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Latest revision as of 04:02, 31 July 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Sahar Memar Montazerin, M.D.[3]

Overview

Chronic epileptic episodes and the subsequent catecholamine surges and hypoxic events may affect the heart and coronary vessels and result in the dysfunction of the heart. This condition is known as the "epileptic heart." This concept was first described by Dr. Richard L. Verrier and his colleagues in 2020.

Historical Perspective

Absence of cardiac activity during epileptic seizure was first described by Dr. A.E. Russell, an English physician, in 1906.^[1]
The epileptic heart was first described by Drs. Verrier, Pang, Nearing, and Schachter, in 2020.^[2]

Classification

There is no established system for the classification of the epileptic heart.

Pathophysiology

The exact mechanisms involved in the development of the epileptic heart are still being elucidated. However, the conceptual framework below provides helpful information on the development of heart disease in patients with epilepsy.^[3]

Chronic epilepsy

Repeated hypoxia and subsequent myocardial ischemia

Accelerated atherosclerosis

Myocardial stunning

Vacuolization of myocytes and fibrosis

Catecholamine-induced cardiotoxicity

Epileptic Heart

❑ Cardiac electrical instability
❑ T wave alternans

Epilepsy and Cardiac Arrhythmia

Cardiac arrhythmias have long been observed in patients with epilepsy. Three different mechanisms explain this association:^[4]

Direct (causal) pathway
Co-existence of epilepsy and cardiac arrhythmia in the context of genetic disorders:
- Genes involved in epilepsy: SCN1A, KCNA1, and SCN8A
- Genes involved in inherited arrhythmogenic heart diseases: KCNQ1, KCNH2, SCN5A, RYR2
Resultant association:
- Certain anti-epileptic medications with sodium channel blocking properties have been known to cause arrhythmia.
- Seizure may also cause arrhythmia.
  - Ictal phase may be associated with tachycardia, asystole, bradycardia, and AV block.
  - Postictal phase may be associated with asystole, AV block, atrial flutter or fibrillation, and ventricular fibrillation.

Epilepsy and Structural Heart Disease

Three mechanisms have been suggested to explain the association between epilepsy and structural heart disease:^[4]

Direct (causal) pathway in which structural heart disease may result in embolic stroke and subsequent epilepsy.
Common risk factors contribute to the development of both epilepsy and structural heart disease.
Resultant pathway:
- Epilepsy may stimulate myocardial ischemia and a Takotsubo-like syndrome.
- Certain anti-epileptic medications contribute to the development of arteriosclerosis, weight gain, non-alcoholic fatty liver disease and metabolic syndrome and result in a poorer cardiovascular risk profile.^[5]^[6]
On microscopic histopathological analysis of patients with epilepsy a range of pathologies has been reported. These changes include fibrosis, myofibrillar degeneration, ventricular hypertrophy, focal myocardial fibrosis, perivascular and interstitial myocardial fibrosis, and mild to moderate coronary atherosclerosis.^[7]^[8]^[9]

Causes

Epileptic heart may be caused by the following:

Accelerated atherosclerotic process due to side effect of longstanding antiepileptic therapy such as carbamazepine, gabapentin on lipid profile ^[10]^[11]
Increased occurrence of arrhythmia due to hyperadrenergic state in seizure episodes ^[12]
Cardiac autonomic dysfunction due to repeated siezue episodes, a predisposing factor of arrhythmia ^[13]
Arrhythmogenic effect of antiepileptic drugs due to blockage of sodium channels on heart ^[14]^[15]

Susceptibility to ventricular fibrillation before or after seizure episodes ^[16]
Structural myocardium damage due to repeated seizures, such as myocardial calcified lesions, myocardial stiffness, cardiomegaly, ventricular hypertrophy, left artial dilation ^[17]^[18]
Neurogenic stunned myocardium similar to tukotsubo, a reversible cardiomyopathy after a seizure episode ^[19]
Increased occurrence of atrial fibrillation after seizure episode ^[20]

Differentiating epileptic heart from other Diseases

Epileptic heart must be differentiated from other diseases that cause loss of consciousness or sudden death such as:

Sudden unexpected death in epilepsy( SUDEP)
Convulsion syncope
Epileptic seizure

Epileptic heart

Sudden unexpected death in epilepsy SUDEP

Convulsion syncope

Epileptic seizure

Structural and functional heart disease as a result of autonomous dysfunction due to the longstanding effect of seizure episodes on the heart
Increased occurrence of sudden cardiac death related or unrelated to siezue episodes ^[21]
Increased occurrence of coronary artery disease in earlier age compared with patients without epilepsy
Myocardial injury due to repeated sympathetic stimulation of seizure episodes
Hypertrophy in the ventricular myocardium
Increased occurrence of arrhythmia due to conduction, repolarization abnormality, cardiac electerical instability

Sudden death related to pulmonary dysfunction and apnea in the postictal period^[22]
Not categorized as sudden cardiac death
Common age:20-40 years old^[23]
Risk factors: youth, early age at seizure onset, Presence of generalized tonic clonic seizure, male, being in bed at the time of death^[24]

Cardiac syncope and seizure preceding each other
Cardiac syncope definition: brief, reversible, transient loss of consciousness due to cerebral hypoperfusion following reflex mediated syncope, structural heart disease, arrhythmia, orthostasis hypotension
Seizure preceding ictal sinus tachycardia, ventricular fibrillation, bradycardia,asystole^[25]
Arrhythmia preceding seizure
Identifying same genes mutation in brain and cardiac which are responsible of epilepsy and arrhythmia^[26]

Transient loss of consciousness due to abnormal neuronal discharge in the brain
Repetitive

High frequency of misdiagnosis with cardiac syncope
Tongue biting
Sense of deja vu or jamais vu before spells, preoccupation, hallucination,mood changes, somatosensory auras, trembling
Unusual posturing, Jerking limbs
Blue face, acrocyanosis
Postictall blurred period

Epidemiology and Demographics

The incidence of heart disease such as coronary artery disease, heart attack in patients with epilepsy is approximately 25600 per 100,000 individuals between 45-64 years old. This amount in patients without epilepsy is 11500 per 100,000 individuals between 45-64 years old. ^[21]
In 2018, the incidence of sudden cardiac death in epileptic patients was estimated to be 4400 cases per 100,000 individuals in the united states which was 4.5 fold of SUDEP cases. ^[27]
The incidence of heart disease in patients with epilepsy was 9% higher than patients without epilepsy. ^[21]

Age

Sudden cardiac death associated with chronic epilepsy is more commonly observed among patients older than 40 years old. ^[28]
Cardiac diseases associated to the chronic epilepsy is more commonly observed among patients between 45-64 years old. ^[21]

Gender

Males are more commonly affected with the epileptic heart than females.

Race

There is no racial predilection for epileptic heart.

Risk Factors

Common risk factors in the development of epileptic heart may include:
Low socioeconomic status ^[21]
Long-standing antiepileptic therapy
Hypertension
Hyperlipidemia
Diabetes mellitus
Male sex
Smoking
Aging
Progression of underlying cardiac disease

Screening

Currently, there is no guideline statement that recommended routine cardiac evaluation of patients with epilepsy. However, a resting 12-lead EKG and/or ambulatory EKG patch recording may be useful in identifying the patients at risk of cardiac pathology and further follow the progression of their cardiac pathology. ^[2]

Natural History, Complications and Prognosis

Patients with epileptic heart suffer from chronic epilepsy and antiepileptic drug resistance for many years.
Early clinical features include manifestation related to cardiac involvement such as syncope, chest discomfort, exertional dyspnea, and palpitation.
Patients with chronic epilepsy may progress to develop complications of arrhythmia and myocardial ischemia.
Common complications of the epileptic heart include coronary artery disease, heart failure, sudden cardiac arrest, sudden cardiac death.
Prognosis is generally poor, and the 1-year mortality of patients with chronic epilepsy due to sudden cardiac death is approximately 4.4%. ^[27]

Diagnosis

Diagnostic Criteria

The diagnosis of the epileptic heart is made when the following diagnostic criteria are met:

Resistant epilepsy
Longstanding use of antiepileptic drugs
Presence of arrhythmia syncope and high level of T waves alternance as a marker of repolarization abnormality and ventricular fibrillation on ECG
Presence of ischemic heart disease earlier than the common age
Evidence of myocardial injury such as high level of troponin I ^[29]

Hisory and Symptoms

Symptoms of the epileptic heart may include the following:

Physical Examination

Physical examination associated with epilepsy include:

Physical examination associated with heart involvement in chronic epilepsy may include:

Laboratory Findings

Common laboratory findings related to epileptic heart may include:

An elevated concentration of serum troponin I as the marker of myocardial injury in patients with generalized tonic-clonic seizure ^[30]
Increased CRP, lipid profile due to induction of cytochrome P450 by antiepileptic drugs such as carbamazepine, gabapentin ^[31]

Electrocardiogram

An ECG may be helpful in the diagnosis of epileptic heart. Findings on an ECG suggestive of effects of seizure on the heart include: ^[32]^[33]^[34]

Bundle-branch block
ST-segment changes indicating myocardial ischemia in 40% of seizures ^[35]
T-wave inversion
Bradycardia, asystole due to hypoxia or respiratory disturbance in postictal phase
Sinus tachycardia in ictal phase due to sympathetic activity or reduction in vagal tone in 82% of cases
QT interval prolongation
QT interval dispersion
Increased T wave alternance in preictal and post ictal phases of generalized tonic-clonic seizure indicating repolarization abnormality
Decreased heart rate variability indicating decreased vagus nerve activity during seizure
Sinus tachycardia, heart rate >150/min indicating sympathetic discharge

Common ECG markers associated sudden cardiac death include:

Peri ictal QT prolongation
Increased T waves alternance
Decreased heart rate variability ^[36]

Arrhythmia associated seizure include: ^[37]

Ictal asystole, bradycardia, AV block were self limiting.
Post ictal arrhythmia such as asystole, AV block, atrial fibrillation, ventricular fibrillation were associated with near SUDEP or convulsion syncope.

X-ray

A Chest-x-ray may be helpful in the diagnosis of atherosclerosis associated with chronic epilepsy. Findings on an CXR suggestive of heart involvement in epilepsy include:

Aortic arch calcification ^[39]

Echocardiography or Ultrasound

Echocardiography may be helpful in the diagnosis of epilectic heart. Findings on an echocardiography diagnostic of epileptic heart include: ^[32]

Increased left ventricular filling pressures
Increased left atrial volume
Increase left ventricular end systolic diameter
Increased left ventricular end systolic volume 64,65,66

CT scan

Coronary CT angiography may be helpful in the diagnosis of ischemic heart disease in chronic epilepsy. Findings on coronary CTangiography suggestive of ischemic hear disease include:^[40]

MRI

Cardiac magnetic resonance angiograpgy (MRA) may be helpful in the diagnosis of ischemic heart disease in chronic epilepsy. Findings on MRA suggestive of high-risk patients include: ^[41]

Severe coronary artery stenosis(>70%)
Plaque with thick lipid-rich core and a thin fibrous cap and intraplaque inflammation

Other Imaging Findings

There are no other imaging findings associated with epileptic heart.

Other Diagnostic Studies

Holter ECG 24-48 hours may be helpful in the diagnosis of the arrhythmia-related epileptic heart. Findings suggestive the probability of the occurrence of ventricular fibrillation include: ^[42]

Higher level of T waves alternance
Decrease heart rate variability
QT prolongation

Other diagnostic studies for epileptic include ECG patches which are worn for 14 days with a higher chance for detection of tachyarrhythmia compared with Holter ECG.

Treatment

Medical Therapy

The mainstay of therapy for epileptic heart is autonomic modulation by increased parasympathetic activity, decreased sympathetic activity which is effective for reducing the seizure episodes and increased cardiac electrical stability by the following: ^[43]

Changing the arrhythmogenic antiepileptic drugs to other types
vagus nerve stimulation therapy for reducing sympathetic activity which is a major risk factor for ventricular fibrillation ^[43]

Surgery

Vagus Nerve Stimulation (VNS) can be used in resistance epilepsy by inserting a pacemaker under the skin in the chest and sending regular, mild pulses to the brain via the vagus nerve.^[44]

Prevention

Primary prevention measures in epileptic heart include:

Screening risk factors of coronary artery disease in every patients diagnosed with epilepsy consisting obesity,hypertension, hyperlipidemia,diabetes mellitus,smoking
The role of ICD implantation for primary prevention of ventricular tachyarrhythmia in patients with chronic epilepsy is unclear. ^[28]

The strategy for secondary prevention in chronic epileptic patients who are at risk of arrhythmia include:
Changing arrhythmogenic drugs that block sodium channel such as carbamazepine, phenytoin to other types
Vagus Nerve Stimulation therapy (VNS) for a reduction in T wave alternans ^[43]

Chronic epileptic patients should be followed up for detection of T waves alternans and finding the risk of ventricular fibrillation by: ^[2]^[45]

12 lead ECG
Holter ECG 24-48 hours
Wireless ECG patches(patient-friendly tool, worn for 14 days, increased chance for detection of arrhythmia compared with Holter ECG)

References

↑ Russell, A.E. (1906). "CESSATION OF THE PULSE DURING THE ONSET OF EPILEPTIC FITS,". The Lancet. 168 (4325): 152–154. doi:10.1016/S0140-6736(01)30477-4. ISSN 0140-6736.
↑ ^2.0 ^2.1 ^2.2 Verrier, Richard L.; Pang, Trudy D.; Nearing, Bruce D.; Schachter, Steven C. (2020). "The Epileptic Heart: Concept and clinical evidence". Epilepsy & Behavior. 105: 106946. doi:10.1016/j.yebeh.2020.106946. ISSN 1525-5050.
↑ Verrier, Richard L.; Schachter, Steven C. (2018). "Is heart disease in chronic epilepsy a consequence of seizures or a fellow traveler?". Epilepsy & Behavior. 86: 211–213. doi:10.1016/j.yebeh.2018.06.027. ISSN 1525-5050.
↑ ^4.0 ^4.1 Shmuely, S.; van der Lende, M.; Lamberts, R.J.; Sander, J.W.; Thijs, R.D. (2017). "The heart of epilepsy: Current views and future concepts". Seizure. 44: 176–183. doi:10.1016/j.seizure.2016.10.001. ISSN 1059-1311.
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↑ Espinosa, P. S.; Lee, J. W.; Tedrow, U. B.; Bromfield, E. B.; Dworetzky, B. A. (2009). "SUDDEN UNEXPECTED NEAR DEATH IN EPILEPSY: MALIGNANT ARRHYTHMIA FROM A PARTIAL SEIZURE". Neurology. 72 (19): 1702–1703. doi:10.1212/WNL.0b013e3181a55f90. ISSN 0028-3878.
↑ Iijima, Katsuya; Hashimoto, Hiroko; Hashimoto, Masayoshi; Son, Bo-Kyung; Ota, Hidetaka; Ogawa, Sumito; Eto, Masato; Akishita, Masahiro; Ouchi, Yasuyoshi (2010). "Aortic arch calcification detectable on chest X-ray is a strong independent predictor of cardiovascular events beyond traditional risk factors". Atherosclerosis. 210 (1): 137–144. doi:10.1016/j.atherosclerosis.2009.11.012. ISSN 0021-9150.
↑ Kolossváry, Márton; Szilveszter, Bálint; Merkely, Béla; Maurovich-Horvat, Pál (2017). "Plaque imaging with CT—a comprehensive review on coronary CT angiography based risk assessment". Cardiovascular Diagnosis and Therapy. 7 (5): 489–506. doi:10.21037/cdt.2016.11.06. ISSN 2223-3652.
↑ Yuan, Chun; Kerwin, William S. (2004). "MRI of atherosclerosis". Journal of Magnetic Resonance Imaging. 19 (6): 710–719. doi:10.1002/jmri.20070. ISSN 1053-1807.
↑ Takasugi, Nobuhiro; Goto, Hiroko; Takasugi, Mieko; Verrier, Richard L.; Kuwahara, Takashi; Kubota, Tomoki; Toyoshi, Hiroyuki; Nakashima, Takashi; Kawasaki, Masanori; Nishigaki, Kazuhiko; Minatoguchi, Shinya (2016). "Prevalence of Microvolt T-Wave Alternans in Patients With Long QT Syndrome and Its Association With Torsade de Pointes". Circulation: Arrhythmia and Electrophysiology. 9 (2). doi:10.1161/CIRCEP.115.003206. ISSN 1941-3149.
↑ ^43.0 ^43.1 ^43.2 Schomer, Andrew C.; Nearing, Bruce D.; Schachter, Steven C.; Verrier, Richard L. (2014). "Vagus nerve stimulation reduces cardiac electrical instability assessed by quantitative T-wave alternans analysis in patients with drug-resistant focal epilepsy". Epilepsia. 55 (12): 1996–2002. doi:10.1111/epi.12855. ISSN 0013-9580.
↑ Johnson RL, Wilson CG (2018). "A review of vagus nerve stimulation as a therapeutic intervention". J Inflamm Res. 11: 203–213. doi:10.2147/JIR.S163248. PMC 5961632. PMID 29844694.
↑ Pang, Trudy D.; Nearing, Bruce D.; Krishnamurthy, Kaarkuzhali Babu; Olin, Bryan; Schachter, Steven C.; Verrier, Richard L. (2019). "Cardiac electrical instability in newly diagnosed/chronic epilepsy tracked by Holter and ECG patch". Neurology. 93 (10): 450–458. doi:10.1212/WNL.0000000000008077. ISSN 0028-3878.

[Russell1906-1] Russell, A.E. (1906). "CESSATION OF THE PULSE DURING THE ONSET OF EPILEPTIC FITS,". The Lancet. 168 (4325): 152–154. doi:10.1016/S0140-6736(01)30477-4. ISSN 0140-6736.

[VerrierPang2020-2] 2.0 ^2.1 ^2.2 Verrier, Richard L.; Pang, Trudy D.; Nearing, Bruce D.; Schachter, Steven C. (2020). "The Epileptic Heart: Concept and clinical evidence". Epilepsy & Behavior. 105: 106946. doi:10.1016/j.yebeh.2020.106946. ISSN 1525-5050.

[VerrierSchachter2018-3] Verrier, Richard L.; Schachter, Steven C. (2018). "Is heart disease in chronic epilepsy a consequence of seizures or a fellow traveler?". Epilepsy & Behavior. 86: 211–213. doi:10.1016/j.yebeh.2018.06.027. ISSN 1525-5050.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{SI}}
-{{CMG}} {{AE}} {{Sahar}}
+{{CMG}} {{AE}} {{Sara.Zand}} {{Sahar}}
-{{SK}}
 ==Overview==
 Chronic [[epileptic]] episodes and the subsequent [[catecholamine]] surges and [[hypoxia|hypoxic]] events may affect the [[heart]] and [[coronary]] [[vessels]] and result in the [[dysfunction]] of the [[heart]].  This [[condition]] is known as the "epileptic heart." This concept was first described by Dr. Richard L. Verrier and his colleagues in 2020.
 ==Historical Perspective==
-*Absence of [[cardiac]] activity during [[epilepsy|epileptic seizure]], first described by Dr. A.E. Russell, an English physician, in 1906.<ref name="Russell1906">{{cite journal|last1=Russell|first1=A.E.|title=CESSATION OF THE PULSE DURING THE ONSET OF EPILEPTIC FITS,|journal=The Lancet|volume=168|issue=4325|year=1906|pages=152–154|issn=01406736|doi=10.1016/S0140-6736(01)30477-4}}</ref>
+*Absence of [[cardiac]] activity during [[epilepsy|epileptic seizure]] was first described by Dr. A.E. Russell, an English physician, in 1906.<ref name="Russell1906">{{cite journal|last1=Russell|first1=A.E.|title=CESSATION OF THE PULSE DURING THE ONSET OF EPILEPTIC FITS,|journal=The Lancet|volume=168|issue=4325|year=1906|pages=152–154|issn=01406736|doi=10.1016/S0140-6736(01)30477-4}}</ref>
 *The epileptic heart was first described by Drs. Verrier, Pang, Nearing, and Schachter, in 2020.<ref name="VerrierPang2020">{{cite journal|last1=Verrier|first1=Richard L.|last2=Pang|first2=Trudy D.|last3=Nearing|first3=Bruce D.|last4=Schachter|first4=Steven C.|title=The Epileptic Heart: Concept and clinical evidence|journal=Epilepsy & Behavior|volume=105|year=2020|pages=106946|issn=15255050|doi=10.1016/j.yebeh.2020.106946}}</ref>
@@ Line 57: / Line 55: @@
 [[Epileptic heart]] may be caused by the following:
-*Accelerated [[atherosclerotic]] process due to side effect of longstanding [[antiepileptic]] therapy such as [[carbamazepine]], [[gabapentin]] on [[lipid profile]]<ref name="GranbichlerOberaigner2014">{{cite journal|last1=Granbichler|first1=Claudia A.|last2=Oberaigner|first2=Willi|last3=Kuchukhidze|first3=Giorgi|last4=Bauer|first4=Gerhard|last5=Ndayisaba|first5=Jean-Pierre|last6=Seppi|first6=Klaus|last7=Trinka|first7=Eugen|title=Cause-specific mortality in adult epilepsy patients from Tyrol, Austria: hospital-based study|journal=Journal of Neurology|volume=262|issue=1|year=2014|pages=126–133|issn=0340-5354|doi=10.1007/s00415-014-7536-z}}</ref>
+*Accelerated [[atherosclerotic]] process due to side effect of longstanding [[antiepileptic]] therapy such as [[carbamazepine]], [[gabapentin]] on [[lipid profile]] <ref name="HookanaAnsakorpi2016">{{cite journal|last1=Hookana|first1=Eeva|last2=Ansakorpi|first2=Hanna|last3=Kortelainen|first3=Marja-Leena|last4=Junttila|first4=M. Juhani|last5=Kaikkonen|first5=Kari S|last6=Perkiömäki|first6=Juha|last7=Huikuri|first7=Heikki V|title=Antiepileptic medications and the risk for sudden cardiac death caused by an acute coronary event: a prospective case-control study|journal=Annals of Medicine|volume=48|issue=1-2|year=2016|pages=111–117|issn=0785-3890|doi=10.3109/07853890.2016.1140225}}</ref><ref name="GranbichlerOberaigner2014">{{cite journal|last1=Granbichler|first1=Claudia A.|last2=Oberaigner|first2=Willi|last3=Kuchukhidze|first3=Giorgi|last4=Bauer|first4=Gerhard|last5=Ndayisaba|first5=Jean-Pierre|last6=Seppi|first6=Klaus|last7=Trinka|first7=Eugen|title=Cause-specific mortality in adult epilepsy patients from Tyrol, Austria: hospital-based study|journal=Journal of Neurology|volume=262|issue=1|year=2014|pages=126–133|issn=0340-5354|doi=10.1007/s00415-014-7536-z}}</ref>
+*Increased occurrence of [[arrhythmia]] due to hyperadrenergic state in [[seizure]] episodes <ref name="Baysal-KiracSerbest2017">{{cite journal|last1=Baysal-Kirac|first1=Leyla|last2=Serbest|first2=Nail Güven|last3=Şahin|first3=Erdi|last4=Dede|first4=Hava Özlem|last5=Gürses|first5=Candan|last6=Gökyiğit|first6=Ayşen|last7=Bebek|first7=Nerses|last8=Bilge|first8=Ahmet Kaya|last9=Baykan|first9=Betül|title=Analysis of heart rate variability and risk factors for SUDEP in patients with drug-resistant epilepsy|journal=Epilepsy & Behavior|volume=71|year=2017|pages=60–64|issn=15255050|doi=10.1016/j.yebeh.2017.04.018}}</ref>
+*[[Cardiac]] autonomic dysfunction due to repeated [[siezue]] episodes, a predisposing factor of [[arrhythmia]] <ref name="DeGiorgioMiller2010">{{cite journal|last1=DeGiorgio|first1=Christopher M.|last2=Miller|first2=Patrick|last3=Meymandi|first3=Sheba|last4=Chin|first4=Alex|last5=Epps|first5=Jordan|last6=Gordon|first6=Steven|last7=Gornbein|first7=Jeffrey|last8=Harper|first8=Ronald M.|title=RMSSD, a measure of vagus-mediated heart rate variability, is associated with risk factors for SUDEP: The SUDEP-7 Inventory|journal=Epilepsy & Behavior|volume=19|issue=1|year=2010|pages=78–81|issn=15255050|doi=10.1016/j.yebeh.2010.06.011}}</ref>
+*[[Arrhythmogenic]] effect of [[antiepileptic]] drugs due to blockage of [[sodium channels ]] on [[heart]] <ref name="ZaccaraLattanzi2019">{{cite journal|last1=Zaccara|first1=Gaetano|last2=Lattanzi|first2=Simona|title=Comorbidity between epilepsy and cardiac arrhythmias: Implication for treatment|journal=Epilepsy & Behavior|volume=97|year=2019|pages=304–312|issn=15255050|doi=10.1016/j.yebeh.2019.05.038}}</ref><ref name="RenouxDell'Aniello2015">{{cite journal|last1=Renoux|first1=Christel|last2=Dell'Aniello|first2=Sophie|last3=Saarela|first3=Olli|last4=Filion|first4=Kristian B|last5=Boivin|first5=Jean-François|title=Antiepileptic drugs and the risk of ischaemic stroke and myocardial infarction: a population-based cohort study|journal=BMJ Open|volume=5|issue=8|year=2015|pages=e008365|issn=2044-6055|doi=10.1136/bmjopen-2015-008365}}</ref>
-* Increased occurrence of [[arrhythmia]] due to hyperadrenergic state in [[seizure]] episodes
+*Susceptibility  to [[ventricular fibrillation]] before or after [[seizure]] episodes <ref name="KiechlBardai2012">{{cite journal|last1=Kiechl|first1=Stefan|last2=Bardai|first2=Abdennasser|last3=Lamberts|first3=Robert J.|last4=Blom|first4=Marieke T.|last5=Spanjaart|first5=Anne M.|last6=Berdowski|first6=Jocelyn|last7=van der Staal|first7=Sebastiaan R.|last8=Brouwer|first8=Henk J.|last9=Koster|first9=Rudolph W.|last10=Sander|first10=Josemir W.|last11=Thijs|first11=Roland D.|last12=Tan|first12=Hanno L.|title=Epilepsy Is a Risk Factor for Sudden Cardiac Arrest in the General Population|journal=PLoS ONE|volume=7|issue=8|year=2012|pages=e42749|issn=1932-6203|doi=10.1371/journal.pone.0042749}}</ref>
-* Cardiac autonomic dysfunction due to repeated [[siezue]] episodes, a predisposing factor of [[arrhythmia]] <ref name="DeGiorgioMiller2010">{{cite journal|last1=DeGiorgio|first1=Christopher M.|last2=Miller|first2=Patrick|last3=Meymandi|first3=Sheba|last4=Chin|first4=Alex|last5=Epps|first5=Jordan|last6=Gordon|first6=Steven|last7=Gornbein|first7=Jeffrey|last8=Harper|first8=Ronald M.|title=RMSSD, a measure of vagus-mediated heart rate variability, is associated with risk factors for SUDEP: The SUDEP-7 Inventory|journal=Epilepsy & Behavior|volume=19|issue=1|year=2010|pages=78–81|issn=15255050|doi=10.1016/j.yebeh.2010.06.011}}</ref>
+*Structural [[myocardium]] damage due to repeated [[seizures]], such as [[myocardial]] calcified lesions, myocardial stiffness, [[cardiomegaly]], [[ventricular hypertrophy]], [[left artial dilation]] <ref name="FineschiSilver2005">{{cite journal|last1=Fineschi|first1=V.|last2=Silver|first2=M.D.|last3=Karch|first3=S.B.|last4=Parolini|first4=M.|last5=Turillazzi|first5=E.|last6=Pomara|first6=C.|last7=Baroldi|first7=G.|title=Myocardial disarray: an architectural disorganization linked with adrenergic stress?|journal=International Journal of Cardiology|volume=99|issue=2|year=2005|pages=277–282|issn=01675273|doi=10.1016/j.ijcard.2004.01.022}}</ref><ref name="ZhaoZhang2019">{{cite journal|last1=Zhao|first1=Haiting|last2=Zhang|first2=Honghai|last3=Schoen|first3=Frederick J.|last4=Schachter|first4=Steven C.|last5=Feng|first5=Hua-Jun|title=Repeated generalized seizures can produce calcified cardiac lesions in DBA/1 mice|journal=Epilepsy & Behavior|volume=95|year=2019|pages=169–174|issn=15255050|doi=10.1016/j.yebeh.2019.04.010}}</ref>
+*Neurogenic stunned myocardium similar to [[tukotsubo]], a reversible [[cardiomyopathy]] after a [[seizure]] episode <ref name="ChinBranch2005">{{cite journal|last1=Chin|first1=P. S.|last2=Branch|first2=K. R.|last3=Becker|first3=K. J.|title=Postictal neurogenic stunned myocardium|journal=Neurology|volume=64|issue=11|year=2005|pages=1977–1978|issn=0028-3878|doi=10.1212/01.WNL.0000163858.77494.7A}}</ref>
+*Increased occurrence of [[atrial fibrillation ]] after [[seizure]] episode <ref name="NaylorChurilov2018">{{cite journal|last1=Naylor|first1=Jillian|last2=Churilov|first2=Leonid|last3=Johnstone|first3=Benjamin|last4=Guo|first4=Ruibing|last5=Xiong|first5=Yunyun|last6=Koome|first6=Miriam|last7=Chen|first7=Ziyi|last8=Thevathasan|first8=Arthur|last9=Chen|first9=Ziyuan|last10=Liu|first10=Xinfeng|last11=Kwan|first11=Patrick|last12=Campbell|first12=Bruce C.V.|title=The Association Between Atrial Fibrillation and Poststroke Seizures is Influenced by Ethnicity and Environmental Factors|journal=Journal of Stroke and Cerebrovascular Diseases|volume=27|issue=10|year=2018|pages=2755–2760|issn=10523057|doi=10.1016/j.jstrokecerebrovasdis.2018.05.044}}</ref>
-* [[Arrhythmogenic]] effect of [[antiepileptic]] drugs due to blockage of [[sodium channels ]] on [[heart]]
+==Differentiating [[epileptic heart]] from other Diseases==
-* Susceptibility  to [[ventricular fibrillation]] before or after [[seizure]] episods<ref name="KiechlBardai2012">{{cite journal|last1=Kiechl|first1=Stefan|last2=Bardai|first2=Abdennasser|last3=Lamberts|first3=Robert J.|last4=Blom|first4=Marieke T.|last5=Spanjaart|first5=Anne M.|last6=Berdowski|first6=Jocelyn|last7=van der Staal|first7=Sebastiaan R.|last8=Brouwer|first8=Henk J.|last9=Koster|first9=Rudolph W.|last10=Sander|first10=Josemir W.|last11=Thijs|first11=Roland D.|last12=Tan|first12=Hanno L.|title=Epilepsy Is a Risk Factor for Sudden Cardiac Arrest in the General Population|journal=PLoS ONE|volume=7|issue=8|year=2012|pages=e42749|issn=1932-6203|doi=10.1371/journal.pone.0042749}}</ref>
-* Structural [[myocardium]] damage due to repeated [[seizures]], such as [[myocardial]] calcified lesions, myocardial stiffness, [[cardiomegaly]], [[ventricular hypertrophy]], [[left artial dilation]]<ref name="FineschiSilver2005">{{cite journal|last1=Fineschi|first1=V.|last2=Silver|first2=M.D.|last3=Karch|first3=S.B.|last4=Parolini|first4=M.|last5=Turillazzi|first5=E.|last6=Pomara|first6=C.|last7=Baroldi|first7=G.|title=Myocardial disarray: an architectural disorganization linked with adrenergic stress?|journal=International Journal of Cardiology|volume=99|issue=2|year=2005|pages=277–282|issn=01675273|doi=10.1016/j.ijcard.2004.01.022}}</ref>
-*Neurogenic stunned myocardium similar to [[tukotsubo]], a reversible [[cardiomyopathy]] after a [[seizure]] episode
+*[[Epileptic heart]]  must be differentiated from other diseases that cause  [[loss of consciousness]] or [[sudden death]]  such as:
-* Increased occurance of [[atrial fibrillation ]]
-==Differentiating [[epileptic heart]] from other Diseases==
-*[[Epileptic heart]]  must be differentiated from other diseases that cause  [[loss of consciousness]] or [[sudden death]]  such as:
 :*Sudden unexpected death in epilepsy( SUDEP)
 :*[[Convulsion syncope]]
 :*[[Epileptic seizure]]
-{| style="border: 2px solid #4479BA; align="left"
-! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF|[[Epileptic heart]]}}
+{| style="border: 2px solid #4479BA; align=" left"
-! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[Sudden unexpected death in epilepsy]] [[SUDEP]]}}
+! style="width: 200px; background: #4479BA;" |{{fontcolor|#FFF|[[Epileptic heart]]}}
-! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[Convulsion syncope]]}}
+! style="width: 300px; background: #4479BA;" |{{fontcolor|#FFF|[[Sudden unexpected death in epilepsy]] [[SUDEP]]}}
-! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[Epileptic seizure]]}}
+! style="width: 300px; background: #4479BA;" |{{fontcolor|#FFF|[[Convulsion syncope]]}}
+! style="width: 300px; background: #4479BA;" |{{fontcolor|#FFF|[[Epileptic seizure]]}}
 |-
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
-* Structural and functional heart disease as a result of autonomous dysfunction of the [[heart]] due to the longstanding effect of [[seizure]] episodes on the [[heart]]
+*Structural and functional heart disease as a result of autonomous dysfunction due to the longstanding effect of [[seizure]] episodes on the [[heart]]
-*Increased occurrence of [[sudden cardiac death]] related or unrelated to [[siezue]] episodes in older age> 40 years<ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
+*Increased occurrence of [[sudden cardiac death]] related or unrelated to [[siezue]] episodes <ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
-*Increased occurrence of [[coronary artery disease]] in earlier age ( mean age:55-year-old) compared with patients without [[epilepsy]]( mean age:69 year old)
+*Increased occurrence of [[coronary artery disease]] in earlier age compared with patients without [[epilepsy]]
-* [[Myocardial injury ]] due to  repeated [[sympathetic]] stimulation of [[seizure]] episodes
+*[[Myocardial injury ]] due to  repeated [[sympathetic]] stimulation of [[seizure]] episodes
 *[[Hypertrophy]] in the ventricular myocardium
 *Increased occurrence of [[arrhythmia]] due to conduction, [[repolarization abnormality]], [[cardiac electerical instability]]
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 *[[Sudden death]] related to [[pulmonary dysfunction]] and [[apnea]] in the [[postictal period]]<ref name="NashefSo2012">{{cite journal|last1=Nashef|first1=Lina|last2=So|first2=Elson L.|last3=Ryvlin|first3=Philippe|last4=Tomson|first4=Torbjörn|title=Unifying the definitions of sudden unexpected death in epilepsy|journal=Epilepsia|volume=53|issue=2|year=2012|pages=227–233|issn=00139580|doi=10.1111/j.1528-1167.2011.03358.x}}</ref>
+*Not categorized as [[sudden cardiac death]]
-* Not categorized as [[sudden cardiac death]]
+*Common age:20-40 years old<ref name="TomsonWalczak2005">{{cite journal|last1=Tomson|first1=Torbjorn|last2=Walczak|first2=Ted|last3=Sillanpaa|first3=Matti|last4=Sander|first4=Josemir W. A. S.|title=Sudden Unexpected Death in Epilepsy: A Review of Incidence and Risk Factors|journal=Epilepsia|volume=46|issue=s11|year=2005|pages=54–61|issn=0013-9580|doi=10.1111/j.1528-1167.2005.00411.x}}</ref>
-* Common age:20-40 years old<ref name="TomsonWalczak2005">{{cite journal|last1=Tomson|first1=Torbjorn|last2=Walczak|first2=Ted|last3=Sillanpaa|first3=Matti|last4=Sander|first4=Josemir W. A. S.|title=Sudden Unexpected Death in Epilepsy: A Review of Incidence and Risk Factors|journal=Epilepsia|volume=46|issue=s11|year=2005|pages=54–61|issn=0013-9580|doi=10.1111/j.1528-1167.2005.00411.x}}</ref>
+*[[Risk factors]]: [[youth]], early age at [[seizure]] onset, Presence of [[generalized tonic clonic seizure]], [[male]], being in bed at the time of [[death]]<ref name="SurgesThijs2009">{{cite journal|last1=Surges|first1=Rainer|last2=Thijs|first2=Roland D.|last3=Tan|first3=Hanno L.|last4=Sander|first4=Josemir W.|title=Sudden unexpected death in epilepsy: risk factors and potential pathomechanisms|journal=Nature Reviews Neurology|volume=5|issue=9|year=2009|pages=492–504|issn=1759-4758|doi=10.1038/nrneurol.2009.118}}</ref>
-*Risk factors: [[youth]], early age at [[seizure]] onset, Presence of [[generalized tonic clonic seizure]], [[male]], being in bed at the time of [[death]]<ref name="SurgesThijs2009">{{cite journal|last1=Surges|first1=Rainer|last2=Thijs|first2=Roland D.|last3=Tan|first3=Hanno L.|last4=Sander|first4=Josemir W.|title=Sudden unexpected death in epilepsy: risk factors and potential pathomechanisms|journal=Nature Reviews Neurology|volume=5|issue=9|year=2009|pages=492–504|issn=1759-4758|doi=10.1038/nrneurol.2009.118}}</ref>
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
-* [[Cardiac]] [[syncope]] and [[seizure]] preceding each other
+*[[Cardiac]] [[syncope]] and [[seizure]] preceding each other
-* [[Cardiac]] [[syncope]] definition: brief, reversible, [[transient loss of consciousness]] due to [[cerebral hypoperfusion]] following [[reflex mediated syncope]], [[structural heart disease]], [[arrhythmia]], [[orthostasis hypotension]]
+*[[Cardiac]] [[syncope]] definition: brief, reversible, [[transient loss of consciousness]] due to [[cerebral hypoperfusion]] following [[reflex mediated syncope]], [[structural heart disease]], [[arrhythmia]], [[orthostasis hypotension]]
 *[[Seizure]] preceding  ictal [[sinus tachycardia]], [[ventricular fibrillation]], [[bradycardia]],[[asystole]]<ref name="ReevesNollet1996">{{cite journal|last1=Reeves|first1=Andrew L.|last2=Nollet|first2=Kenneth E.|last3=Klass|first3=Donald W.|last4=Sharbrough|first4=Frank W.|last5=So|first5=Elson L.|title=The Ictal Bradycardia Syndrome|journal=Epilepsia|volume=37|issue=10|year=1996|pages=983–987|issn=0013-9580|doi=10.1111/j.1528-1157.1996.tb00536.x}}</ref>
 *[[Arrhythmia]] preceding [[seizure]]
-* Identifying same genes mutation in [[brain]] and [[cardiac]] leading to [[epilepsy]] and [[arrhythmia]]<ref name="NashefWalker1996">{{cite journal|last1=Nashef|first1=L|last2=Walker|first2=F|last3=Allen|first3=P|last4=Sander|first4=J W|last5=Shorvon|first5=S D|last6=Fish|first6=D R|title=Apnoea and bradycardia during epileptic seizures: relation to sudden death in epilepsy.|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=60|issue=3|year=1996|pages=297–300|issn=0022-3050|doi=10.1136/jnnp.60.3.297}}</ref>
+*Identifying same genes mutation in [[brain]] and [[cardiac]] which are responsible of [[epilepsy]] and [[arrhythmia]]<ref name="NashefWalker1996">{{cite journal|last1=Nashef|first1=L|last2=Walker|first2=F|last3=Allen|first3=P|last4=Sander|first4=J W|last5=Shorvon|first5=S D|last6=Fish|first6=D R|title=Apnoea and bradycardia during epileptic seizures: relation to sudden death in epilepsy.|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=60|issue=3|year=1996|pages=297–300|issn=0022-3050|doi=10.1136/jnnp.60.3.297}}</ref>
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 *[[Transient loss of consciousness]] due to abnormal neuronal discharge in the [[brain]]
 *Repetitive
-* High frequency of misdiagnosis with [[cardiac syncope]]
+*High frequency of misdiagnosis with [[cardiac syncope]]
 *[[Tongue biting]]
 *[[Sense of deja vu]] or [[jamais vu]] before spells, preoccupation, [[hallucination]],[[ mood changes]], [[somatosensory auras]], [[trembling]]
-* [[Unusual posturing]], [[Jerking limbs]]
+*[[Unusual posturing]], [[Jerking limbs]]
 *[[Blue face]], [[acrocyanosis]]
 *Postictall blurred period
 |-
 |}
-{{clear}}
 ==Epidemiology and Demographics==
-* The incidence of heart disease such as [[coronary artery disease]], [[heart attack]] in patients with epilepsy is approximately 25600 per 100,000 individuals between 45-64 years old. This amount in patients without [[epilepsy]] is 11500 per 100,000 individuals between 45-64 years old..<ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
-* In 2018, the incidence of [[sudden cardiac death ]] in epileptic patients was estimated to be 4400 cases per 100,000 individuals in the united states which was 4.5 fold of [[SUDEP]] cases.<ref name="BenjaminVirani2018">{{cite journal|last1=Benjamin|first1=Emelia J.|last2=Virani|first2=Salim S.|last3=Callaway|first3=Clifton W.|last4=Chamberlain|first4=Alanna M.|last5=Chang|first5=Alexander R.|last6=Cheng|first6=Susan|last7=Chiuve|first7=Stephanie E.|last8=Cushman|first8=Mary|last9=Delling|first9=Francesca N.|last10=Deo|first10=Rajat|last11=de Ferranti|first11=Sarah D.|last12=Ferguson|first12=Jane F.|last13=Fornage|first13=Myriam|last14=Gillespie|first14=Cathleen|last15=Isasi|first15=Carmen R.|last16=Jiménez|first16=Monik C.|last17=Jordan|first17=Lori Chaffin|last18=Judd|first18=Suzanne E.|last19=Lackland|first19=Daniel|last20=Lichtman|first20=Judith H.|last21=Lisabeth|first21=Lynda|last22=Liu|first22=Simin|last23=Longenecker|first23=Chris T.|last24=Lutsey|first24=Pamela L.|last25=Mackey|first25=Jason S.|last26=Matchar|first26=David B.|last27=Matsushita|first27=Kunihiro|last28=Mussolino|first28=Michael E.|last29=Nasir|first29=Khurram|last30=O’Flaherty|first30=Martin|last31=Palaniappan|first31=Latha P.|last32=Pandey|first32=Ambarish|last33=Pandey|first33=Dilip K.|last34=Reeves|first34=Mathew J.|last35=Ritchey|first35=Matthew D.|last36=Rodriguez|first36=Carlos J.|last37=Roth|first37=Gregory A.|last38=Rosamond|first38=Wayne D.|last39=Sampson|first39=Uchechukwu K.A.|last40=Satou|first40=Gary M.|last41=Shah|first41=Svati H.|last42=Spartano|first42=Nicole L.|last43=Tirschwell|first43=David L.|last44=Tsao|first44=Connie W.|last45=Voeks|first45=Jenifer H.|last46=Willey|first46=Joshua Z.|last47=Wilkins|first47=John T.|last48=Wu|first48=Jason HY.|last49=Alger|first49=Heather M.|last50=Wong|first50=Sally S.|last51=Muntner|first51=Paul|title=Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association|journal=Circulation|volume=137|issue=12|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000558}}</ref>
+*The [[incidence]] of [[heart disease]] such as [[coronary artery disease]], [[heart attack]] in [[patients]] with [[epilepsy]] is approximately 25600 per 100,000 individuals between 45-64 years old. This amount in [[patients]] without [[epilepsy]] is 11500 per 100,000 individuals between 45-64 years old. <ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
-*The incidence of [[heart disease]] in patients with [[epilepsy]] was 9% higher than patients without [[epilepsy]].<ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
+*In 2018, the incidence of [[sudden cardiac death ]] in epileptic patients was estimated to be 4400 cases per 100,000 individuals in the united states which was 4.5 fold of [[SUDEP]] cases. <ref name="BenjaminVirani2018">{{cite journal|last1=Benjamin|first1=Emelia J.|last2=Virani|first2=Salim S.|last3=Callaway|first3=Clifton W.|last4=Chamberlain|first4=Alanna M.|last5=Chang|first5=Alexander R.|last6=Cheng|first6=Susan|last7=Chiuve|first7=Stephanie E.|last8=Cushman|first8=Mary|last9=Delling|first9=Francesca N.|last10=Deo|first10=Rajat|last11=de Ferranti|first11=Sarah D.|last12=Ferguson|first12=Jane F.|last13=Fornage|first13=Myriam|last14=Gillespie|first14=Cathleen|last15=Isasi|first15=Carmen R.|last16=Jiménez|first16=Monik C.|last17=Jordan|first17=Lori Chaffin|last18=Judd|first18=Suzanne E.|last19=Lackland|first19=Daniel|last20=Lichtman|first20=Judith H.|last21=Lisabeth|first21=Lynda|last22=Liu|first22=Simin|last23=Longenecker|first23=Chris T.|last24=Lutsey|first24=Pamela L.|last25=Mackey|first25=Jason S.|last26=Matchar|first26=David B.|last27=Matsushita|first27=Kunihiro|last28=Mussolino|first28=Michael E.|last29=Nasir|first29=Khurram|last30=O’Flaherty|first30=Martin|last31=Palaniappan|first31=Latha P.|last32=Pandey|first32=Ambarish|last33=Pandey|first33=Dilip K.|last34=Reeves|first34=Mathew J.|last35=Ritchey|first35=Matthew D.|last36=Rodriguez|first36=Carlos J.|last37=Roth|first37=Gregory A.|last38=Rosamond|first38=Wayne D.|last39=Sampson|first39=Uchechukwu K.A.|last40=Satou|first40=Gary M.|last41=Shah|first41=Svati H.|last42=Spartano|first42=Nicole L.|last43=Tirschwell|first43=David L.|last44=Tsao|first44=Connie W.|last45=Voeks|first45=Jenifer H.|last46=Willey|first46=Joshua Z.|last47=Wilkins|first47=John T.|last48=Wu|first48=Jason HY.|last49=Alger|first49=Heather M.|last50=Wong|first50=Sally S.|last51=Muntner|first51=Paul|title=Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association|journal=Circulation|volume=137|issue=12|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000558}}</ref>
+*The [[incidence]] of [[heart disease]] in [[patients]] with [[epilepsy]] was 9% higher than [[patients]] without [[epilepsy]]. <ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
 ===Age===
-*[[Sudden cardiac death]] associated with [[epileptic heart]]  is more commonly observed among patients older than 40 years old.
+*[[Sudden cardiac death]] associated with chronic [[epilepsy]]  is more commonly observed among patients older than 40 years old. <ref name="SteckerReinier2013">{{cite journal|last1=Stecker|first1=Eric C.|last2=Reinier|first2=Kyndaron|last3=Uy-Evanado|first3=Audrey|last4=Teodorescu|first4=Carmen|last5=Chugh|first5=Harpriya|last6=Gunson|first6=Karen|last7=Jui|first7=Jonathan|last8=Chugh|first8=Sumeet S.|title=Relationship Between Seizure Episode and Sudden Cardiac Arrest in Patients With Epilepsy|journal=Circulation: Arrhythmia and Electrophysiology|volume=6|issue=5|year=2013|pages=912–916|issn=1941-3149|doi=10.1161/CIRCEP.113.000544}}</ref>
-*Accelerated [[atherosclerosis]] associated to the [[epileptic heart]] is more commonly observed among younger age (mean age 55 years old) compared with the general population ( mean age 69-year-old)
+*[[Cardiac]] diseases associated to the [[chronic]] [[epilepsy]] is more commonly observed among patients between 45-64 years old. <ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
 ===Gender===
-*Males are more commonly affected with epileptic heart than females
+*Males are more commonly affected with the epileptic heart than females.
 ===Race===
 *There is no racial predilection for epileptic heart.
 ==Risk Factors==
-*Common risk factors in the development of [[epileptic heart]] may include:
-*Low [[socioeconomic status]]
+*Common [[risk factors]] in the development of [[epileptic heart]] may include:
-*Long standing [[antiepileptic]] therapy
+*Low [[socioeconomic status]] <ref name="ZackLuncheon2018">{{cite journal|last1=Zack|first1=Matthew|last2=Luncheon|first2=Cecily|title=Adults with an epilepsy history, notably those 45–64 years old or at the lowest income levels, more often report heart disease than adults without an epilepsy history|journal=Epilepsy & Behavior|volume=86|year=2018|pages=208–210|issn=15255050|doi=10.1016/j.yebeh.2018.05.021}}</ref>
+*Long-standing [[antiepileptic]] therapy
 *[[Hypertension]]
 *[[Hyperlipidemia]]
@@ Line 147: / Line 143: @@
 *Progression of underlying cardiac disease
-== Natural History, Complications and Prognosis==
+==Screening==
-*Patients with [[epileptic heart]] suffer from chronic [[epilepsy]] and [[antiepileptic drug]] resistance for many years.
+Currently, there is no guideline statement that recommended routine [[cardiac]] evaluation of [[patients]] with [[epilepsy]]. However, a resting 12-lead [[EKG]] and/or ambulatory [[EKG]] patch recording may be useful in identifying the [[patients]] at risk of [[cardiac]] pathology and further follow the progression of their [[cardiac]] pathology. <ref name="VerrierPang2020">{{cite journal|last1=Verrier|first1=Richard L.|last2=Pang|first2=Trudy D.|last3=Nearing|first3=Bruce D.|last4=Schachter|first4=Steven C.|title=The Epileptic Heart: Concept and clinical evidence|journal=Epilepsy & Behavior|volume=105|year=2020|pages=106946|issn=15255050|doi=10.1016/j.yebeh.2020.106946}}</ref>
-*Early clinical features include manifestation related to [[cardiac involvement]] such as [[syncope]], [[chest discomfort]], [[exertional dyspnea]], [[palpitation]].
+==Natural History, Complications and Prognosis==
-*Patients with [[chronic epilepsy]] may progress to develop complications of [[arrhythmia]] and [[myocardial ischemia]].
-*Common complications of the epileptic [[heart]] include [[coronary artery disease]], [[heart failure]], [[sudden cardiac arrest]], [[sudden cardiac death]].
+*[[Patients]] with [[epileptic heart]] suffer from chronic [[epilepsy]] and [[antiepileptic drug]] resistance for many years.
-*Prognosis is generally poor, and the 1-year mortality of patients with chronic [[epilepsy]] due to [[sudden cardiac death]] is approximately 4.4%.<ref name="BenjaminVirani2018">{{cite journal|last1=Benjamin|first1=Emelia J.|last2=Virani|first2=Salim S.|last3=Callaway|first3=Clifton W.|last4=Chamberlain|first4=Alanna M.|last5=Chang|first5=Alexander R.|last6=Cheng|first6=Susan|last7=Chiuve|first7=Stephanie E.|last8=Cushman|first8=Mary|last9=Delling|first9=Francesca N.|last10=Deo|first10=Rajat|last11=de Ferranti|first11=Sarah D.|last12=Ferguson|first12=Jane F.|last13=Fornage|first13=Myriam|last14=Gillespie|first14=Cathleen|last15=Isasi|first15=Carmen R.|last16=Jiménez|first16=Monik C.|last17=Jordan|first17=Lori Chaffin|last18=Judd|first18=Suzanne E.|last19=Lackland|first19=Daniel|last20=Lichtman|first20=Judith H.|last21=Lisabeth|first21=Lynda|last22=Liu|first22=Simin|last23=Longenecker|first23=Chris T.|last24=Lutsey|first24=Pamela L.|last25=Mackey|first25=Jason S.|last26=Matchar|first26=David B.|last27=Matsushita|first27=Kunihiro|last28=Mussolino|first28=Michael E.|last29=Nasir|first29=Khurram|last30=O’Flaherty|first30=Martin|last31=Palaniappan|first31=Latha P.|last32=Pandey|first32=Ambarish|last33=Pandey|first33=Dilip K.|last34=Reeves|first34=Mathew J.|last35=Ritchey|first35=Matthew D.|last36=Rodriguez|first36=Carlos J.|last37=Roth|first37=Gregory A.|last38=Rosamond|first38=Wayne D.|last39=Sampson|first39=Uchechukwu K.A.|last40=Satou|first40=Gary M.|last41=Shah|first41=Svati H.|last42=Spartano|first42=Nicole L.|last43=Tirschwell|first43=David L.|last44=Tsao|first44=Connie W.|last45=Voeks|first45=Jenifer H.|last46=Willey|first46=Joshua Z.|last47=Wilkins|first47=John T.|last48=Wu|first48=Jason HY.|last49=Alger|first49=Heather M.|last50=Wong|first50=Sally S.|last51=Muntner|first51=Paul|title=Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association|journal=Circulation|volume=137|issue=12|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000558}}</ref>
+*Early clinical features include manifestation related to [[cardiac involvement]] such as [[syncope]], [[chest discomfort]], [[exertional dyspnea]], and [[palpitation]].
+*[[Patients]] with chronic [[epilepsy]] may progress to develop complications of [[arrhythmia]] and [[myocardial ischemia]].
+*Common [[complications]] of the epileptic [[heart]] include [[coronary artery disease]], [[heart failure]], [[sudden cardiac arrest]], [[sudden cardiac death]].
+*[[Prognosis]] is generally poor, and the 1-year mortality of [[patients]] with chronic [[epilepsy]] due to [[sudden cardiac death]] is approximately 4.4%. <ref name="BenjaminVirani2018">{{cite journal|last1=Benjamin|first1=Emelia J.|last2=Virani|first2=Salim S.|last3=Callaway|first3=Clifton W.|last4=Chamberlain|first4=Alanna M.|last5=Chang|first5=Alexander R.|last6=Cheng|first6=Susan|last7=Chiuve|first7=Stephanie E.|last8=Cushman|first8=Mary|last9=Delling|first9=Francesca N.|last10=Deo|first10=Rajat|last11=de Ferranti|first11=Sarah D.|last12=Ferguson|first12=Jane F.|last13=Fornage|first13=Myriam|last14=Gillespie|first14=Cathleen|last15=Isasi|first15=Carmen R.|last16=Jiménez|first16=Monik C.|last17=Jordan|first17=Lori Chaffin|last18=Judd|first18=Suzanne E.|last19=Lackland|first19=Daniel|last20=Lichtman|first20=Judith H.|last21=Lisabeth|first21=Lynda|last22=Liu|first22=Simin|last23=Longenecker|first23=Chris T.|last24=Lutsey|first24=Pamela L.|last25=Mackey|first25=Jason S.|last26=Matchar|first26=David B.|last27=Matsushita|first27=Kunihiro|last28=Mussolino|first28=Michael E.|last29=Nasir|first29=Khurram|last30=O’Flaherty|first30=Martin|last31=Palaniappan|first31=Latha P.|last32=Pandey|first32=Ambarish|last33=Pandey|first33=Dilip K.|last34=Reeves|first34=Mathew J.|last35=Ritchey|first35=Matthew D.|last36=Rodriguez|first36=Carlos J.|last37=Roth|first37=Gregory A.|last38=Rosamond|first38=Wayne D.|last39=Sampson|first39=Uchechukwu K.A.|last40=Satou|first40=Gary M.|last41=Shah|first41=Svati H.|last42=Spartano|first42=Nicole L.|last43=Tirschwell|first43=David L.|last44=Tsao|first44=Connie W.|last45=Voeks|first45=Jenifer H.|last46=Willey|first46=Joshua Z.|last47=Wilkins|first47=John T.|last48=Wu|first48=Jason HY.|last49=Alger|first49=Heather M.|last50=Wong|first50=Sally S.|last51=Muntner|first51=Paul|title=Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association|journal=Circulation|volume=137|issue=12|year=2018|issn=0009-7322|doi=10.1161/CIR.0000000000000558}}</ref>
-== Diagnosis ==
+==Diagnosis==
 ===Diagnostic Criteria===
 *The diagnosis of the epileptic heart is made when the following  diagnostic criteria are met:
-:* Resistant [[epilepsy]]
-:* Longstanding use of [[antiepileptic]] drugs
+:*Resistant [[epilepsy]]
+:*Longstanding use of [[antiepileptic]] drugs
 :*Presence of  arrhythmia syncope and high level of [[T waves]] alternance  as a marker of [[repolarization abnormality]] and [[ventricular fibrillation]] on [[ECG]]
-:* Presence of [[ischemic heart disease]] earlier than the common age
+:*Presence of [[ischemic heart disease]] earlier than the common age
-:* Evidence of [[myocardial injury]] such as  high level of [[troponin I]]
+:*Evidence of [[myocardial injury]] such as  high level of [[troponin I]] <ref name="NassMotloch2019">{{cite journal|last1=Nass|first1=Robert D.|last2=Motloch|first2=Lukas J.|last3=Paar|first3=Vera|last4=Lichtenauer|first4=Michael|last5=Baumann|first5=Jan|last6=Zur|first6=Berndt|last7=Hoppe|first7=Uta C.|last8=Holdenrieder|first8=Stefan|last9=Elger|first9=Christian E.|last10=Surges|first10=Rainer|title=Blood markers of cardiac stress after generalized convulsive seizures|journal=Epilepsia|volume=60|issue=2|year=2019|pages=201–210|issn=0013-9580|doi=10.1111/epi.14637}}</ref>
+===Hisory and Symptoms===
+*[[Symptoms]] of the [[epileptic heart]] may include the following:
-=== History and Symptoms ===
-*Symptoms of the [[epileptic heart]] may include the following:
 :*Abrupt [[palpitation]]
-:* [[Shortness of breath]]
+:*[[Shortness of breath]]
-:* [[Angina pectori]]
+:*[[Angina pectori]]
-:* [[lightheadness]]
+:*[[lightheadness]]
-:* [[Dizziness]]
+:*[[Dizziness]]
-:* [[Falling]]
+:*[[Falling]]
-:* [[Near falling]]
+:*[[Near falling]]
+===Physical Examination===
-=== Physical Examination ===
 *Physical examination associated with [[epilepsy]] include:
-:* [[Automatic behaviors]]
-:* [[Upward eye-rolling]]
+:*[[Automatic behaviors]]
-:* [[Unconsciousness]]
+:*[[Upward eye-rolling]]
-:* [[Drolling]]
+:*[[Unconsciousness]]
-:* [[Cyanosis]]
+:*[[Drolling]]
-:* [[Tachycardia]]
+:*[[Cyanosis]]
-:* [[Hypertension]]
+:*[[Tachycardia]]
-:* [[Postictal drowsiness]]
+:*[[Hypertension]]
-:* [[Fever]]
+:*[[Postictal drowsiness]]
-:* [[Mydriasis]]
+:*[[Fever]]
-:* [[Nystagmus]]
+:*[[Mydriasis]]
-:* [[Urine]] and [[fecal incontinence]]
+:*[[Nystagmus]]
-:* [[Disorientation]] to person, place, time
+:*[[Urine]] and [[fecal incontinence]]
-:* [[Altered mental status]]
+:*[[Disorientation]] to person, place, time
+:*[[Altered mental status]]
 *[[Physical examination]] associated with [[heart]] involvement in chronic [[epilepsy]] may include:
-:* [[Syncope]]
-:* [[Leg edema]]
-:* Elevated [[JVP]]
-:* [[S3]],[[S4]]
-:* [[Tachypnea]]
-:* [[ Hypotension]]
-:* [[ Pulsus alternans]]
-:* [[Systolic murmur]] in [[heart apex]]
-:* [[Irregular pulses]]
-=== Laboratory Findings ===
+:*[[Syncope]]
+:*[[Leg edema]]
+:*Elevated [[JVP]]
+:*[[S3]],[[S4]]
+:*[[Tachypnea]]
+:*[[ Hypotension]]
+:*[[ Pulsus alternans]]
+:*[[Systolic murmur]] in [[heart apex]]
+:*[[Irregular pulses]]
+===Laboratory Findings===
 Common laboratory findings related to [[epileptic heart]] may include:
-*An elevated concentration of serum [[troponin I]] as the  marker of [[ myocardial injury]] in patients with [[generalized tonic-clonic seizure]].41.63.67
-* Increased [[CRP]], [[lipid]] profile due to induction of [[cytochrome P450]]  by antiepileptic drugs such as [[carbamazepine]], [[gabapentin]]
+*An elevated concentration of serum [[troponin I]] as the  marker of [[ myocardial injury]] in patients with [[generalized tonic-clonic seizure]] <ref name="HajsadeghiAfsharian2009">{{cite journal|last1=Hajsadeghi|first1=Shekoufeh|last2=Afsharian|first2=Shila|last3=Fereshtehnejad|first3=Seyed-Mohammad|last4=Keramati|first4=Mohammad Reza|last5=Mollahoseini|first5=Reza|title=Serum Levels of Cardiac Troponin I in Patients with Uncomplicated Epileptic Seizure|journal=Archives of Medical Research|volume=40|issue=1|year=2009|pages=24–28|issn=01884409|doi=10.1016/j.arcmed.2008.10.002}}</ref>
+*Increased [[CRP]], [[lipid]] profile due to induction of [[cytochrome P450]]  by [[antiepileptic]] drugs such as [[carbamazepine]], [[gabapentin]] <ref name="MintzerMiller2016">{{cite journal|last1=Mintzer|first1=Scott|last2=Miller|first2=Rachael|last3=Shah|first3=Krunal|last4=Chervoneva|first4=Inna|last5=Nei|first5=Maromi|last6=Skidmore|first6=Christopher|last7=Sperling|first7=Michael R.|title=Long-term effect of antiepileptic drug switch on serum lipids and C-reactive protein|journal=Epilepsy & Behavior|volume=58|year=2016|pages=127–132|issn=15255050|doi=10.1016/j.yebeh.2016.02.023}}</ref>
 ===Electrocardiogram===
-An [[ECG]] may be helpful in the diagnosis of [[epileptic heart]]. Findings on an [[ECG]] suggestive of effects of [[seizure]] on the [[heart]] include:
+An [[ECG]] may be helpful in the diagnosis of [[epileptic heart]]. Findings on an [[ECG]] suggestive of effects of [[seizure]] on the [[heart]] include: <ref name="M. RamadanEl-Shahat2013">{{cite journal|last1=M. Ramadan|first1=Mahmoud|last2=El-Shahat|first2=Nader|last3=A. Omar|first3=Ashraf|last4=Gomaa|first4=Mohamed|last5=Belal|first5=Tamer|last6=A. Sakr|first6=Sherif|last7=Abu-Hegazy|first7=Mohammad|last8=Hakim|first8=Hazem|last9=A. Selim|first9=Heba|last10=A. Omar|first10=Sabry|title=Interictal Electrocardiographic and Echocardiographic Changes in Patients With Generalized Tonic-Clonic Seizures|journal=International Heart Journal|volume=54|issue=3|year=2013|pages=171–175|issn=1349-2365|doi=10.1536/ihj.54.171}}</ref><ref name="LendeArends2019">{{cite journal|last1=Lende|first1=Marije|last2=Arends|first2=Johan B.|last3=Lamberts|first3=Robert J.|last4=Tan|first4=Hanno L.|last5=Lange|first5=Frederik J.|last6=Sander|first6=Josemir W.|last7=Aerts|first7=Arnaud J.|last8=Swart|first8=Henk P.|last9=Thijs|first9=Roland D.|title=The yield of long‐term electrocardiographic recordings in refractory focal epilepsy|journal=Epilepsia|volume=60|issue=11|year=2019|pages=2215–2223|issn=0013-9580|doi=10.1111/epi.16373}}</ref><ref name="OpeskinThomas2000">{{cite journal|last1=Opeskin|first1=Kenneth|last2=Thomas|first2=Anthony|last3=Berkovic|first3=Samuel F.|title=Does cardiac conduction pathology contribute to sudden unexpected death in epilepsy?|journal=Epilepsy Research|volume=40|issue=1|year=2000|pages=17–24|issn=09201211|doi=10.1016/S0920-1211(00)00098-X}}</ref>
-*[[Bundle-branch block]]
-*[[ST-segment changes]] indicating  [[myocardial ischemia]] in 40% of [[seizures]]
+*[[Bundle-branch block]]
+*[[ST-segment changes]] indicating  [[myocardial ischemia]] in 40% of [[seizures]] <ref name="TigaranMolgaard2003">{{cite journal|last1=Tigaran|first1=S.|last2=Molgaard|first2=H.|last3=McClelland|first3=R.|last4=Dam|first4=M.|last5=Jaffe|first5=A.S.|title=Evidence of cardiac ischemia during seizures in drug refractory epilepsy patients|journal=Neurology|volume=60|issue=3|year=2003|pages=492–495|issn=0028-3878|doi=10.1212/01.WNL.0000042090.13247.48}}</ref>
 *[[T-wave]] inversion
 *[[Bradycardia]], [[asystole]] due to [[hypoxia]] or [[respiratory disturbance]] in [[postictal phase]]
@@ Line 214: / Line 223: @@
 *[[QT interval ]] prolongation
 *[[QT]] interval dispersion
-* Increased [[T wave]] alternance in preictal and post ictal phases of [[generalized tonic-clonic seizure]] indicating [[repolarization]] abnormality
+*Increased [[T wave]] alternance in preictal and post ictal phases of [[generalized tonic-clonic seizure]] indicating [[repolarization]] abnormality
-* Decreased [[heart rate variability]] indicating  decreased [[vagus nerve]] activity   during [[seizure]]
+*Decreased [[heart rate variability]] indicating  decreased [[vagus nerve]] activity   during [[seizure]]
-* [[Sinus tachycardia]], [[heart rate]] >150/min indicating sympathetic discharge
+*[[Sinus tachycardia]], [[heart rate]] >150/min indicating sympathetic discharge
-:* Common [[ECG]] markers associated [[sudden cardiac death]] include:
-* [[Peri ictal]] [[QT]] prolongation
+:*Common [[ECG]] markers associated [[sudden cardiac death]] include:
+*[[Peri ictal]] [[QT]] prolongation
 *Increased [[T waves alternance]]
-*Decreased [[heart rate variability]]
+*Decreased [[heart rate variability]] <ref name="LotufoValiengo2012">{{cite journal|last1=Lotufo|first1=Paulo A.|last2=Valiengo|first2=Leandro|last3=Benseñor|first3=Isabela M.|last4=Brunoni|first4=Andre R.|title=A systematic review and meta-analysis of heart rate variability in epilepsy and antiepileptic drugs|journal=Epilepsia|volume=53|issue=2|year=2012|pages=272–282|issn=00139580|doi=10.1111/j.1528-1167.2011.03361.x}}</ref>
-::*Arrhythmia associated [[seizure]] include:<ref name="van der LendeSurges2015">{{cite journal|last1=van der Lende|first1=Marije|last2=Surges|first2=Rainer|last3=Sander|first3=Josemir W|last4=Thijs|first4=Roland D|title=Cardiac arrhythmias during or after epileptic seizures|journal=Journal of Neurology, Neurosurgery & Psychiatry|year=2015|pages=jnnp-2015-310559|issn=0022-3050|doi=10.1136/jnnp-2015-310559}}</ref>
+::*Arrhythmia associated [[seizure]] include: <ref name="van der LendeSurges2015">{{cite journal|last1=van der Lende|first1=Marije|last2=Surges|first2=Rainer|last3=Sander|first3=Josemir W|last4=Thijs|first4=Roland D|title=Cardiac arrhythmias during or after epileptic seizures|journal=Journal of Neurology, Neurosurgery & Psychiatry|year=2015|pages=jnnp-2015-310559|issn=0022-3050|doi=10.1136/jnnp-2015-310559}}</ref>
 *[[Ictal]] [[bradycardia]]
@@ Line 229: / Line 241: @@
 *[[Post ictal]] [[AV conduction block]]
 *[[Post ictal]] [[atrial flutter]]
-*[[Post ictal]] [[ventricular fibrillation]]
+*[[Post ictal]] [[ventricular fibrillation]] <ref name="EspinosaLee2009">{{cite journal|last1=Espinosa|first1=P. S.|last2=Lee|first2=J. W.|last3=Tedrow|first3=U. B.|last4=Bromfield|first4=E. B.|last5=Dworetzky|first5=B. A.|title=SUDDEN UNEXPECTED NEAR DEATH IN EPILEPSY: MALIGNANT ARRHYTHMIA FROM A PARTIAL SEIZURE|journal=Neurology|volume=72|issue=19|year=2009|pages=1702–1703|issn=0028-3878|doi=10.1212/WNL.0b013e3181a55f90}}</ref>
 ::*Ictal [[asystole]], [[bradycardia]], [[AV block]] were self limiting.
-::* Post ictal arrhythmia such as [[asystole]], [[AV block]], [[atrial fibrillation]], [[ventricular fibrillation]] were associated with near [[SUDEP]] or [[convulsion syncope]].
+::*Post ictal arrhythmia such as [[asystole]], [[AV block]], [[atrial fibrillation]], [[ventricular fibrillation]] were associated with near [[SUDEP]] or [[convulsion syncope]].
 ===X-ray===
-A [[Chest-x-ray]] may be helpful in the diagnosis of [[heart involvement]] associated with [[chronic epilepsy]]. Findings on an [[CXR]] suggestive of [[heart]] involvement in [[epilepsy]] include:
+A [[Chest-x-ray]] may be helpful in the [[diagnosis]] of [[atherosclerosis]] associated with [[chronic epilepsy]]. Findings on an [[CXR]] suggestive of [[heart]] involvement in [[epilepsy]] include:
-:*[[Aortic arch calcification]]<ref name="IijimaHashimoto2010">{{cite journal|last1=Iijima|first1=Katsuya|last2=Hashimoto|first2=Hiroko|last3=Hashimoto|first3=Masayoshi|last4=Son|first4=Bo-Kyung|last5=Ota|first5=Hidetaka|last6=Ogawa|first6=Sumito|last7=Eto|first7=Masato|last8=Akishita|first8=Masahiro|last9=Ouchi|first9=Yasuyoshi|title=Aortic arch calcification detectable on chest X-ray is a strong independent predictor of cardiovascular events beyond traditional risk factors|journal=Atherosclerosis|volume=210|issue=1|year=2010|pages=137–144|issn=00219150|doi=10.1016/j.atherosclerosis.2009.11.012}}</ref>
+:*[[Aortic arch calcification]] <ref name="IijimaHashimoto2010">{{cite journal|last1=Iijima|first1=Katsuya|last2=Hashimoto|first2=Hiroko|last3=Hashimoto|first3=Masayoshi|last4=Son|first4=Bo-Kyung|last5=Ota|first5=Hidetaka|last6=Ogawa|first6=Sumito|last7=Eto|first7=Masato|last8=Akishita|first8=Masahiro|last9=Ouchi|first9=Yasuyoshi|title=Aortic arch calcification detectable on chest X-ray is a strong independent predictor of cardiovascular events beyond traditional risk factors|journal=Atherosclerosis|volume=210|issue=1|year=2010|pages=137–144|issn=00219150|doi=10.1016/j.atherosclerosis.2009.11.012}}</ref>
 :*[[Cardiomegaly]]
@@ Line 248: / Line 261: @@
 *Increased [[left ventricular filling pressures]]
 *Increased [[left atrial]] volume
 *Increase [[left ventricular]] end systolic diameter
 *Increased [[left ventricular]] [[end systolic volume]] 64,65,66
@@ Line 263: / Line 276: @@
 ===MRI===
-[[Cardiac magnetic resonance angiograpgy]] ([[MRA]]) may be helpful in the diagnosis of [[ischemic heart disease]] in chronic [[epilepsy]]. Findings on [[MRA]] suggestive of high-risk patients include:<ref name="YuanKerwin2004">{{cite journal|last1=Yuan|first1=Chun|last2=Kerwin|first2=William S.|title=MRI of atherosclerosis|journal=Journal of Magnetic Resonance Imaging|volume=19|issue=6|year=2004|pages=710–719|issn=1053-1807|doi=10.1002/jmri.20070}}</ref>
+[[Cardiac magnetic resonance angiograpgy]] ([[MRA]]) may be helpful in the diagnosis of [[ischemic heart disease]] in chronic [[epilepsy]]. Findings on [[MRA]] suggestive of high-risk patients include: <ref name="YuanKerwin2004">{{cite journal|last1=Yuan|first1=Chun|last2=Kerwin|first2=William S.|title=MRI of atherosclerosis|journal=Journal of Magnetic Resonance Imaging|volume=19|issue=6|year=2004|pages=710–719|issn=1053-1807|doi=10.1002/jmri.20070}}</ref>
-* Severe [[coronary artery]] stenosis(>70%)
+*Severe [[coronary artery]] stenosis(>70%)
 *Plaque with thick lipid-rich core and a thin [[fibrous cap]] and [[intraplaque inflammation]]
@@ Line 272: / Line 285: @@
 ===Other Diagnostic Studies===
+[[Holter ECG]] 24-48 hours may be helpful in the diagnosis of the arrhythmia-related [[epileptic heart]]. Findings suggestive the probability of the occurrence of [[ventricular fibrillation]]  include: <ref name="TakasugiGoto2016">{{cite journal|last1=Takasugi|first1=Nobuhiro|last2=Goto|first2=Hiroko|last3=Takasugi|first3=Mieko|last4=Verrier|first4=Richard L.|last5=Kuwahara|first5=Takashi|last6=Kubota|first6=Tomoki|last7=Toyoshi|first7=Hiroyuki|last8=Nakashima|first8=Takashi|last9=Kawasaki|first9=Masanori|last10=Nishigaki|first10=Kazuhiko|last11=Minatoguchi|first11=Shinya|title=Prevalence of Microvolt T-Wave Alternans in Patients With Long QT Syndrome and Its Association With Torsade de Pointes|journal=Circulation: Arrhythmia and Electrophysiology|volume=9|issue=2|year=2016|issn=1941-3149|doi=10.1161/CIRCEP.115.003206}}</ref>
+:*Higher level of [[T waves]] alternance
+:*Decrease [[heart rate variability ]]
+:*[[QT prolongation]]
+*Other [[diagnostic]] studies for epileptic include [[ECG]] patches which are worn for 14 days with a higher chance for detection of [[tachyarrhythmia]] compared with Holter [[ECG]].
-[[Holter ECG]] 24-48 hours may be helpful in the diagnosis of the arrhythmia-related [[epileptic heart]]. Findings suggestive of the occurance of [[ventricular fibrillation]]  include:
+==Treatment==
-:* Higher level of [[T waves]] alternance
+===Medical Therapy===
-:* Decrease [[heart rate variability ]]
-:* [[QT prolongation]]
+*The mainstay of therapy for [[epileptic heart]] is [[autonomic modulation]] by increased [[parasympathetic activity]], decreased [[sympathetic activity]] which is effective for reducing the [[seizure]] episodes and increased [[cardiac electrical]] stability by the following: <ref name="SchomerNearing2014">{{cite journal|last1=Schomer|first1=Andrew C.|last2=Nearing|first2=Bruce D.|last3=Schachter|first3=Steven C.|last4=Verrier|first4=Richard L.|title=Vagus nerve stimulation reduces cardiac electrical instability assessed by quantitative T-wave alternans analysis in patients with drug-resistant focal epilepsy|journal=Epilepsia|volume=55|issue=12|year=2014|pages=1996–2002|issn=00139580|doi=10.1111/epi.12855}}</ref>
-*Other diagnostic studies for epileptic include [[ECG]] patches which are worn for 14 days with a higher chance for detection of [[tachyarrhythmia]] compared with [[Holter ECG]].
+:*Changing the [[arrhythmogenic]] [[antiepileptic drugs]] to other types
+:*[[vagus nerve stimulation]] therapy for reducing [[sympathetic activity]] which is a major risk factor for [[ventricular fibrillation]] <ref name="SchomerNearing2014">{{cite journal|last1=Schomer|first1=Andrew C.|last2=Nearing|first2=Bruce D.|last3=Schachter|first3=Steven C.|last4=Verrier|first4=Richard L.|title=Vagus nerve stimulation reduces cardiac electrical instability assessed by quantitative T-wave alternans analysis in patients with drug-resistant focal epilepsy|journal=Epilepsia|volume=55|issue=12|year=2014|pages=1996–2002|issn=00139580|doi=10.1111/epi.12855}}</ref>
+===Surgery===
+*[[Vagus Nerve Stimulation]] ([[VNS]]) can be used in resistance [[epilepsy]] by inserting a [[pacemaker]] under the [[skin]] in the [[chest]] and sending regular, mild [[pulses]] to the [[brain]] via the [[vagus]] [[nerve]].<ref name="pmid29844694">{{cite journal |vauthors=Johnson RL, Wilson CG |title=A review of vagus nerve stimulation as a therapeutic intervention |journal=J Inflamm Res |volume=11 |issue= |pages=203–213 |date=2018 |pmid=29844694 |pmc=5961632 |doi=10.2147/JIR.S163248 |url=}}</ref>
+===Prevention===
-== Treatment ==
+*[[Primary prevention]] measures in [[epileptic heart]] include:
-=== Medical Therapy ===
+:*Screening [[risk factors]] of [[coronary artery disease]] in every [[patients]] diagnosed with [[epilepsy]] consisting [[obesity]],[[hypertension]], [[hyperlipidemia]],[[diabetes mellitus]],[[smoking]]
-*The mainstay of therapy for [[epileptic heart]] is [[autonomic modulation]] by increased [[parasympathetic activity]], decreased [[sympathetic activity]] which is effective for reducing the [[seizure]] episodes and increased [[cardiac electrical]] stability by the following:
+:*The role of [[ICD]] implantation for [[primary prevention]] of [[ventricular tachyarrhythmia]] in patients with chronic [[epilepsy]] is unclear. <ref name="SteckerReinier2013">{{cite journal|last1=Stecker|first1=Eric C.|last2=Reinier|first2=Kyndaron|last3=Uy-Evanado|first3=Audrey|last4=Teodorescu|first4=Carmen|last5=Chugh|first5=Harpriya|last6=Gunson|first6=Karen|last7=Jui|first7=Jonathan|last8=Chugh|first8=Sumeet S.|title=Relationship Between Seizure Episode and Sudden Cardiac Arrest in Patients With Epilepsy|journal=Circulation: Arrhythmia and Electrophysiology|volume=6|issue=5|year=2013|pages=912–916|issn=1941-3149|doi=10.1161/CIRCEP.113.000544}}</ref>
-:*Changing the [[arrhythmogenic]] [[antiepileptic drugs]] to other types
-:* [[vagus nerve stimulation]] therapy for reduction [[sympathetic activity]] which is a major risk factor for [[ventricular fibrillation]]
-=== Surgery ===
-* [[Left stellectomy]] can only be performed for patients with [[Long QT syndrome]] who are at risk of [[ventricular fibrillation]].
-=== Prevention ===
-*[[Primary prevention]] measures in [[epileptic heart]] include:
-:*Screening risk factors of [[coronary artery disease]] in every patient diagnosed with [[epilepsy]] consisting [[obesity]],[[hypertension]], [[hyperlipidemia]],[[diabetes mellitus]],[[smoking]]
-:*The role of [[ICD]] implantation for [[primary prevention]] of [[ventricular tachyarrhythmia]] in patients with chronic [[epilepsy]] is unclear.<ref name="SteckerReinier2013">{{cite journal|last1=Stecker|first1=Eric C.|last2=Reinier|first2=Kyndaron|last3=Uy-Evanado|first3=Audrey|last4=Teodorescu|first4=Carmen|last5=Chugh|first5=Harpriya|last6=Gunson|first6=Karen|last7=Jui|first7=Jonathan|last8=Chugh|first8=Sumeet S.|title=Relationship Between Seizure Episode and Sudden Cardiac Arrest in Patients With Epilepsy|journal=Circulation: Arrhythmia and Electrophysiology|volume=6|issue=5|year=2013|pages=912–916|issn=1941-3149|doi=10.1161/CIRCEP.113.000544}}</ref>
 *The strategy for [[secondary prevention]] in [[chronic epileptic]] patients who are at risk of arrhythmia include:
 *Changing  [[arrhythmogenic]] drugs  that block [[sodium channel]] such as [[carbamazepine]], [[phenytoin]] to other types
-*[[Vagus Nerve Stimulation]] therapy ([[VNS]]) for a reduction in [[T wave]] alternance
+*[[Vagus Nerve Stimulation]] therapy ([[VNS]]) for a reduction in [[T wave]] alternans <ref name="SchomerNearing2014">{{cite journal|last1=Schomer|first1=Andrew C.|last2=Nearing|first2=Bruce D.|last3=Schachter|first3=Steven C.|last4=Verrier|first4=Richard L.|title=Vagus nerve stimulation reduces cardiac electrical instability assessed by quantitative T-wave alternans analysis in patients with drug-resistant focal epilepsy|journal=Epilepsia|volume=55|issue=12|year=2014|pages=1996–2002|issn=00139580|doi=10.1111/epi.12855}}</ref>
-::*[[Chronic epileptic]] patients should be followed up for detection of [[T waves]] alternance  and finding the risk of [[ventricular fibrillation]] by:.<ref name="VerrierPang2020">{{cite journal|last1=Verrier|first1=Richard L.|last2=Pang|first2=Trudy D.|last3=Nearing|first3=Bruce D.|last4=Schachter|first4=Steven C.|title=The Epileptic Heart: Concept and clinical evidence|journal=Epilepsy Behavior|volume=105|year=2020|pages=106946|issn=15255050|doi=10.1016/j.yebeh.2020.106946}}</ref>
+::*[[Chronic epileptic]] patients should be followed up for detection of [[T waves]] alternans and finding the risk of [[ventricular fibrillation]] by: <ref name="VerrierPang2020">{{cite journal|last1=Verrier|first1=Richard L.|last2=Pang|first2=Trudy D.|last3=Nearing|first3=Bruce D.|last4=Schachter|first4=Steven C.|title=The Epileptic Heart: Concept and clinical evidence|journal=Epilepsy Behavior|volume=105|year=2020|pages=106946|issn=15255050|doi=10.1016/j.yebeh.2020.106946}}</ref><ref name="PangNearing2019">{{cite journal|last1=Pang|first1=Trudy D.|last2=Nearing|first2=Bruce D.|last3=Krishnamurthy|first3=Kaarkuzhali Babu|last4=Olin|first4=Bryan|last5=Schachter|first5=Steven C.|last6=Verrier|first6=Richard L.|title=Cardiac electrical instability in newly diagnosed/chronic epilepsy tracked by Holter and ECG patch|journal=Neurology|volume=93|issue=10|year=2019|pages=450–458|issn=0028-3878|doi=10.1212/WNL.0000000000008077}}</ref>
 :* 12 lead [[ECG]]
-:*[[Holter ECG]] 24-48 hours
+:* Holter [[ECG]] 24-48 hours
-:*[[Wireless ECG patches]] (patient-friendly tool, worn for 14 days, increased chance for detection of arrhythmia compared  with [[Holter ECG]])
+:* Wireless [[ECG]] patches(patient-friendly tool, worn for 14 days, increased chance for detection of [[arrhythmia]] compared  with Holter [[ECG]])
 ==References==
 {{Reflist|2}}
+[[Category:Cardiology]]
-[[Category:Pick One of 28 Approved]]
+[[Category:Neurology]]
+[[Category:Up-To-Date]]
-{{WS}}
-{{WH}}