Electrocardiographic Changes at the Early Stage of Status Epilepticus: First Insights From the ICTAL Registry*

Abstract

Objectives: To describe early electrocardiogram (ECG) abnormalities after status epilepticus (SE) and evaluate their association with 90-day neurological outcomes. Design: Retrospective analysis of a multicenter, national prospective registry between February 2018 and June 2020. Setting: Sixteen ICUs in France, IctalGroup Research Network. Patients: Adults with available ECG performed less than or equal to 24 hours after the onset of SE and less than or equal to 12 hours after its resolution. Intervention: Double-blinded review of all ECGs was performed by two independent cardiologists. ECGs were categorized as normal/abnormal and then with minor/major early ECG abnormalities according to the Novacode ECG Classification system. Measurements and Main Results: Among 155 critically ill patients with SE, early ECG abnormalities were encountered in 145 (93.5%), categorized as major in 91 of 145 (62.8%). In addition to sinus tachycardia, the main abnormalities were in the ST segment (elevation [16.6%] or depression [17.9%]) or negative T waves (42.1%). Major early ECG abnormalities were significantly associated with respiratory distress and sinus tachycardia at the scene and hyperlactatemia at ICU admission. By multivariable analysis, three variables were significantly associated with 90-day poor outcome: age, preexisting ultimately fatal comorbidity, and cerebral insult as the cause of SE. Early major ECG abnormalities were not independently associated with 90-day functional outcome. Conclusions: In our study, early ECG abnormalities in the acute phase of SE were frequent, often unrecognized and were associated with clinical and biological stigma of hypoxemia. Although they were not independently associated with 90-day functional outcome, ECG changes at the early stage of SE should be systematically evaluated. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT03457831.

Status epilepticus: what's new for the intensivist

“…The immediate systemic complications can include hemodynamic instability. A tonic-clonic seizure involves first a hyperadrenergic state (hypertension, tachycardia, arrhythmia, stress cardiomyopathy, hyperventilation, hyperthermia, hyperglycemia) to match the increased cerebral metabolic demand [27 ▪ ]. Then, a second state resulting in severe and prolonged hypotension or hemodynamic instability can lead to brain ischemia [28].…”

When the Electric Circuit Is Not Working, It Is Time to Check All Outlets: How Status Epilepticus May Impact Cardiac Electric Activity*

“…What conclusions can we draw from the study by Chinardet et al (8)? The inability to tease out effects of antiseizure medications, relevant severity of ECG findings and standardized assessment of reversibility of ECG findings render these cohort findings an important, yet very preliminary, stab at characterizing a potential impact of downstream electrical impact of status epilepticus.…”

“…For example, over 10% ( n = 19/180) registry subjects were excluded due to lack of ECG meeting inclusion criteria. Intriguingly, the study by Chinardet et al (8) exposes a discrepancy between the high percentage of ECGs obtained and rather infrequent identification of ECG abnormalities by ICU physician (even for major abnormalities, 45.1%); however, this could be a result of underreporting from retrospective data abstraction from medical records.…”

“…In this issue of Critical Care Medicine , Chinardet et al (8) report their observed ECG changes early during status epilepticus. The study by Chinardet et al (8) represents the opening step by the ICTAL investigators in shedding light on the potential ramifications of brain-heart crosstalk in this setting.…”

“…In this issue of Critical Care Medicine , Chinardet et al (8) report their observed ECG changes early during status epilepticus. The study by Chinardet et al (8) represents the opening step by the ICTAL investigators in shedding light on the potential ramifications of brain-heart crosstalk in this setting. They retrospectively investigated serial ECG and outcomes in a multicentric cohort comprising 155 status epilepticus patients admitted to 16F ICUs from 2018 to 2020.…”