Where is the Heart in Epilepsy Care?

The body is a complex system of organs working together to keep us moving each day. Medical specialization, however, can have the unintended consequence of viewing these organs as separate entities. Specialists target treatment to specific regions only after problems arise. Specifically within neurology, organs like the heart can be seen as subservient to the brain, existing to simply keep the blood flowing.

The Brain & The Heart

Cardiac and neurologic disorders can share a number of common symptoms, such as dizziness, fainting, and abnormal body movements. Furthermore, heart health should be a concern to neurologists due to cerebral emboli¹, or for epileptologists specifically, differentiating epileptic from syncopal episodes². Recent research indicates an increased rate of cardiovascular comorbidities in patients with epilepsy as high as 62-82%.³ In patients suffering from chronic epilepsy, the damage that recurrent seizures may inflict on the heart has also started to receive direct attention, leading to the concept of the “Epileptic Heart.”^{3, 4} Given this accumulating evidence that brain and heart health go hand in hand, it is necessary for neurologists to consider the heart when treating patients with epilepsy.

Cardiac Death & Epilepsy

The risk of sudden cardiac death (SCD) is distinct from the well-known Sudden Unexplained Death in Epilepsy Patients (SUDEP). SUDEP is a fatal and unexplained phenomenon typically impacting individuals with epilepsy between the ages of 20-40, and is potentially caused by post-ictal pulmonary failure ⁵. However, by definition, a SUDEP diagnosis precludes evidence of sudden cardiac death (SCD). Patients with epilepsy, nonetheless, present a unique risk for SCD, as these patients have an estimated risk three times higher than the general population^{6, 7}. These estimates rise to a five-fold risk in patients over 50 years of age with epilepsy⁶, and a six-fold risk in patients with symptomatic epilepsy⁷ – and these risks are independent of the risk of SUDEP

A More Cohesive Approach

Although ambulatory, multiday cardiac monitoring is not currently the routine practice of neurologists and epileptologists, mounting evidence strongly suggests that comprehensive epilepsy care requires these procedures to be included.

In practice, the question becomes – when should I order concurrent cardiac monitoring, and what kind of monitoring is needed? The table below can provide guidance on when cardiac monitoring can be a suitable supplement to at home EEG.

Indications for Long-term Video EEG or Concomitant Long-term VEEG + MCT

VEEG Alone

Suspected epilepsy
Suspected psychogenic events
Brain injury
Alzheimer’s disease / dementia

VEEG + MCT Monitoring

Confusion
Suspected Syncope
Recurrent episodes of non-convulsive transient loss of consciousness followed, or not followed by jerks or involuntary movements
Identification of tachyarrhthmia, bradyarrhythmia or screening for asystole accompanying a seizure

With Stratus, our concurrent in-home video EEG and mobile cardiac monitoring are easy for patients and neurologists. Additionally, we have partnered with Heartbeat Health to offer a national cardiologist reader group to assist with diagnosis and recommended treatment plans for ordering neurologists.

About the Author

Jeremy D. Slater, MD, FAAN, FAES, FACNS is the Chief Medical Officer for Stratus. Dr. Slater has worked in the field of epilepsy for more than 27 years and has served as an investigator for numerous clinical trials and research initiatives. He served as Director of the Texas Comprehensive Epilepsy Program, one of the largest epilepsy surgery programs in the country, and currently heads up MERLN, Stratus’ R&D division.

References

Oppenheimer SM, Lima J. Neurology and the heart. J Neurol Neurosurg Psychiatry. 1998;64(3):289-97. doi:10.1136/jnnp.64.3.289
Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A, Jr., et al. ACC/AHA Guidelines for Ambulatory Electrocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Developed in collaboration with the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol. 1999;34(3):912-48. doi:10.1016/s0735-1097(99)00354-x
Verrier RL, Pang TD, Nearing BD, Schachter SC. The Epileptic Heart: Concept and clinical evidence. Epilepsy Behav. 2020;105:106946. doi:10.1016/j.yebeh.2020.106946
Verrier RL, Pang TD, Nearing BD, Schachter SC. Epileptic heart: A clinical syndromic approach. Epilepsia. 2021. doi:10.1111/epi.16966
Ryvlin P, Nashef L, Lhatoo SD, Bateman LM, Bird J, Bleasel A, et al. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. The Lancet Neurology. 2013;12(10):966-77. doi:http://dx.doi.org/10.1016/S1474-4422(13)70214-X
Bardai A, Lamberts RJ, Blom MT, Spanjaart AM, Berdowski J, van der Staal SR, et al. Epilepsy is a risk factor for sudden cardiac arrest in the general population. PLoS One. 2012;7(8):e42749. doi:10.1371/journal.pone.0042749
Bardai A, Blom MT, van Noord C, Verhamme KM, Sturkenboom MC, Tan HL. Sudden cardiac death is associated both with epilepsy and with use of antiepileptic medications. Heart. 2015;101(1):17-22. doi:10.1136/heartjnl-2014-305664