I have high blood pressure — does that disqualify me from ketamine therapy?

Not by itself. Controlled hypertension on stable medication usually does not disqualify a patient. Uncontrolled or labile hypertension does, until it is brought under control with your prescribing provider. We measure your blood pressure at the start of every session, and we delay treatment if your readings are out of our acceptable range that day.

How high does blood pressure go during a ketamine session?

Most patients see a transient rise of roughly 10 to 25 mmHg in systolic pressure, with a similar bump in heart rate. Per the FDA-approved Spravato label, peak blood pressure typically occurs around 40 minutes after dosing and elevations resolve over about four hours. Severe hypertensive responses are uncommon but documented in the cardiac-safety literature, which is why continuous monitoring matters.

What is the blood pressure threshold where you would cancel a session?

It is a clinical judgment call, not a single number. We commonly delay a session if pre-infusion blood pressure is meaningfully above range, with thresholds in the neighborhood of 140/90 to 160/100 depending on your history, your usual readings, and what your prescribing provider has documented. The goal is for you to start the infusion well-controlled, not borderline.

Should I take my blood pressure medications the morning of the infusion?

Generally yes. We want you well-controlled at the start of the session, so most patients take their usual antihypertensive regimen on schedule the day of treatment. We confirm specifics during medical screening and do not advise stopping or changing any medication on your own. Always coordinate medication changes with your prescribing provider.

What are the absolute deal-breakers for ketamine treatment?

Per the Spravato prescribing information, contraindications include aneurysmal vascular disease (including thoracic, abdominal aortic, and intracranial aneurysms), arteriovenous malformation, and a history of intracerebral hemorrhage. The ASRA, AAPM, and ASA chronic-pain consensus also lists poorly controlled cardiovascular disease, recent myocardial infarction, and severe uncontrolled hypertension as reasons to defer treatment until cleared by a cardiologist.

Ketamine and Hypertension: The Transient BP Rise and How We Screen

Why Ketamine Raises Blood Pressure in the First Place

Ketamine has a well-known cardiovascular signature that distinguishes it from most other anesthetics. While drugs like propofol typically lower blood pressure, ketamine reliably raises it. This is not a side effect we hope to avoid. It is a predictable pharmacological feature of the drug, and any clinician working with ketamine has to plan around it.

The mechanism is sympathomimetic. Ketamine triggers a release of catecholamines, primarily norepinephrine, and partially blocks their reuptake. The result is increased sympathetic nervous system tone during the active window of the dose. Heart rate climbs, cardiac output increases, and systolic and diastolic blood pressure rise above baseline. In most patients, the effect is transient and self-limiting. In patients whose cardiovascular system is already pushed to its limit, that same effect can be a problem.

Ketamine is FDA-approved as an anesthetic. Its use for depression, anxiety, PTSD, and chronic pain is off-label, and esketamine (Spravato) is FDA-approved specifically for treatment-resistant depression and major depressive disorder with acute suicidal ideation. The blood pressure response is similar across both forms of the drug because the underlying pharmacology is the same.

What the Spravato Label Actually Says

The Spravato prescribing information is the clearest regulatory document we have on the cardiovascular profile of esketamine, and the same physiology applies to IV ketamine. According to the FDA-approved label, Spravato can cause increases in systolic and diastolic blood pressure, with peak effects occurring around 40 minutes after the dose and elevations resolving over approximately four hours.

The label sets out specific contraindications tied to vascular disease. Spravato is contraindicated in patients with aneurysmal vascular disease, including thoracic and abdominal aortic aneurysms, intracranial aneurysms, and peripheral arterial aneurysms. It is also contraindicated in patients with arteriovenous malformation and in those with a history of intracerebral hemorrhage. The reasoning is straightforward: a transient surge in blood pressure can be dangerous to a vessel that is already compromised.

The label also flags hypertensive encephalopathy as a condition requiring caution and recommends that patients with cardiovascular or cerebrovascular conditions be assessed before treatment. Cardiac-safety analyses of esketamine in treatment-resistant depression trials, published in journals including the Journal of Affective Disorders, have generally found the BP elevations to be transient and well-tolerated, with severe hypertension uncommon but documented. That last word matters. It is uncommon, not zero.

What the 2018 ASRA, AAPM, and ASA Consensus Says

The most cited clinical guidance for IV ketamine in chronic pain and acute pain is the 2018 consensus statement by Cohen and colleagues, published in Regional Anesthesia & Pain Medicine, jointly issued by the American Society of Regional Anesthesia, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. It was written precisely because clinicians needed a defensible, expert-reviewed framework for who is and is not a candidate.

On cardiovascular screening, the consensus is direct. Poorly controlled cardiovascular disease is listed as a relative contraindication to IV ketamine infusions for chronic pain. Severe or uncontrolled hypertension falls into the same category. Active or recent cardiac events — recent myocardial infarction, unstable angina, decompensated heart failure — are stronger reasons to defer treatment until a cardiologist has weighed in. The consensus recommends pre-procedure cardiovascular screening, including a thorough history and, in higher-risk patients, formal cardiology clearance.

The practical takeaway is that ketamine in the right patient is a reasonable option, but the screening is not optional. If a patient has cardiac history beyond well-controlled hypertension, the right answer is often a conversation with their cardiologist before we move forward. We do not try to substitute our judgment for theirs on cardiac questions. That is what their primary care physician and cardiologist are for.

Controlled Hypertension Versus Uncontrolled: Where the Line Sits

The single most common question we field on this topic is some version of: I have high blood pressure, can I still do ketamine? The honest answer is that it depends on what kind of high blood pressure.

Controlled hypertension — meaning a patient is on a stable medication regimen, sees their primary care physician regularly, and consistently shows readings within or near target range — is usually compatible with ketamine therapy. We screen, we measure baseline blood pressure at every session, and we monitor throughout. The catecholamine bump from ketamine adds to a number that is already in a reasonable place. In a typical session, most patients see a transient rise on the order of 10 to 25 mmHg in systolic pressure, returning toward baseline within hours.

Uncontrolled hypertension is a different conversation. If readings are routinely high, if blood pressure is labile, if the patient has not been seen by a prescribing provider recently, or if they are not on stable medication, we are stacking a sympathomimetic surge on top of an already-strained system. That is the scenario the Spravato label and the ASRA consensus warn against. In that case, the right step is to defer treatment, get the hypertension under control with the prescribing provider, and revisit the conversation once readings are reliably in range. We have had this conversation many times. Patients almost always understand it once we explain why.

Absolute Contraindications and Recent Cardiac Events

A small number of conditions move the conversation from caution to a clear no. Per the Spravato label, those include aneurysmal vascular disease, arteriovenous malformation, and a history of intracerebral hemorrhage. The 2018 ASRA, AAPM, and ASA consensus adds severe uncontrolled hypertension and active or recent unstable cardiac disease to the list of reasons to defer.

Recent myocardial infarction is the most common scenario where we recommend a hard pause and a cardiology conversation. Acute, unstable cardiac disease is another. In any of these situations, our position is the same: cardiac questions belong with cardiologists. We can describe how ketamine affects blood pressure and heart rate. We cannot tell you whether your specific cardiac risk profile is compatible with that effect. Your cardiologist or primary care physician can. We are happy to coordinate with them and we do so regularly. For more on how we approach ketamine and heart conditions in general, see our companion article.

Our Session Protocol: Baseline Reading, Delay Thresholds, and Monitoring

The cardiovascular profile is exactly why ketamine therapy belongs in a clinical setting with anesthesia-trained monitoring rather than at home or in an unmonitored environment. At Music City Ketamine, every session follows a consistent protocol designed to catch problems early.

Each session begins with a baseline blood pressure and heart rate reading before any medication is administered. If the pre-session reading is meaningfully out of range, the session is delayed. The thresholds we use are clinical judgment calls that depend on the patient’s history, their typical readings, and what their prescribing provider has documented — commonly in the neighborhood of 140/90 to 160/100 for the upper bound, with adjustments based on context. There is no single magic number. There is a clinician making a thoughtful decision.

During the infusion, we maintain continuous pulse oximetry and periodic blood pressure checks. Marla Peterson, CRNA, oversees every session and uses anesthesia-level monitoring throughout. If blood pressure climbs above acceptable bounds during the infusion, we have rescue medications available and the option to slow or stop the infusion. If you want a deeper look at why having a CRNA in the room matters, our article on what a CRNA does goes into detail.

Patients who are new to the process often want to know what the room and the experience feel like before they commit. Our walk-through of your first ketamine infusion covers what to expect minute by minute. Our broader safety standards and our deeper dive on whether ketamine therapy is safe spell out the full monitoring picture.

Medications and Information to Bring to Your Consultation

If you have any cardiovascular history, the consultation is where we do most of our screening work, and it goes much better when you arrive prepared. Bring a current list of every medication you take, including the dose and how long you have been on it. We pay particular attention to antihypertensives, stimulants, MAOIs, decongestants, and anything else that interacts with sympathetic tone or with ketamine itself. Our overview of common ketamine medication interactions is a useful primer before the visit.

It also helps to bring recent blood pressure readings if you track them, your most recent visit notes from your primary care physician or cardiologist, and any documentation from a stress test, echocardiogram, or recent cardiac workup. If you are not sure whether your hypertension is well-controlled, that is itself a useful piece of information — we can help you think through whether to check in with your prescribing provider before the consult.

One thing we ask every patient: do not stop, start, or change any medication on your own in advance of the appointment. Generally, we want patients to take their usual antihypertensive regimen the morning of a session so they arrive well-controlled. Specifics get confirmed during medical screening and are coordinated with your prescribing provider. Research suggests that consistent control around the time of dosing produces the most predictable cardiovascular response, and that is what we are aiming for.

The Bottom Line

Ketamine raises blood pressure and heart rate during the dose. That is not a bug; it is a known feature of the drug. For patients with controlled hypertension and a clean cardiovascular workup, the rise is monitorable and almost always uneventful. For patients with uncontrolled hypertension, recent cardiac events, aneurysm, AVM, or a history of intracerebral hemorrhage, ketamine is either contraindicated outright or requires a cardiologist’s sign-off before we proceed.

We screen at the consult. We screen at every session. And when the question is genuinely cardiac — not psychiatric, not pain — we send it where it belongs, to your primary care physician or your cardiologist. That is the version of cautious that actually helps people.