Our general medicine consultation service was asked to evaluate a 63‐year‐old woman who was admitted to the psychiatric ward with severe bipolar disorder. She initially presented with catatonia and severe depression. After undergoing serial electroconvulsive therapy (ECT), the patient was more interactive and expressed a positive mood. During recovery from one of her ECT sessions, she was noted to have abnormalities on cardiac monitoring. A 12‐lead electrocardiogram (ECG) was performed. This revealed deep T‐wave inversions in leads I, aVL, and V2 through V6 in addition to QT prolongation. These findings were significantly different compared to a normal baseline ECG from 1 month earlier. She denied any constitutiona complaints, chest pain or palpitations. She was not known to have cardiac disease and had a normal cardiac catheterization 7 years earlier. She was normolensive, and her cardiac exam was normal. Subsequent serial cardiac enzymes and transthoracic echocardiogram were normal.
ECT has recently seen increased use in the treatment of a wide variety of psychiatric illness. The hospitalist will be asked more frequently to consult on a variety of medical issues such as interpreting an abnormal ECG. Significant acute ECG changes have been associated with severe neurologic injures such as subarachnoid hemorrhage. They have also been associated with seizure, cerebral tumors and acute strokes. Similar ECG abnormalities have also been seen after ECT, but these are less commonly reported. Early studies suggested these can be found in up to 4% of patients receiving ECT. These changes have often been referred to as cerebral T waves and can persist for several weeks before resolution. The mechanism is postulated to be from cerebrally mediated increases in sympathetic and vagal tone. Although debated, it is generally not thought to represent true myocardial ischemia. The ECG changes in this patient were consistent with other described cases. As in those cases, her cardiac workup did not identify ischemia and the remainder of her hospital course was uneventful.
This case demonstrates an uncommon ECG finding associated with ECT. This unusual finding emphasizes a poorly understood relationship between the brain and the heart. The Hospitalist should be aware that a preceding neurologic event can result in ECG abnormalities even without underlying cardiac disease.
D. Cho, none.