LAUSR

secutory delusions and hallucinatory behaviors. Risperidone was titrated to 1.5 mg/day, and she achieved full remission within the next 2 weeks. Repeat echocardiogram showed ejection fraction of 65% and no regional wall motion abnormalities. Outpatient myocardial perfusion imaging showed a small area (<5%) of mild ischemia. She had no further cardiac events during the following 12 months. The psychiatry, cardiology, and anesthesia teams worked closely to mitigate ECT-related cardiac risks. Bifrontal electrode placement was chosen as it carries the lowest risk of bradycardia and asystole. An energy level of 70% was prescribed based on estimation of seizure threshold from previously recorded ECT parameters – this circumvented the need for dose titration and repeated stimulation, minimizing additive cardiac risks associated with subconvulsive stimuli. We used the Thymatron System IV-Integrated ECT machine from Somatics LLC (Venice, FL, USA). Because a different ECT machine (MECTA) was used in her previous psychotic episode, millicoulomb conversion was done. Omission of lorazepam on pre-ECT nights and use of lowest titrated dose of anesthetic agent (thiopental 2.7 mg/kg) ensured that a therapeutic seizure was achieved each time. EEG seizures were rated using a quality rating system and were satisfactory in all sessions. An additional 2.5 mg of bisoprolol was served on pre-ECT nights to counteract the sympathetic-mediated tachycardia during ECT. The patient’s peri-ECT mean arterial pressure and heart rate were maintained close to her baseline at >60 mmHg and 70 beats per minute. Post-ECT monitoring involved continuous cardiac monitoring (parameters and electrocardiographic) until she was fully alert, followed by hourly monitoring for the next 6 hours. We considered but ultimately did not use anti-muscarinic agents, such as glycopyrrolate, to blunt the initial parasympathetic effects of the ECT stimulus, due to risks of rebound tachycardia and hypertension. In this report, we have described practical measures to minimize ECT-related cardiac risks following recent MI. By optimizing the therapeutic benefit of each ECT session, we minimized the number of ECT sessions required, and avoided a protracted treatment course. Quite remarkably, the patient achieved rapid and complete relief from lifethreatening catatonia with just three sessions of ECT. This case illustrates that with appropriate risk-mitigation measures, ECT may be delivered safely post-MI when its benefits are compelling. Written informed consent was obtained from the patient to write up and publish this case report.