Cardiovascular risk factors and homocysteine in epilepsy

Comparison of Cardiovascular Outcomes and All-Cause Mortality Between Patients With and Without Epilepsy: A Systematic Review and Meta-Analysis of Observational Studies

This meta-analysis aimed to assess the all-cause mortality and cardiovascular outcomes among patients diagnosed with epilepsy. The entire process of this systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure transparency and reporting completeness. A comprehensive search strategy was employed to identify relevant studies in electronic databases, including PubMed, Embase, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL), from January 1, 2010, to January 15, 2024. Outcomes assessed in this meta-analysis included all-cause mortality, cardiovascular mortality, stroke, myocardial infarction, and arrhythmias. A total of 12 studies were included in this meta-analysis with a pooled sample size of 7,026,313. The majority of included studies were conducted in Taiwan (n=4). Our study revealed that individuals with epilepsy faced a higher risk of all-cause mortality, cardiovascular mortality, and stroke. Although there was a higher incidence of myocardial infarction and arrhythmias among epilepsy patients, this disparity did not reach statistical significance. There is a need for future research to explore the impact of epilepsy types, antiepileptic drugs, and lifestyle factors on cardiovascular outcomes.

Long-Term Effects of Antiseizure Medications

Most patients with epilepsy will benefit from seizure control with one of an array of chronic antiseizure medications. Knowledge of the potential long-term effects of these medications is critical to prevent adverse consequences on overall health. Antiseizure medications vary in their capacities to affect the brain and peripheral nerves, hormones, bone mineralization, cardiovascular risk, renal health, hepatic, hematological, and dermatological systems. Understanding of pathophysiology and population risk has evolved, although most of the data available are still on older generation antiseizure medications such as phenytoin, carbamazepine, and valproic acid. The enzyme-inducing properties of some antiseizure medications make their effects on cardiovascular risk and bone health detrimental. Few clear guidelines exist for monitoring long-term effects of medication therapy for epilepsy. When selecting an antiseizure medication, consideration should be given to the individual patient's risks of adverse consequences on other organ systems. During monitoring of patients on chronic therapy, screening tools such as metabolic panels and bone density measurements can help stratify risk and guide management.

Serum folate levels in children on long-term anti-seizure medication in a Nigerian tertiary center-Implications for practice and public health

BACKGROUND

Epilepsy is the most common childhood neurological disorder in Nigeria. Treatment of epilepsy is long-term and sometimes lifelong with anti-seizure medications. There are conflicting reports on the effect of anti-seizure medications on serum folate. There is therefore a need to determine the effect of a commonly used anti-seizure medication's on serum folate levels of children. This would provide an evidence-based consideration for folic acid supplementation in children on anti-seizure medication as has been suggested by some studies.

STUDY OBJECTIVES

To determine whether serum folate levels were lower in children taking long-term carbamazepine or sodium valproate, compared to a control group.

METHODS

Serum folic acid levels were measured from well-nourished children between the ages of 1-17 years on carbamazepine and sodium valproate monotherapy and their age/sex-matched controls, using spectrophotometry.

RESULTS

The mean serum folate levels of patients on carbamazepine (43) and sodium valproate (22) were 0.032 mg/l ± 0.009 and 0.028 mg/l  ±  0.008, respectively. The mean folate levels of the controls were 0.046 mg/l  ±  0.03 (p = 0 001). No statistically significant difference was observed between the serum folate levels of children on the two anti-seizure medications, that is, carbamazepine and valproate.

CONCLUSION

The children on treatment with carbamazepine and sodium valproate for more than 6 months had statistically significantly lower serum levels of folic acid compared to the standard reference range and controls. The serum folate levels of children on carbamazepine were not statistically different from those on sodium valproate.

Epilepsy, antiepileptic drugs, and the risk of major cardiovascular events

OBJECTIVE

This study was undertaken to determine whether epilepsy and antiepileptic drugs (including enzyme-inducing and non-enzyme-inducing drugs) are associated with major cardiovascular events using population-level, routinely collected data.

METHODS

Using anonymized, routinely collected, health care data in Wales, UK, we performed a retrospective matched cohort study (2003-2017) of adults with epilepsy prescribed an antiepileptic drug. Controls were matched with replacement on age, gender, deprivation quintile, and year of entry into the study. Participants were followed to the end of the study for the occurrence of a major cardiovascular event, and survival models were constructed to compare the time to a major cardiovascular event (cardiac arrest, myocardial infarction, stroke, ischemic heart disease, clinically significant arrhythmia, thromboembolism, onset of heart failure, or a cardiovascular death) for individuals in the case group versus the control group.

RESULTS

There were 10 241 cases (mean age = 49.6 years, 52.2% male, mean follow-up = 6.1 years) matched to 35 145 controls. A total of 3180 (31.1%) cases received enzyme-inducing antiepileptic drugs, and 7061 (68.9%) received non-enzyme-inducing antiepileptic drugs. Cases had an increased risk of experiencing a major cardiovascular event compared to controls (adjusted hazard ratio = 1.58, 95% confidence interval [CI] = 1.51-1.63, p < .001). There was no notable difference in major cardiovascular events between those treated with enzyme-inducing antiepileptic drugs and those treated with non-enzyme-inducing antiepileptic drugs (adjusted hazard ratio = .95, 95% CI = .86-1.05, p = .300).

SIGNIFICANCE

Individuals with epilepsy prescribed antiepileptic drugs are at an increased risk of major cardiovascular events compared with population controls. Being prescribed an enzyme-inducing antiepileptic drug is not associated with a greater risk of a major cardiovascular event compared to treatment with other antiepileptic drugs. Our data emphasize the importance of cardiovascular risk management in the clinical care of people with epilepsy.

Hyperhomocysteinemia and risk of incident cognitive outcomes: An updated dose-response meta-analysis of prospective cohort studies

OBJECTIVE

This study aimed to comprehensively assess the dose-response relationship between blood homocysteine levels and risk of all cause, Alzheimer and vascular dementia, as well as cognitive impairment without dementia (CIND).

METHOD

We searched for all related prospective cohort studies reporting homocysteine as an exposure from patients with cognitive disorders as a result in the PubMed and EMBASE databases up to June 18, 2018. Pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) were extracted. The dose-response meta-analyses were conducted to assess potential linear and non-linear dose-response relations. Summary RRs and 95% CIs were calculated using a random- or fixed-effects model.

RESULTS

Twenty-eight prospective cohort studies were eligible in this meta-analysis. During average follow-up periods ranging from 2.7 to 35 years there were 2557 cases (1035 all-cause dementia, 530 Alzheimer's disease, 92 vascular dementia and > 900 CIND) among 28,257 participants. There was a clear linear dose-response relationship between blood homocysteine concentration and risk of Alzheimer-type dementia (P > 0.05 for non-linearity). The pooled RR of Alzheimer-type dementia was 1.15 (95% CI: 1.04 to 1.26; I² = 56.6%, n = 5) for every 5 μmol/L increase in blood homocysteine. Sensitivity analysis showed similar results, and there was no clear evidence of publication bias with Begg's and Egger's tests for Alzheimer dementia (P = 0.806, 0.084, respectively), strengthening the linear relationship between blood homocysteine levels and risk of Alzheimer dementia. Due to the presence of publication bias and low statistical power, elevated levels of blood homocysteine were not appreciably associated with risk of all-cause, vascular dementia and CIND.

CONCLUSIONS

Every 5 μmol/L increase in blood homocysteine is linearly associated with a 15% increase in relative risk of Alzheimer-type dementia. This meta-analysis provides further evidence that a higher concentration of blood homocysteine is associated with a higher risk of Alzheimer-type dementia.

Effects of Folate Supplementation on Carotid Intima-Media Thickness, Biomarkers of Inflammation, and Oxidative Stress in Carbamazepine-Treated Epileptic Children

Background:

This study was conducted to assess the effects of folate supplementation on carotid intima-media thickness (CIMT), biomarkers of inflammation, and oxidative stress in carbamazepine-treated epileptic children.

Methods:

This randomized, double-blind, placebo-controlled trial was carried out in 54 epileptic children aged 2–12 years old receiving carbamazepine monotherapy. Participants were randomly allocated into two groups to receive either 5 mg folate supplements or placebo (n = 27 in each group) for 12 weeks.

Results:

After the 12-week intervention, compared with the placebo, folate supplementation resulted in a significant reduction in plasma homocysteine (Hcy) (changes from baseline − 2.1 ± 2.5 vs. +0.1 ± 0.4 μmol/L, P < 0.001), serum high-sensitivity C-reactive protein (hs-CRP) (changes from baseline − 1.5 ± 3.5 vs. +0.4 ± 1.4 mg/L, P = 0.01), a significant increase in plasma nitric oxide (NO) (changes from baseline + 1.9 ± 5.8 vs. −2.0 ± 6.4 μmol/L, P = 0.02), and total antioxidant capacity (TAC) concentrations (changes from baseline + 88.6 ± 116.0 vs. +1.8 ± 77.4 mmol/L, P = 0.002). We did not observe any significant effects in mean levels of left and right CIMT, maximum levels of left and right CIMT, and total glutathione (GSH) and malondialdehyde (MDA) levels following the supplementation of folate compared with the placebo.

Conclusions:

Overall, folate supplementation at a dosage of 5 mg/day for 12 weeks among epileptic children receiving carbamazepine had beneficial effects on Hcy, hs-CRP, NO, and TAC levels, but did not affect CIMT, and GSH and MDA levels.

Oxcarbazepine administration and the serum levels of homocysteine, vitamin B12 and folate in epileptic patients: A systematic review and meta-analysis

The objectives were to determine the influence of oxcarbazepine (OXC) monotherapy on the serum levels of total homocysteine (tHcy), vitamin B12 and folate in patient with epilepsy pooling together case-control or interventional studies. A comprehensive literature search was done through four databases including MEDLINE/PubMed, Scopus, Embase and Web of Science from January 2000 to February 2016. A random effects model (the DerSimonian-Laird estimator) was utilized to pool the effect sizes of the individual studies. The between-study variance was assessed using the Q2 test (significance level p<0.1) and quantified using the I² test (>50% indicated evidence of heterogeneity). Overall, six studies found eligible for inclusion. The meta-analysis for tHcy revealed that the serum level of tHcy was no significant difference between patient on OXC monotherapy and healthy people [mean difference (MD) 0.31; 95% CI -1.05, 1.67, p=0.653]. The meta-analysis for vitamin B12 [MD -46.51; 95% CI -113.63, 20.62, p=0.174] and folate [MD -0.48; 95% CI -1.06, 0.11, p=0.113] indicated that there was no significant difference between patients on OXC monotherapy and healthy people. In conclusion, the meta-analysis does not support the hypotheses that OXC monotherapy changes the serum levels of tHcy, vitamin B12 and folate.

Metabolic syndrome in young adults with epilepsy

PURPOSE

Persons with epilepsy have higher cardiovascular mortality and morbidity compared to general population and alteration of their biochemical milieu is one of the proposed mechanisms. We aimed to study the prevalence of metabolic syndrome and cardiovascular risk factors in young adults with epilepsy and the association with antiepileptic drug use.

METHOD

An observational study was conducted in persons with epilepsy aged 20-49 years using antiepileptic drugs regularly for the previous three years. The subjects were examined and their blood samples were collected for fasting blood glucose and lipid profile.

RESULTS

Over 18 months, 183 patients (120 males; 63 females) were recruited (mean age 32.5 ± 8.9 years). Metabolic syndrome (MetS) by ATP III criteria was present in 54 (29.5%) subjects. People with MetS in our group had higher frequency of abdominal obesity (50.0%) and hypertriglyceridemia (55.5%) than diabetes/impaired fasting glucose (27.8%). Older age (p=0.005) and use of valproate (p=0.012) were associated with significant risk of MetS.

CONCLUSION

Clinicians need to be vigilant regarding the risk of MetS while initiating treatment and following up persons with epilepsy.

Cognitive deterioration in adult epilepsy: Does accelerated cognitive ageing exist?

A long-standing concern has been whether epilepsy contributes to cognitive decline or so-called 'epileptic dementia'. Although global cognitive decline is generally reported in the context of chronic refractory epilepsy, it is largely unknown what percentage of patients is at risk for decline. This review is focused on the identification of risk factors and characterization of aberrant cognitive trajectories in epilepsy. Evidence is found that the cognitive trajectory of patients with epilepsy over time differs from processes of cognitive ageing in healthy people, especially in adulthood-onset epilepsy. Cognitive deterioration in these patients seems to develop in a 'second hit model' and occurs when epilepsy hits on a brain that is already vulnerable or vice versa when comorbid problems develop in a person with epilepsy. Processes of ageing may be accelerated due to loss of brain plasticity and cognitive reserve capacity for which we coin the term 'accelerated cognitive ageing'. We believe that the concept of accelerated cognitive ageing can be helpful in providing a framework understanding global cognitive deterioration in epilepsy.

Effects of valproate on the carotid artery intima-media thickness in epileptics

Objective:

The objective was to explore the effects of valproate (VPA) on the carotid artery intima-media thickness (CA-IMT) in epileptics.

Materials and Methods:

A total of 30 epileptic patients treated with VPA was included as disease group, while 33 healthy people who matched general basic demographic details were the control group. The IMTs of the left and right carotids of the both groups were measured, and the average CA-IMT was calculated. The IMT-related risk factors were acquired for the univariate and multivariate analysis.

Results:

The bilateral carotid and average CA-IMTs of the disease group were significantly higher than the control group (P < 0.001). The multivariant gradual regressive analysis screened out two CA-IMT-related factors, namely the disease duration and the drug administration duration were positively correlated with the average CA-IMT. The epileptic patients with disease course of more than 3 years had much higher average CA-IMT than that of the epileptics with ≤3 years disease (P < 0.001). The average CA-IMT of the patients with VPA-administration duration >1 year was also higher than that of the patients with VPA-administration duration <1 year, while the difference was not statistically significant (P = 0.196).

Conclusions:

The average CA-IMT of the epileptic patients treated with VPA was higher than that of healthy people.

Stroke after adult-onset epilepsy: a population-based retrospective cohort study

BACKGROUND

Earlier studies indicate a higher risk of subsequent stroke in PWE aged ≥60. However, little is known of the incidence of subsequent stroke in people with epilepsy (PWE) aged 35 through 60. We determined the risk factors that increase the incidence of stroke following adult-onset epilepsy in a large statewide population over a 10-year period.

METHODS

South Carolina hospital discharge and emergency department (ED) data from 2000 to 2011 were used. The study was limited to persons aged ≥35years without prior stroke. Cases included patients diagnosed with epilepsy who were hospitalized or visited the ED. Controls were people with an isolated fracture of the lower extremity without any history of epilepsy or seizure disorders, presumed to approximate the health status of the general population. Epilepsy, fracture, stroke, and comorbid conditions were ascertained by diagnostic codes from health-care encounters. Only persons having stroke occurring ≥6months after the onset of epilepsy or after the first clinical encounter for controls were included. Cox proportional hazards modeling was performed to determine the risk of stroke.

RESULTS

There were 21,035 cases with epilepsy and 16,638 controls who met the inclusion criteria. Stroke incidence was 2.5 times higher following adult-onset epilepsy (6.3%) compared with controls (2.5%). After adjusting for comorbidities and other factors, cases with epilepsy showed a 60% higher risk of stroke (HR=1.6; 95% CI: 1.42-1.80) compared with controls. Nearly half of the strokes in cases with epilepsy occurred in those with first diagnosis between ages 35 and 55. Somatic comorbidities associated with increased risk of stroke were more prevalent in cases with epilepsy than controls yet similar in both groups with stroke. Risk of stroke increased with increasing age in both groups. However, the risk of stroke in cases with epilepsy increased faster and was similar to that in controls who were ≥10years older.

CONCLUSION

Adult-onset epilepsy at age 35 and older warrants consideration for occult cerebrovascular disease as an etiology of the epilepsy, which may also increase the risk of subsequent stroke. Somatic comorbidities frequently associated with epilepsy include comorbid conditions that share the same underlying pathology with stroke (i.e., hypertension, hyperlipidemia, myocardial infarction, diabetes, and arteriosclerosis). This increased risk of stroke in patients with adult-onset epilepsy should dictate the evaluation and management of stroke risk factors to prevent stroke.

Weight and fat distribution in patients taking valproate: a valproate-discordant gender-matched twin and sibling pair study

OBJECTIVES

Chronic treatment with valproate (VPA) is commonly associated with weight gain, which potentially has important health implications, in particular increased central fat distribution. We utilized a VPA-discordant same-sex, twin and matched sibling pair study design to primarily examine for differences in fat distribution between patients with epilepsy treated with VPA compared to their matched twin or sibling control. Weight, blood pressure, and leptin levels were assessed.

METHODS

Height, weight, waist and hip measurements, exercise, blood pressure (BP), and serum leptin levels were measured. Body composition was measured using dual-energy x-ray absorptiometry (DXA). Abdominal fat was expressed as a percentage of the abdominal region (AFat%); and of whole body fat (WBF); (AFat%WBF). Mean within-pair differences were assessed (VPA-user and nonuser). Restricted maximum likelihood (REML) linear mixed model analysis was fitted to examine associations of anthropometrics, zygosity, gender, menopausal status, VPA dose and duration, with weight and AFat%.

RESULTS

We studied 19 pairs of VPA-discordant, gender-matched (five male, 14 female) twins and siblings. Mean (standard deviation, SD) duration of therapy for VPA users was 11.0 (7.4) years. There were no statistically significant within-pair differences in age, height, weight, body mass index (BMI), BP, leptin level, WBF, AFat%, or AFat%WBF. For pairs in which VPA-user was treated for >11 years there were statistically significant mean within-pair differences in AFat%, (+7.1%, p = 0.03, n = 10 pairs), mean BP (+11.0 mm Hg, p = 0.006, n = 8 pairs); but not in AFat%WBF. VPA duration was positively associated with weight (estimate +0.98 kg/per year of VPA, p = 0.03); VPA treatment duration and dose were not significantly associated with AFat%.

SIGNIFICANCE

This study demonstrated a relationship between long-term VPA use and abdominal adiposity (AFat%), which could have significant health implications. We recommend ongoing monitoring of weight, BMI, and blood pressure for patients taking VPA.

Metabolic and endocrine effects of valproic acid chronic treatment

Treatment of epileptic patients with valproic acid (VPA) may be associated with substantial weight changes that may increase morbidity and impair adherence to the treatment regimen. VPA-induced weight gain seems to be associated with many metabolic disturbances; the most frequent are hyperinsulinemia and insulin resistance, hyperleptinemia and leptin resistance. Patients who gain weight during VPA therapy can develop dyslipidemia and metabolic syndrome that are associated with long-term vascular complications such as hypertension and atherosclerosis. Moreover, an elevation in the levels of uric acid and homocysteine, together with oxidative stress, may contribute to atherosclerotic risk in patients under long-term therapy with VPA. The aim of this review is to discuss the metabolic and endocrine effects of VPA chronic treatment in patients with epilepsy.

Risk of ischemic cerebrovascular and coronary events in adult users of anticonvulsant medications in routine care settings

Background

Older‐generation anticonvulsants that highly induce cytochrome P450 enzyme system activity produce metabolic abnormalities that may increase cardiovascular risk. The objective of this study was to evaluate the risk of ischemic cerebrovascular and coronary events in adult new users of anticonvulsants that highly induce cytochrome P450 activity compared with other anticonvulsant agents, as observed in a routine care setting.

Methods and Results

This was a cohort study of patients 40 to 64 years old from the HealthCore Integrated Research Database who had initiated an anticonvulsant medication between 2001 and 2006 and had no recorded major coronary or cerebrovascular condition in the 6 months before treatment initiation. Propensity score (PS) matching was used to evaluate ischemic cerebrovascular and coronary risk among anticonvulsant new users. High‐dimensional propensity score (hdPS)–matched analyses were used to confirm adjusted findings. The study identified 913 events in 166 031 unmatched new treatment episodes with anticonvulsant drugs. In a PS‐matched population of 22 864 treatment episodes, the rate ratio (RR) for ischemic coronary or cerebrovascular events associated with highly inducing agents versus other agents was 1.22 (95% CI, 0.90‐1.65). The RR moved to 0.99 (95% CI, 0.73‐1.33) with adjustment for hdPS matching (RR, 1.47; 95% CI, 0.95‐2.28 for cerebrovascular events; RR, 0.70; 95% CI, 0.47‐1.05 for coronary events).

Conclusions

In this exploratory analysis, there was no evidence of a consistent and statistically significant effect of initiating anticonvulsants that highly induce cytochrome P450 activity on ischemic coronary or cerebrovascular outcomes compared with other agents, given routine care utilization patterns.

Role of CYP2C9 polymorphism in phenytoin-related metabolic abnormalities and subclinical atherosclerosis in young adult epileptic patients

PURPOSE

We investigated the influence of the CYP2C9 polymorphism on the lipid profile, insulin resistance, and subclinical atherosclerosis in young epileptic patients.

METHODS

We performed a cross-sectional study to evaluate the association between CYP2C9 polymorphism and lipid profile, glucose homeostasis, and subclinical atherosclerosis in young epileptic patients via the ankle brachial index.

RESULTS

The frequencies of CYP2C9*1 (CYP2C9 wild type gene) and CYP2C9*3 (CYP2C9 polymorphism gene) were 75% and 25%, respectively. The mean serum total triglyceride and LDL levels were significantly higher in the wild type gene subjects than in the CYP 2C9 polymorphism gene subjects. Also, the CYP 2C9 polymorphism had marginally significant lower mean serum HDL levels than the wild type gene subjects. No patients with CYP 2C9 polymorphism gene had elevated fasting blood sugar, and insulin resistance was found in only 10 of the 75 subjects. The mean ABI was statistically significantly lower in the wild type subjects than in the CYP2C9 polymorphism gene subjects.

CONCLUSION

Our study indicates that young epileptic patients with the CYP2C9 polymorphism gene have a low risk of subclinical atherosclerosis.

The effect of vitamin B supplementation on homocysteine metabolism and clinical state of patients with chronic epilepsy treated with carbamazepine and valproic acid

PURPOSE

To investigate the influence of vitamin B supplementation on the plasma total homocysteine (p-tHcy), serum folate (s-FA), serum B12 (s-B12), and clinical state of patients with chronic epilepsy.

METHODS

Beck Depression Inventory (BDI) scores and p-tHcy, s-B12, and s-FA levels were assessed at baseline, after 1 year of supplementation (G1), and before and after 1 year of VPA or CBZ therapy (G2).

RESULTS

Eighty-one patients participated in the study: 51 patients with chronic epilepsy (G1) treated with carbamazepine (CBZ) or valproic acid (VPA), and 30 patients with newly diagnosed epilepsy (G2). At baseline, mean p-tHcy level was significantly higher in G1 than G2 (p=0.0001) with no significant differences in s-FA or s-B12 levels. p-tHcy level significantly decreased in CBZ-treated G1 patients (p=0.00002) after 1 year of supplementation and increased in G2 after 1 year of anti-epileptic drug (AED) therapy without supplementation. BDI scores in G1 decreased significantly after 1 year of supplementation (p=0.0001) and increased significantly in VPA-treated G2 patients after 1 year of AED therapy (p=0.02). The number of hyperhomocysteinemic patients significantly decreased in G1 after vitamin B supplementation (p=0.01) and increased in G2 (p=0.002). We also observed improved BDI scores and reduced seizure frequency in patients with chronic epilepsy.

CONCLUSIONS

These data support the hypothesis that AEDs play a major role in hyperhomocysteinemia development in patients with epilepsy. Adding folate and vitamin B12 to AED therapy is a safe and inexpensive way to reduce the risk of hyperhomocysteinemia.

Psychiatric co-morbidities and cardiovascular risk factors in people with lifetime history of epilepsy of an urban community

OBJECTIVES

Depression has been consistently reported in people with epilepsy. Several studies also suggest a higher burden of cardiovascular diseases. We therefore analysed psychosocial co-morbidity and cardiovascular risk factors in patients with a lifetime history of epilepsy in the PsyCoLaus study, a Swiss urban population-based assessment of mental health and cardiovascular risk factors in adults aged between 35 and 66 years.

PATIENTS AND METHODS

Among 3719 participants in the PsyCoLaus study, we retrospectively identified those reporting at least 2 unprovoked seizures, defined as epilepsy. These subjects were compared to all others regarding psychiatric, social, and cardiovascular risk factors data using uni- and multivariable assessments.

RESULTS

A significant higher need for social help (p<0.001) represented the only independent difference between 43 subjects with a history of epilepsy and 3676 controls, while a higher prevalence of psychiatric co-morbidities (p=0.015) and a lower prevalent marital status (p=0.01) were only significant on univariate analyses. Depression and cardio-vascular risk factors, as well as educational level and employment, were similar among the groups.

CONCLUSIONS

This analysis confirms an increased prevalence of psychosocial burden in subjects with a lifetime history of epilepsy; conversely, we did not find a higher cardiovascular risk. The specific urban and geographical location of our cohort and the age span of the studied population may account for the differences from previous studies.

Effects of epilepsy and selected antiepileptic drugs on risk of myocardial infarction, stroke, and death in patients with or without previous stroke: a nationwide cohort study

PURPOSE

Patients with epilepsy have increased morbidity and mortality. We evaluated the risk of myocardial infarction (MI), stroke, and death associated with epilepsy and examined if this risk was modified by treatment with antiepileptic drugs (AEDs).

METHODS

A cohort consisting of the Danish population was followed from January 1997 to December 2006. The risk of MI, stroke, cardiovascular death, and all-cause death associated with epilepsy was estimated by multivariable Cox proportional hazard models stratified for occurrence of previous stroke. AED use was determined at baseline, and risks associated with exposure to individual AEDs were examined in patients with epilepsy.

RESULTS

In patients without previous stroke, AED-treated epilepsy was associated with an increased risk of MI (hazard ratio [HR], 1.09; 95%CI, 1.00-1.19), stroke (HR, 2.22; 95%CI, 2.09-2.36), cardiovascular death (HR, 1.64; 95%CI, 1.57-1.72), and all-cause death (HR, 1.92; 95%CI, 1.86-1.97). Compared with carbamazepine monotherapy, valproate was associated with a decreased risk of MI (HR, 0.72; 95%CI, 0.59-0.87) and stroke (HR, 0.86; 95%CI, 0.76-0.96), oxcarbazepine and phenobarbital with increased risk of cardiovascular death (HR, 1.10; 95%CI, 1.02-1.19 and HR, 1.08; 95%CI, 1.00-1.17, respectively) and all-cause death (HR, 1.11; 95%CI, 1.05-1.18 and HR, 1.18; 95%CI, 1.12-1.25, respectively), and oxcarbazepine with increased risk of stroke (HR, 1.21; 95%CI, 1.10-1.34), in patients with epilepsy.

CONCLUSIONS

Patients with epilepsy exhibit increased risk of MI, stroke, cardiovascular death, and all-cause death. Compared with carbamazepine monotherapy, valproate may decrease, and oxcarbazepine and phenobarbital may increase, the risk of adverse cardiovascular events in these patients.

Effects of AEDs on biomarkers in people with epilepsy: CRP, HbA1c and eGFR

The standardised mortality ratio in people with epilepsy is raised to between 2 and 3 compared with the general population. Some biomarker levels, including higher C-reactive protein (CRP), higher glycosylated haemoglobin (HbA1c) and lower estimated glomerular filtration rate (eGFR), are associated with an increase risk of premature mortality. These biomarkers were measured in 125 people with refractory epilepsy to estimate the potential effect of antiepileptic drug (AED) use on these markers. Multiple regression analysis showed that valproate (N=50) use was associated with 55% lower mean CRP concentrations and higher mean eGFR values; and phenytoin (N=32) use with 4% lower mean HbA1c values. These potentially represent health markers improved by AEDs. On the other hand, lamotrigine use (N=48) was associated with 13% lower mean eGFR and this may represent a negative effect on a health marker. These preliminary observations clearly require further controlled studies ideally in people on AED monotherapy.

Hyperhomocysteinemia in epileptic patients on new antiepileptic drugs

PURPOSE

Older enzyme-inducing antiepileptic drugs (AEDs) may induce supraphysiologic plasma concentrations of total (t) homocysteine (Hcy). The aim of the present study was to investigate the effect of new AEDs on plasma tHcy levels.

METHODS

Patients 18-50 years of age, on AEDs monotherapy, with no other known cause of hyper-tHcy were enrolled. Plasma tHcy, folate, vitamin B(12), and AEDs levels were determined by standard high-performance liquid chromatography (HPLC) methods. Methylenetetrahydrofolate-reductase (MTHFR) polymorphisms were checked using Puregene genomic DNA purification system (Gentra, Celbio, Italy). A group of healthy volunteers matched for age and sex was taken as control.

RESULTS

Two hundred fifty-nine patients (151 on newer and 108 on older AEDs) and 231 controls were enrolled. Plasma tHcy levels were significantly higher [mean values, standard error (SE) 16.8, 0.4 vs. 9.1, 0.2 microm; physiologic range 5-13 microm] and folate lower (6.3, 0.1 vs. 9.3, 0.1 nm; normal > 6.8 nm) in patients compared to controls. Patients treated with oxcarbazepine, topiramate, carbamazepine, and phenobarbital exhibited mean plasma tHcy levels above the physiologic range [mean values (SE) 16 (0.8), 19.1 (0.8), 20.5 (1.0), and 18.5 (1.5) microm, respectively]. Conversely, normal tHcy concentrations were observed in the lamotrigine and levetiracetam groups [both 11.1 (0.5) microm].

DISCUSSION

Oxcarbazepine and topiramate might cause hyper-tHcy, most likely because of the capacity of these agents to induce the hepatic enzymes. Because literature data suggest that hyper-tHcy may contribute to the development of cerebrovascular diseases and brain atrophy, a supplement of folate can be considered in these patients to normalize plasma tHcy.

Assessing the link between omega-3 fatty acids, cardiac arrest, and sudden unexpected death in epilepsy

People with epilepsy may have abnormal cardiac function. This has been linked to a greater incidence of sudden unexpected death in epilepsy (SUDEP). In the present review, we assess the evidence linking cardiac failure to SUDEP, and propose the use of the maximal pentylenetetrazol seizure test to model SUDEP in animals to identify causal links between cardiac failure and SUDEP. We also discuss recent claims on the use of omega-3 polyunsaturated fatty acids to reduce the incidence of SUDEP because of their cardioprotective and anticonvulsant effects.