Abstract
Objective: We aimed to evaluate and contrast the hypothalamo-pituitary-adrenal (HPA) response to direct current (DC) cardioversion and electroconvulsive therapy (ECT).
Subjects: Six male subjects (mean age 61.2 years, range 46-74) with chronic atrial fibrillation were selected for cardioversion. Six subjects with depression (one male, five female; mean age 43.2 years, range 31-59) were selected for ECT. Those taking glucocorticoid drugs, opiates or beta-adrenoceptor antagonists were excluded.
Measurements: Patients attended for serial blood sampling on the day of cardioversion or ECT, and for an equivalent time period on a control day at least one week before. Intravenous propofol was given to each subject for anaesthesia on the day of cardioversion or ECT. On both study and control days, blood samples were taken at -30, -15, 0 (just prior to cardioversion or ECT), +5, +10, +15, +30, +60, +90 and +120 minutes for assay of cortisol, PRL, ACTH, AVP and CRH.
Results: For cardioversion: plasma cortisol increased from 252.5 +/- 39.8 to a maximum of 721.3 +/- 50 nmol/l at 30 minutes (P < 0.0001 compared with control day). ACTH increased from 12.8 +/- 2.8 to a maximum of 64 +/- 14 pmol/l at 5 minutes (P < 0.0001 compared with control day). AVP increased from 6.6 +/- 3.3 to a maximum of 42.9 +/- 16 pmol/l at 5 minutes post-cardioversion (P < 0.005 compared with control day). PRL increased from 141 +/- 28 mlU/l to a maximum of 873 +/- 219 mlU/l at 10 minutes (P < 0.001 compared with control day). There was no significant difference in CRH responses between cardioversion and control days. There was no significant correlation between total electrical energy delivered and maximum ACTH and AVP responses (R = 0.54 and -0.13, respectively). For ECT: on the day of ECT plasma cortisol increased from 419.5 +/- 25.9 to a maximum of 614.7 +/- 26.9 nmol/l (P < 0.002 compared with control day). ACTH increased from 22.7 +/- 6.2 to a maximum of 77.8 +/- 19.1 pmol/l (P < 0.0003 compared with control day). PRL increased from 771 +/- 317 to a maximum of 3152 +/- 703 mlU/l (P < 0.001 compared with control day, and significantly greater than the peak response to cardioversion, P < 0.03). AVP increased from 13.0 +/- 10.8 to a maximum of 35.1 +/- 5.6 pmol/l (P < 0.02 compared with control day). There was no significant difference in CRH responses between ECT and control days. Peak cortisol and ACTH responses did not differ significantly between ECT and cardioversion. Baseline cortisol levels, however, were significantly higher in the depressed group compared with the cardioversion group, P < 0.02, but not ACTH or AVP.
Conclusion: Significant hypothalamic-pituitary-adrenal activation and PRL release occur in response to both cardioversion and ECT. AVP may have an important role in mediating the acute ACTH response to electrical stimulation.