Epileptic heart: A clinical syndromic approach

Abstract

Prevention of premature death in patients with chronic epilepsy remains a major challenge. Multiple pathophysiologic factors have been implicated, with intense investigation of cardiorespiratory mechanisms. Up to four in five patients with chronic epilepsy exhibit cardiovascular comorbidities. These findings led us to propose the concept of an “epileptic heart,” defined as “a heart and coronary vasculature damaged by chronic epilepsy as a result of repeated surges in catecholamines and hypoxemia leading to electrical and mechanical dysfunction.” Among the most prominent changes documented in the literature are high incidence of myocardial infarction and arrhythmia, altered autonomic tone, diastolic dysfunction, hyperlipidemia, and accelerated atherosclerosis. This suite of pathologic changes prompted us to propose for the first time in this review a syndromic approach for improved clinical detection of the epileptic heart condition. In this review, we discuss the key pathophysiologic mechanisms underlying the candidate criteria along with standard and novel techniques that permit evaluation of each of these factors. Specifically, we present evidence of the utility of standard 12‐lead, ambulatory, and multiday patch‐based electrocardiograms, along with measures of cardiac electrical instability, including T‐wave alternans, heart rate variability to detect altered autonomic tone, echocardiography to detect diastolic dysfunction, and plasma biomarkers for assessing hyperlipidemia and accelerated atherosclerosis. Ultimately, the proposed clinical syndromic approach is intended to improve monitoring and evaluation of cardiac risk in patients with chronic epilepsy to foster improved therapeutic strategies to reduce premature cardiac death.

Late-Onset Ictal Asystole and Falls Related to Severe Coronary Artery Stenosis: A Case Report

“…Indeed, a seizure activity may have deleterious impact on the structural integrity of the heart and its vasculature leading to myocardial fibrosis, accelerated atherosclerosis, systolic and diastolic dysfunction, and arrhythmias. Likewise, coronary artery diseases, especially stenosis of left anterior descending artery, are risk factors for almost any kind of arrhythmia, and contribute to ictal heart rate abnormalities, altered autonomic function, and potentially deleterious arrhythmias (16,17), which may be a pre-requisite for sudden unexpected death in epilepsy (8,10,12,13). During our patient's first video-EEG/ECG monitoring prior to angioplasty, all recorded seizures were always associated with bradyarrhythmia or asystole.…”

“…In a recent study, we also depicted ECG abnormalities, most frequently bradyarrhythmia, in ∼15% of patients with a confirmed diagnosis of refractory epilepsy (12). More importantly, some patients have potentially showed to have life-threatening cardiac arrhythmias, which may make them more vulnerable to seizures that may become fatal (8).…”

“…We believe that the interaction of the ictal temporal discharge superimposed on a chronic coronary is probably responsible for the genesis of ictal asystole in our patient. There is now a large body of evidence of frequent peri-ictal cardiac dysfunction and stress in association with different seizure types (8,10,12,13). Indeed, a seizure activity may have deleterious impact on the structural integrity of the heart and its vasculature leading to myocardial fibrosis, accelerated atherosclerosis, systolic and diastolic dysfunction, and arrhythmias.…”

“…Most reported cases had late-onset IA on the ground of long-standing drug-resistant focal epilepsy, and IA typically appeared after the onset of epilepsy with delay of many years (1). Nonetheless, it has also been recognized as a newonset IA group with high prevalence of pre-existing heart conditions (1,8,9). IA has been hypothesized as one of the several mechanisms of sudden unexpected death in epilepsy (10), and this risk highlights the need for complete seizure control, cardiac evaluation, and potential cardiac intervention (11).…”

Corpus Callosotomy in 3 Cavalier King Charles Spaniel Dogs with Drug-Resistant Epilepsy

“…Although the risk factors for SUDEP in dogs is still under debate, the characteristics of this case are similar to those of SUDEP in humans. In recent years, cardiac dysfunction in epileptic patients has been studied in humans, and the concept of the “epileptic heart” has been proposed [ 17 , 18 ]. This indicates that surges in catecholamines and hypoxemia leading by recurrent epileptic seizures can cause myocardial damage, leading to electrical and mechanical dysfunction.…”