or other arrhythmias during the procedure 4, 6

Multidisciplinary Coordination

Coordinate with cardiology for:

• Confirmation of anticoagulation strategy 3
• Optimization of rate control 2
• Assessment of need for transesophageal echocardiography if AF duration uncertain 3

The cardiovascular complications of ECT are generally minor and manageable with appropriate pre-ECT evaluation and a comprehensive team approach. 7