I had a heart attack a few years ago — am I a candidate for ketamine therapy?

It depends. Time since the event, current cardiac function, ejection fraction, current medications, and your cardiologist's clearance all factor in. We do not decide alone in these cases. We will request records and a written clearance from your cardiologist before scheduling, and we may decline if the cardiac picture is not stable.

Do you require an EKG before ketamine treatment?

Not for every patient. We may request a recent EKG and a cardiology note depending on your history, age, medications, and screening blood pressure. Patients with known cardiac disease, prior arrhythmia, prior MI, or significant risk factors usually need one. Healthy patients with no cardiac history typically do not.

What about atrial fibrillation — can I have ketamine therapy with AFib?

Often, yes — if your AFib is rate-controlled, stable, and you are on appropriate medication and anticoagulation. Uncontrolled or rapid AFib is not a fit. We coordinate with your cardiologist before treatment and monitor heart rate continuously during every infusion.

Heart failure — yes or no for ketamine?

Compensated, stable heart failure with a reasonable ejection fraction and written cardiology clearance is sometimes workable in our outpatient setting. Decompensated heart failure, recent hospitalization for heart failure, or severely reduced ejection fraction is a no. The increased myocardial oxygen demand ketamine causes is not appropriate in those cases.

What if my cardiologist says no to ketamine therapy?

Then it is a no. We would rather lose a patient than ignore a real cardiac signal. We can discuss alternatives such as Spravato in a more closely monitored setting if appropriate, or non-ketamine treatments better suited to your cardiac risk profile. The goal is the right treatment, not just any treatment.

Ketamine and Heart Conditions: Who's a Candidate, Who Isn't, and How We Screen

Why Ketamine Stresses the Heart: Sympathomimetic Effects

Ketamine is a useful drug in part because it preserves airway reflexes and respiratory drive far better than most anesthetics. The trade-off for that property is what it does to the cardiovascular system. Ketamine is sympathomimetic. It causes a release of norepinephrine and inhibits its reuptake, which translates clinically into higher heart rate, higher blood pressure, and increased myocardial contractility during administration.

For a healthy patient, this is an unremarkable transient effect. Heart rate may climb 15 to 25 percent. Systolic blood pressure typically rises 20 to 40 mm Hg from baseline during the infusion and returns to normal within 15 to 30 minutes after the drug is stopped. The body handles it.

For a patient with significant coronary artery disease, the math is different. A heart that already has trouble getting enough oxygen at rest—because of narrowed arteries, weakened muscle, valvular problems, or arrhythmia—does not have the reserve to absorb a 30 percent jump in workload without consequence. Increased myocardial oxygen demand against fixed or limited supply is the textbook setup for ischemia. That is the cardiac risk profile we are screening against, and it is why we ask the questions we ask. Ketamine is FDA-approved as an anesthetic; its use for depression, chronic pain, and other psychiatric conditions is off-label.

What the Cohen 2018 ASRA/AAPM/ASA Consensus Says

The most cited document on cardiovascular screening for ketamine therapy is the 2018 consensus guideline published by Cohen et al. in Regional Anesthesia & Pain Medicine, jointly issued by the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. The consensus reviewed the published literature on IV ketamine infusions for chronic pain and synthesized recommendations on patient selection, dosing, and monitoring.

On cardiovascular screening, the consensus is direct. Poorly controlled cardiovascular disease is listed as a relative or absolute contraindication depending on severity. Specifically flagged conditions include recent myocardial infarction, severe or unstable angina, severe valvular disease, untreated or poorly controlled hypertension, and clinically significant arrhythmia. The guideline recommends pre-procedure cardiovascular evaluation for patients with a meaningful cardiac history and explicitly endorses obtaining cardiology clearance when the picture is uncertain.

A second major reference for psychiatric ketamine practice is the 2017 American Psychiatric Association consensus on ketamine for mood disorders, which echoed similar concerns about cardiovascular history and called for blood pressure and cardiac rhythm monitoring during every infusion. The themes are consistent across pain and psychiatric guidelines: the cardiovascular system needs to be assessed before treatment and watched during it.

What the Spravato FDA Label Flags

Spravato (esketamine), the intranasal cousin of IV ketamine, is FDA-approved for treatment-resistant depression and major depressive disorder with acute suicidal ideation. Its prescribing information is publicly available, and the cardiovascular language in the label is a useful reference point for any clinician making screening decisions about ketamine itself.

The Spravato label lists three absolute contraindications: aneurysmal vascular disease (including thoracic, abdominal aortic, and intracranial), arteriovenous malformation, and a history of intracerebral hemorrhage. The reasoning is mechanical. A drug that reliably elevates blood pressure should not be given to a patient with a vascular wall that may not tolerate the spike. The label also instructs prescribers to assess blood pressure prior to dosing, monitor it after dosing, and to use caution in patients with cardiovascular and cerebrovascular conditions.

The pivotal Spravato registration trials in treatment-resistant depression—published across the American Journal of Psychiatry and related journals between 2018 and 2020—explicitly excluded patients with significant cardiovascular disease. Cardiovascular safety analyses across those trials reported in subsequent esketamine safety publications found that BP and HR increases during dosing were generally transient and well tolerated in the studied population. Two things follow from that. The drug looks reasonably safe in patients without significant cardiac disease. And we have very limited prospective evidence about how it behaves in patients with significant cardiac disease, because those patients were not enrolled.

Conditions That Typically Rule Out Ketamine Therapy

Not every cardiac history is workable in our outpatient setting. The following conditions, drawn from the ASRA consensus and the Spravato label, are typical exclusions in our screening, though every case is reviewed individually:

Uncontrolled hypertension. Resting BP above roughly 160/100 mm Hg that is not controlled on current medications. We will defer treatment until BP is brought under control by your prescribing provider.
Recent myocardial infarction. An MI within the past 6 to 12 months is generally a no in our outpatient setting. Beyond that window, we evaluate based on cardiac function and cardiology clearance.
Unstable angina. Active anginal pattern that has changed recently or is not controlled is an exclusion.
Severe valvular disease. Severe aortic stenosis is the most concerning, because the stenotic valve does not tolerate the increased contractility and tachycardia ketamine produces.
Decompensated heart failure. Recent hospitalization for heart failure, fluid overload, or severely reduced ejection fraction.
Aneurysmal vascular disease. Thoracic aortic aneurysm, abdominal aortic aneurysm, intracranial aneurysm, or known arteriovenous malformation. This mirrors the absolute contraindications on the Spravato label.
Uncontrolled arrhythmia. Rapid AFib that is not rate-controlled, recurrent ventricular arrhythmia, or any rhythm disturbance that has not been worked up.

For patients with these conditions, we do not push the case. We say no, explain why, and discuss alternatives. Our companion article on ketamine and hypertension goes deeper on the BP screening specifically.

Conditions That Need Cardiology Clearance First

Plenty of patients with cardiac history can be treated safely with the right preparation. The middle category—not an automatic no, not an automatic yes—is where most of our screening time gets spent. Conditions that typically require cardiology clearance before we schedule include:

Stable coronary artery disease. Prior MI more than a year ago, prior stenting or bypass with a stable post-procedure course.
Compensated heart failure with preserved or moderately reduced ejection fraction, on stable medical therapy.
Rate-controlled atrial fibrillation on appropriate anticoagulation, with stable rate response.
Controlled hypertension with one or more meds, especially in patients over 60 or with end-organ involvement.
Mild to moderate valvular disease, with current echo findings.
History of arrhythmia that has been worked up and is currently controlled.

For these patients we typically ask for a recent EKG (within 12 months for most, more recent for higher-risk presentations), the most recent echo if heart function is in question, a current medication list, and a written note from the cardiologist confirming that ketamine therapy is reasonable from a cardiac standpoint. We share the published safety data and the planned dosing range so the cardiologist has what they need to make an informed call.

Our Screening: History, EKG, Medication Review

Every patient at Music City Ketamine goes through a structured medical screening before we accept them for treatment. For patients with any cardiac history, the screening adds depth in three areas:

History. We take a detailed cardiac history during consultation: prior cardiac diagnoses, prior procedures, current symptoms, exercise tolerance, recent changes in chest pain or shortness of breath, episodes of palpitations or syncope, family history of sudden cardiac death. The clinical picture matters more than any single number.

EKG and records. A recent EKG is requested when history warrants it. We also request recent labs, the most recent echocardiogram if available, and the cardiologist's most recent visit note. First-time patients can review what to expect at the first infusion here; for cardiac patients, the screening step adds time on the front end.

Medication review. Several cardiovascular medications interact with ketamine in ways that matter. Beta blockers can blunt the tachycardia response, which is generally helpful. Some antihypertensives may behave unpredictably under sympathetic surge. MAOIs are a hard interaction to manage. Anticoagulants do not contraindicate ketamine therapy but are worth noting for the overall picture. Our medication interactions article covers the full landscape; cardiac patients should expect us to review every medication on their list.

During the infusion itself, every patient is on continuous pulse oximetry, automated blood pressure cycling every 3 to 5 minutes, and continuous heart rate monitoring. Marla Peterson, CRNA, oversees every infusion, and the clinical team is on-site throughout. Anesthesia-level monitoring is the standard, and it is non-negotiable for patients with cardiac history. More on our monitoring approach is on the safety page and in our general safety overview.

Why We'd Rather Refer Out Than Push Someone Who Isn't a Fit

The honest version of this article is that we say no fairly often when the cardiac picture is not right. That is by design. Outpatient ketamine therapy is a great option for many people, but it is not the right setting for someone whose heart cannot tolerate a transient sympathetic surge without consequence. A patient who needs a more closely monitored environment—a hospital infusion suite, an inpatient cardiology team, or a different therapy entirely—deserves to be told that.

For patients who don't qualify for IV ketamine, alternatives may include Spravato in a more closely monitored setting, transcranial magnetic stimulation, or other treatments better suited to the cardiac risk profile. We are happy to discuss options and refer where it makes sense. The goal is the right treatment, not just any treatment.

For patients who do qualify with cardiology clearance, ketamine therapy can proceed with confidence. The safety record in appropriately screened patients is well-documented across the chronic pain and depression literature. Research suggests that with the right screening and monitoring, the cardiovascular effects of ketamine remain manageable even in patients with stable cardiac history. The screening is not designed to keep people out. It is designed to make sure the people who come in are the people we can treat well.

If you have a cardiac history and you're wondering whether ketamine therapy is something you can pursue, the answer is: maybe, and we'll find out together. The screening exists for that reason. Sessions at our clinic are $475 each, and we are transparent about who we can treat and who we cannot.