Epileptic Heart

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


Synonyms and keywords:

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, 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]

Epilepsy and Structural Heart Disease

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

Causes

  • Epileptic heart is caused by the chronic effects of epilepsy on the heart.

Causes

Epileptic heart may be caused by the following:

Differentiating [disease name] from other Diseases

Epileptic heart Sudden unexpected death in epilepsy SUDEP Convulsion syncope Epileptic seizure

Epidemiology and Demographics

  • The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
  • In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

Gender

  • Males are more commonly affected with epileptic heart than females

Race

  • There is no racial predilection for epileptic heart.
  • [Disease name] usually affects individuals of the [race 1] race.
  • [Race 2] individuals are less likely to develop [disease name].

Risk Factors

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, angina pectori.
  • If left untreated, patients with chronic epilepsy may progress to develop complications of arrhythmia and myocardial ischemia.
  • Common complications of epileptic heart include: coronary artery disease, heart failure disease, sudden cardiac arrest, sudden cardiac death.
  • Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

  • The diagnosis of 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 common age
  • Evidence of myocardial injury such as high level of troponin I

History and Symptoms

  • Symptoms of epileptic heart may include the following:
  • Abrupt palpitation
  • Shortness of breath
  • Angina pectori
  • lightheadness
  • Dizziness
  • Falling
  • Near falling

Physical Examination

  • Physical examination associated with epilepsy include:

Laboratory Findings

Common laboratory findings related to epileptic heart may include:\

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:

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

Echocardiography may be helpful in the diagnosis of epilectic heart. Findings on an echocardiography diagnostic of epileptic heart include

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

Holter ECG 24-48 hours may be helpful in the diagnosis of arrhythmia related epileptic heart. Findings suggestive of occurance of ventricular fibrillation include:

  • Higher level of T waves alternance
  • Decrease heart rate variability
  • QT prolongation
  • Other diagnostic studies for epileptic include ECG patches which is worn for 14 days with higher chance for detection of tachyarrhythmia compared with holter ECG.

Treatment

Medical Therapy

  • There is no treatment for [disease name]; the mainstay of therapy is supportive care.
  • The mainstay of therapy for epileptic heart is
  • changing the arrhythmogenic antiepileptic drugs,
  • vagus nerve stimulation therapy for reduction sympathetic activity which is a major risk factor for ventricular fibrillation,
  • autonomic modulation by increased parasympathetic activity, decreased sympathetic activity which is effective for reduction the seizure episodes and increased cardiac electerical stability.

Surgery

  • Surgery is the mainstay of therapy for [disease name].
  • [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
  • [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

  • There are no primary preventive measures available for epileptic heart
  • The role of ICD implantation for primary prevention in patients with chronic epilepsy who are susceptible to arrhythmia is under investigation.
  • The strategy for secondary prevention in chronic epileptic patients who are at risk of arrhythmia includes:
  • Changing arrhythmogenic drugs that blocks sodium channel such as carbamazepine, phenytoin to other types
  • Vagus Nerve Stimulation therapy(VNS) for reduction in T wave alternance
  • Chronic epileptic patients should be follow up for detection of T waves alternance and finding the risk of ventricular fibrillation by:
  • 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

  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.
  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.
  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.
  4. 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.
  5. Hamed, Sherifa A. (2014). "Atherosclerosis in epilepsy: Its causes and implications". Epilepsy & Behavior. 41: 290–296. doi:10.1016/j.yebeh.2014.07.003. ISSN 1525-5050.
  6. Mintzer, Scott; Trinka, Eugen; Kraemer, Günter; Chervoneva, Inna; Werhahn, Konrad J. (2018). "Impact of carbamazepine, lamotrigine, and levetiracetam on vascular risk markers and lipid-lowering agents in the elderly". Epilepsia. 59 (10): 1899–1907. doi:10.1111/epi.14554. ISSN 0013-9580.
  7. Leestma, Jan E.; Walczak, Thaddeus; Hughes, John R.; Kalelkar, Mitra B.; Teas, Shaku S. (1989). "A prospective study on sudden unexpected death in epilepsy". Annals of Neurology. 26 (2): 195–203. doi:10.1002/ana.410260203. ISSN 0364-5134.
  8. Falconer, Bertil; Rajs, Jovan (1976). "Post-mortem findings of cardiac lesions in epileptics: A preliminary report". Forensic Science. 8: 63–71. doi:10.1016/0300-9432(76)90048-0. ISSN 0300-9432.
  9. Bardai, Abdennasser; Blom, Marieke T; van Noord, Charlotte; Verhamme, Katia M; Sturkenboom, Miriam C J M; Tan, Hanno L (2015). "Sudden cardiac death is associated both with epilepsy and with use of antiepileptic medications". Heart. 101 (1): 17–22. doi:10.1136/heartjnl-2014-305664. ISSN 1355-6037.
  10. Reeves, Andrew L.; Nollet, Kenneth E.; Klass, Donald W.; Sharbrough, Frank W.; So, Elson L. (1996). "The Ictal Bradycardia Syndrome". Epilepsia. 37 (10): 983–987. doi:10.1111/j.1528-1157.1996.tb00536.x. ISSN 0013-9580.
  11. Nashef, L; Walker, F; Allen, P; Sander, J W; Shorvon, S D; Fish, D R (1996). "Apnoea and bradycardia during epileptic seizures: relation to sudden death in epilepsy". Journal of Neurology, Neurosurgery & Psychiatry. 60 (3): 297–300. doi:10.1136/jnnp.60.3.297. ISSN 0022-3050.

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Differentiating Epileptic heart from other Diseases

  • Epileptic heart must be differentiated from other causes of sudden death. It should also be distinguished from sudden unexpected death in epilepsy.

Epidemiology and Demographics

Risk Factors

Screening

Currently, there is no guideline statement that recommends 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 to further follow the progression of their cardiac pathology.[1]

References

  1. 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.