Safety of ECT in patients receiving an oral anticoagulant

Abstract

Introduction This study assessed the use, tolerability, and safety of anticoagulation via direct oral anticoagulants or warfarin in medical and psychiatric inpatients receiving ECT. Methods This retrospective cohort study included 32 patients who received ECT while on either a direct oral anticoagulant (9) or warfarin (23) and spanned 247 encounters at Maine Medical Center between December 2012 and December 2018. Data are presented descriptively and analyzed using SPSS version 25 and Microsoft Excel version 2016. Results Among the 247 ECT patient encounters, there were few major adverse effects of ECT in this medically complex population. These adverse effects included headache during 4 encounters (1.6%), respiratory distress during 2 encounters (0.8%) and a cardiovascular event during 1 encounter (0.4%). One patient (3.1%) who was receiving concurrent rivaroxaban and venlafaxine experienced gastrointestinal bleeding that was determined to be unrelated to ECT. One patient on fluoxetine and warfarin experienced hemoptysis thought to be secondary to epistaxis. No other major bleeding or clotting event occurred during an ECT session nor for the duration of the hospitalization. Discussion Direct oral anticoagulants and warfarin appear safe in the treatment of patients with atrial fibrillation or acute venous thromboembolism who are receiving concomitant ECT. Prospective studies are needed to confirm these findings.

Atrial fibrillation, electroconvulsive therapy, stroke risk, and anticoagulation

“…Stroke risk with cardioversion can be mitigated by appropriate periprocedural anticoagulation, but anticoagulation in ECT still poses concerns for major bleeding events, such as intracranial hemorrhage, despite the relative rarity. Several studies have examined safe anticoagulation use in patients with AF who undergo ECT [ 8 , 26 – 28 ]. Warfarin and direct oral anticoagulants (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran were analyzed, and they were determined to be safe without major bleeding events post-ECT [ 8 , 26 – 28 ].…”

“…Several studies have examined safe anticoagulation use in patients with AF who undergo ECT [ 8 , 26 – 28 ]. Warfarin and direct oral anticoagulants (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran were analyzed, and they were determined to be safe without major bleeding events post-ECT [ 8 , 26 – 28 ]. In fact, the patient described by Suzuki et al [ 25 ] may well have avoided stroke had she been adherent to an anticoagulation regimen.…”