Prominent changes in hemodynamics occur during electroconvulsive therapy (ECT) despite general anesthesia and muscle relaxation and regardless of choice of stimulating electrode placement. The most common pattern is hypertension and tachycardia during the seizure, followed by relative bradycardia and a gradual return of blood pressure to normal within minutes of the end of the seizure. The mortal and morbid risk of these changes is generally small; nevertheless, it is common practice to administer antihypertensive medications to blunt this response. Several agents have proven able to reduce ECT-related hypertension and tachycardia; however, it is unknown whether these agents reduce mortality or cardiovascular morbidity or alter efficacy or cognitive effects of ECT. A few case reports suggest intravenous antihypertensives may be positively dangerous on occasion. Based upon these findings, antihypertensives need not be given routinely during ECT, and when given, conservative doses should be used. The short-acting beta blockers may be particularly suited to this task. To prevent needless use of these agents and the possibility of an adverse event, the patient's intravascular volume, blood pressure and pulse should be optimized prior to the first ECT.