A 52-year-old woman with severe depression and psychotic features has failed trials of sertraline, venlafaxine, and augmentation with aripiprazole over 8 weeks. She has stopped eating, expresses suicidal ideation with a plan to hang herself, and refuses all oral medications. Her husband reports she has not slept in 3 days. Physical examination shows a blood pressure of 160/95 mmHg, heart rate 102/min, and she appears catatonic. The psychiatrist plans electroconvulsive therapy (ECT). Which of the following is the most important pre-ECT medical evaluation to perform given her presentation?

Explanation

## Pre-ECT Medical Evaluation in Severe Depression with Catatonia ### Clinical Context This patient presents with severe, treatment-resistant depression with psychotic features and catatonia—a classic indication for ECT. Her elevated blood pressure and tachycardia raise concerns about cardiovascular stability during the procedure. ### Why ECG and Echocardiography Are Essential **Key Point:** Cardiovascular assessment is the single most critical pre-ECT evaluation because ECT induces a transient sympathomimetic surge followed by parasympathomimetic effects, placing significant stress on the heart. **High-Yield:** ECT causes: 1. Initial vagal stimulation → bradycardia and hypotension 2. Subsequent sympathetic activation → tachycardia and hypertension 3. Increased myocardial oxygen demand 4. Risk of arrhythmias, especially in patients with pre-existing cardiac disease ### Pre-ECT Cardiac Workup | Investigation | Rationale | | --- | --- | | **12-lead ECG** | Detects baseline arrhythmias, ischemia, prolonged QT, conduction abnormalities | | **Echocardiography** | Assesses left ventricular function, valvular disease, ejection fraction; identifies high-risk patients | | **Troponin/CK-MB** | If ECG abnormalities or chest pain history | **Clinical Pearl:** Relative contraindications to ECT include recent MI, unstable angina, uncontrolled hypertension, and severe aortic/cerebral aneurysm. This patient's hypertension (160/95) and tachycardia mandate baseline cardiac assessment before proceeding. ### Why Other Options Are Secondary - **Lumbar puncture:** Catatonia in the context of a known psychiatric history and treatment failure does not require CSF analysis unless infectious encephalitis is suspected (no fever, no meningeal signs here). - **MRI brain:** Structural imaging is not routine pre-ECT unless focal neurological signs or atypical presentation suggest organic pathology. - **Electrolytes/LFTs:** While important for overall safety, these do not address the acute cardiovascular risk posed by ECT itself. **Mnemonic:** **CARDIAC** pre-ECT checklist: - **C**ardiac history and exam - **A**rrhythmia risk (ECG) - **R**ecent MI or angina - **D**iabetes and hypertension control - **I**schemia assessment (troponin if indicated) - **A**nesthesia risk (ASA score) - **C**urrent medications (sympathomimetics, stimulants) [cite:Kaplan & Sadock's Synopsis of Psychiatry 12e Ch 35]