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Identifying patients with epilepsy at high risk of cardiac death: signs, risk factors and initial management of high risk of cardiac death Volume 23, numéro 1, February 2021

TEST YOURSELF

(1) What are the main causes of cardiac complications in people with epilepsy?

 

(2) When is it meaningful to search or anticipate cardiac complications in people with epilepsy?

 

(3) How should cardiac complications be managed?

 

 

 

 

 

 

 

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Answers

(1) Seizure-related cardiac complications

  • Ictal tachycardia.
  • Ictal bradyarrhythmia including ictal bradycardia and asystole caused by silencing sinus node and AV node activity.
  • Atrial fibrillation.
  • Ictal ventricular tachycardia or fibrillation.
  • Takotsubo cardiomyopathy and acute myocardial infarction.

 

Epilepsy-related cardiac complications

  • Cardiac autonomic dysfunction reflected by enhanced sympathetic tone and impaired parasympathetic tone, resulting in decreased heart rate variability.
  • The ‘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.”
  • Altered cardiac repolarisation indices which may be favoured by both enhanced sympathetic tone and alterations of the ‘epileptic heart’.
  • Inherited cardiac dysfunction due to genetic syndromes leading to both epilepsy and cardiac diseases.

 

Treatment-related cardiac complications

  • Cardiac arrhythmias due to ASMs, e.g. high doses of sodium channel blockers, combination therapy with several sodium channel blockers or in combination with other cardioactive drugs.
  • Poor profile of circulating cardiovascular risk factors upon enzyme-inducing ASMs (carbamazepine, phenytoin, phenobarbital, and primidone) and ASM-related weight gain (e.g. due to gabapentin, pregabalin, and valproate), increasing the risk of cardiovascular events.
  • Delayed onset of VNS-induced episodic bradycardia and syncope.

 

 

(2)

  • In all patients, at the time of first epilepsy diagnosis, to identify constellations suggestive of inherited cardiac arrhythmiaand to mitigate the risk of false diagnosis of epilepsy.
  • In PWE with onset of new seizure-related symptoms such as LOC that differ from the usual loss of awareness and unusual (atonic) falls.
  • In the aftermaths of a TCS in patients of all ages with new chest pain, with known CAD or in patients older than 70 years.
  • In patients who report new onset of palpitations, episodes with LOC and falls in the absence of typical seizure-related symptoms or other cardiac complaints.
  • If modification of antiseizure drug treatment involving sodium channel blockers is intended, especially in patients with other cardioactive substances (e.g. antihypertensive or antiarrhythmic drugs) or in those with high doses or a combination of sodium channel blockers.

 

(3) Seizure-related cardiac complications

  • Aim to achieve full seizure control.
  • If refractory, implantation of a cardiac pacemaker in patients with ictal asystole and a defibrillator in those with ventricular tachyarrhythmia is advisable.
  • In patients of all ages with new chest pain, with known CAD or in patients older than 70 years, it is advisable to determine troponin levels and perform a 12-lead ECG after TCS to exclude myocardial infarction and Takotsubo cardiomyopathy.

 

Epilepsy-related cardiac complications

  • Refer to cardiologist for further examinations (e.g. Holter recordings, echocardiography, implantation of a loop recorder) if constellation is suggestive of inherited cardiac channelopathy or seizure- and treatment-related causes of cardiac complications are excluded.

 

Treatment-related cardiac complications

  • In case of ASM-related cardiac arrhythmias, switch to alternative treatment strategy.
  • Enzyme-inducing ASMs should be avoided and switched (if possible) because of the negative impact on cardiovascular risk factors, which may further be aggravated by weight gain linked to specific ASMs. =
  • VNS parameters may be changed or VNS switched off in the case of VNS-induced bradycardia and asystole.

 

 

 

 

 

 

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