Cardiac troponin levels following monitored epileptic seizures

Emergent Management of Status Epilepticus

OBJECTIVE

Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control.

LATEST DEVELOPMENTS

Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option.

ESSENTIAL POINTS

As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.

Recurrent cerebellar ischemic infarctions and stereotyped peri-ictal sympathetic responses in a near-SUDEP patient with cardiovascular risk factors

We report a 60-year-old woman who presented to the emergency department after experiencing a witnessed unknown onset bilateral tonic clonic seizure (GTCS) that culminated in cardiac arrest. A neurology consultant uncovered a years-long history of frequent episodic staring followed by confusion and expressive aphasia, which strongly suggested that she suffered from epilepsy. Thus, her cardiac arrest and subsequent resuscitation met criteria for a near-sudden unexpected death in epilepsy (SUDEP) diagnosis. Serial bloodwork demonstrated transient troponin I elevations and leukocytoses, while a brain MRI revealed global cerebral anoxic injury and a small acute right cerebellar ischemic infarction. A review of her medical record uncovered a hospitalization sixteen months earlier for a likely GTCS whose workup showed similar troponin I elevations and leukocytoses, and surprisingly, a different small acute right cerebellar ischemic infarction in the same vascular territory. To our knowledge, this is the first report of subcortical ischemic infarctions occurring concurrently with GTCSs in a near-SUDEP patient. Aside from illustrating the key role of inpatient neurologists in the diagnosis of near-SUDEP, this manuscript discusses the potential significance of postictal ischemic infarctions, transient asymptomatic troponin elevations, and transient non-infectious leukocytoses in epilepsy patients with cardiovascular risk factors.

Impact of Cardiac Injury on the Clinical Outcome of Children with Convulsive Status Epilepticus

Objectives: the aim of this study was to determine the impact of cardiac injury on clinical profile, cardiac evaluation and outcome in patients hospitalized with convulsive status epilepticus (CSE). Materials and methods: this prospective observational study included 74 children with CSE. Cardiac injury was evaluated and defined using combination of cardiac troponin, electrocardiography (ECG) and echocardiography. Clinical outcome and mortality rates were compared in patients with and without cardiac injury. Results: A total of 74 patients with CSE were included in the study. Thirty-six (48.6%) patients demonstrated markers of cardiac injury. ECG changes occurred in 45.9% and echocardiographic signs of left ventricular systolic and diastolic dysfunction reported in 5.4% and 8.1%, respectively. The mean length of hospital stays and need for ICU admission were significantly higher in patients with cardiac injury compared to others. One third of patients with cardiac injury needed mechanical ventilation and this was significantly higher than patients without (p = 0.042). hypotension and/or shock developed in 25% of cardiac injury patients and most of them required inotropic support; this was significantly higher than others without markers of cardiac injury. The overall mortality in cardiac injury group was higher (13.9% vs. 2.6%); however, this difference was not statistically significant. Conclusion: Markers of cardiac injury were common and associated with poor clinical outcome and higher risk of mortality in patients with CSE, so extensive routine cardiovascular evaluation is essential in these patients.

Physiological and Biochemical Markers of the Sex-Specific Sensitivity to Epileptogenic Factors, Delayed Consequences of Seizures and Their Response to Vitamins B1 and B6 in a Rat Model

The disturbed metabolism of vitamins B1 or B6, which are essential for neurotransmitters homeostasis, may cause seizures. Our study aims at revealing therapeutic potential of vitamins B1 and B6 by estimating the short- and long-term effects of their combined administration with the seizure inductor pentylenetetrazole (PTZ). The PTZ dose dependence of a seizure and its parameters according to modified Racine’s scale, along with delayed physiological and biochemical consequences the next day after the seizure are assessed regarding sexual dimorphism in epilepsy. PTZ sensitivity is stronger in the female than the male rats. The next day after a seizure, sex differences in behavior and brain biochemistry arise. The induced sex differences in anxiety and locomotor activity correspond to the disappearance of sex differences in the brain aspartate and alanine, with appearance of those in glutamate and glutamine. PTZ decreases the brain malate dehydrogenase activity and urea in the males and the phenylalanine in the females. The administration of vitamins B1 and B6 24 h before PTZ delays a seizure in female rats only. This desensitization is not observed at short intervals (0.5–2 h) between the administration of the vitamins and PTZ. With the increasing interval, the pyridoxal kinase (PLK) activity in the female brain decreases, suggesting that the PLK downregulation by vitamins contributes to the desensitization. The delayed effects of vitamins and/or PTZ are mostly sex-specific and interacting. Our findings on the sex differences in sensitivity to epileptogenic factors, action of vitamins B1/B6 and associated biochemical events have medical implications.

Ictal and Interictal Cardiac Manifestations in Epilepsy. A Review of Their Relation With an Altered Central Control of Autonomic Functions and With the Risk of SUDEP

There is a complex interrelation between epilepsy and cardiac pathology, with both acute and long-term effects of seizures on the regulation of the cardiac rhythm and on the heart functioning. A specific issue is the potential relation between these cardiac manifestations and the risk of Sudden and Unexpected Death in Epilepsy (SUDEP), with unclear respective role of centrally-control ictal changes, long-term epilepsy-related dysregulation of the neurovegetative control and direct effects on the heart function. In the present review, we detailed available data about ictal cardiac changes, along with interictal cardiac manifestations associated with long-term functional and structural alterations of the heart. Pathophysiological mechanisms of these cardiac changes are discussed, with a specific focus on central mechanisms and the investigation of a possible deregulation of the central control of autonomic functions in addition to the role of catecholamine and hypoxemia on heart.

Cardiovascular complications of epileptic seizures

Seizure disorders are associated with multisystem complications. Cardiovascular complications account for a significant proportion of morbidity and mortality in these patients. As such, particular attention must be paid to the incidence of cardiovascular complications especially in populations at increased risk. The background for cardiac dysfunction lies in the interplay of genetic/molecular, autonomic, and iatrogenic factors that contribute to its onset. The purpose of this review was to summarize the state of literature in the last decade with regard to cardiac complications of epileptic seizures in order to increase awareness of short- and long-term debilitating cardiac complications as well as facilitate informed clinical decision-making. Taken together, the evidence provided in this review suggests that cardiac dysfunction following seizures should not be viewed as a separate entity but as an important complication of epileptic seizures. Appropriate cardiac therapy should be instituted in the postictal medical management of epileptic seizures. In acute states, postictal cardiac troponinemia (elevated cTn) should be worked up. Longer-term, monitoring for the development of cardiac structural and functional abnormalities is prudent.

cTnI, BNP and CRP profiling after seizures in patients with drug-resistant epilepsy

PURPOSE

To profile serum levels of high sensitivity Troponin I (hs-cTnI), B-Type Natriuretic Peptide (BNP), and high sensitivity C Reactive Protein (hs-CRP), after epileptic seizures in patients with focal drug-resistant epilepsy, relating the results to the revised SUDEP-7 inventory.

METHODS

We prospectively evaluated patients admitted to our Epilepsy Monitoring Unit. hs-cTnI, BNP, and hs-CRP were measured at admission and after the first seizure. The revised SUDEP-7 Risk Inventory was calculated. The statistical significance level was set at 0.05.

RESULTS

Fifty-eight patients were included (53.4 % female). The index seizure was a focal to bilateral tonic-clonic seizure (FBTCS) in 25.9 % of the patients, and 17.5 % had post-ictal generalized EEG suppression (PGES). After the seizure, 25.9 % had a significant (above 50 %) increase in hs-cTnI, 23.3 % in BNP, and 4.3 % in hs-CRP. About 40 % had cardiovascular risk factors (CRF), without known cardiac disease. The elevation of one biomarker did not compel the elevation of another. hs-cTnI increase was associated with FBTCS, PGES, longer seizures, maximal ictal heart rate, and HR change. Increases in BNP were associated with CRF. hs-CRP increase was associated with PGES. We found no significant association between SUDEP-7 and any biomarker increase.

SIGNIFICANCE

Several patients had increases in biomarkers of myocardial necrosis/dysfunction after seizures, without significant association with the SUDEP-7 inventory. Different patterns of biomarkers' elevations point to multifactorial pathophysiologies hypothetically associated with incipient myocardial lesions. A larger cohort with follow-up data could help to clarify the clinical relevance of these findings.

Heartbreakers-Cardiac Stress After Uncomplicated Generalized Convulsive Seizures

Blood Markers of Cardiac Stress After Generalized Convulsive Seizures. Nass RD, Motloch LJ, Paar V, Lichtenauer M, Baumann J, Zur B, Hoppe UC, Holdenrieder S, Elger CE, Surges R. Epilepsia. 2019;60(2):201-210. doi:10.1111/epi.14637. Epub 2019 Jan 15. PMID: 30645779 Objective: Generalized convulsive seizures (GCS) are associated with high demands on the cardiovascular system, thereby facilitating cardiac complications. To investigate occurrence, influencing factors, and extent of cardiac stress or injury, the alterations and time course of the latest generation of cardiac blood markers were investigated after documented GCS.

METHODS

Adult patients with refractory epilepsy who underwent video-electroencephalography monitoring along with simultaneous one-lead electrocardiography recordings were included. Cardiac biomarkers (cardiac troponin I [cTNI]; high-sensitivity troponin T [hsTNT]; N-terminal prohormone of brain natriuretic peptide; copeptin; suppression of tumorigenicity-2 [SST-2]; growth differentiation factor 15, [GDF-15]; soluble urokinase plasminogen activator receptor [suPAR]; and heart-type fatty acid binding protein [HFABP]) and catecholamines were measured at inclusion and at different time points after GCS. Peri-ictal cardiac properties were assessed by analyzing heart rate (HR), HR variability (HRV), and corrected QT intervals (QTc).

RESULTS

Thirty-six GCS (6 generalized-onset tonic-clonic seizures and 30 focal to bilateral tonic-clonic seizures) were recorded in 30 patients without a history of cardiac or renal disease. Postictal catecholamine levels were elevated more than 2-fold. A concomitant increase in HR and QTc, as well as a decrease in HRV, was observed. Elevations of cTNI and hsTNT were found in 3 (10%) of 30 patients and 6 (26%) of 23 patients, respectively, which were associated with higher dopamine levels. Copeptin was increased considerably after most GCS, whereas SST-2, HFABP, and GDF-15 displayed only subtle variations, and suPAR was unaltered in the postictal period. Cardiac symptoms did not occur in any patient.

SIGNIFICANCE

The use of more sensitive biomarkers such as hsTNT suggests that signs of cardiac stress occur in about 25% of the patients with GCS without apparent clinical symptoms. Soluble urokinase plasminogen activator receptor may indicate clinically relevant troponin elevations. Copeptin could help to diagnose GCS but specificity needs to be tested.

Blood markers of cardiac stress after generalized convulsive seizures

OBJECTIVE

Generalized convulsive seizures (GCS) are associated with high demands on the cardiovascular system, thereby facilitating cardiac complications. To investigate occurrence, influencing factors, and extent of cardiac stress or injury, the alterations and time course of the latest generation of cardiac blood markers were investigated after documented GCS.

METHODS

Adult patients with refractory epilepsy who underwent video-electroencephalography (EEG) monitoring along with simultaneous one-lead electrocardiography (ECG) recordings were included. Cardiac biomarkers (cardiac troponin I [cTNI]; high-sensitive troponin T [hsTNT]; N-terminal prohormone of brain natriuretic peptide [NT-proBNP]; copeptin; suppression of tumorigenicity-2 [SST-2]; growth differentiation factor 15, [GDF-15]; soluble urokinase plasminogen activator receptor [suPAR]; and heart-type fatty acid binding protein [HFABP]) and catecholamines were measured at inclusion and at different time points after GCS. Periictal cardiac properties were assessed by analyzing heart rate (HR), HR variability (HRV), and corrected QT intervals(QTc).

RESULTS

Thirty-six GCS (6 generalized-onset tonic-clonic seizures and 30 focal to bilateral tonic-clonic seizures) were recorded in 30 patients without a history of cardiac or renal disease. Postictal catecholamine levels were elevated more than twofold. A concomitant increase in HR and QTc, as well as a decrease in HRV, was observed. Elevations of cTNI and hsTNT were found in 3 of 30 patients (10%) and 6 of 23 patients (26%), respectively, which were associated with higher dopamine levels. Copeptin was increased considerably after most GCS, whereas SST-2, HFABP, and GDF-15 displayed only subtle variations, and suPAR was unaltered in the postictal period. Cardiac symptoms did not occur in any patient.

SIGNIFICANCE

The use of more sensitive biomarkers such as hsTNT suggests that signs of cardiac stress occur in about 25% of the patients with GCS without apparent clinical symptoms. SuPAR may indicate clinically relevant troponin elevations. Copeptin could help to diagnose GCS, but specificity needs to be tested.

Closed-loop Neuropharmacology for Epilepsy: Distant Dream or Future Reality?

Epilepsy is considered the most frequent severe neurological condition but most patients treated with medication become seizure free. The management of treatment, however, is highly empirical, mainly relying on observation. A closed-loop therapy for epilepsy would be very valuable for more efficient treatment regimens. Here we discuss monitoring treatment (therapeutic drug monitoring) and the potential developments in this field, as well as providing a review of potential biomarkers that could be used to monitor the disease activity. Finally, we consider the pharmacogenetic input in epilepsy treatment.

Pilocarpine-Induced Status Epilepticus Is Associated with P-Glycoprotein Induction in Cardiomyocytes, Electrocardiographic Changes, and Sudden Death

Sudden unexpected death in epilepsy (SUDEP) is the major cause of death in those patients suffering from refractory epilepsy (RE), with a 24-fold higher risk relative to the normal population. SUDEP risk increases with seizure frequency and/or seizure-duration as in RE and Status Epilepticus (SE). P-glycoprotein (P-gp), the product of the multidrug resistant ABCB1-MDR-1 gene, is a detoxifying pump that extrudes drugs out of the cells and can confer pharmacoresistance to the expressing cells. Neurons and cardiomyocytes normally do not express P-gp, however, it is overexpressed in the brain of patients or in experimental models of RE and SE. P-gp was also detected after brain or cardiac hypoxia. We have previously demonstrated that repetitive pentylenetetrazole (PTZ)-induced seizures increase P-gp expression in the brain, which is associated with membrane depolarization in the hippocampus, and in the heart, which is associated with fatal SE. SE can produce hypoxic-ischemic altered cardiac rhythm (HIACR) and severe arrhythmias, and both are related with SUDEP. Here, we investigate whether SE induces the expression of hypoxia-inducible transcription factor (HIF)-1α and P-gp in cardiomyocytes, which is associated with altered heart rhythm, and if these changes are related with the spontaneous death rate. SE was induced in Wistar rats once a week for 3 weeks, by lithium-pilocarpine-paradigm. Electrocardiograms, HIF-1α, and P-gp expression in cardiomyocytes, were evaluated in basal conditions and 72 h after SE. All spontaneous deaths occurred 48 h after each SE was registered. We observed that repeated SE induced HIF-1α and P-gp expression in cardiomyocytes, electrocardiographic (ECG) changes, and a high rate of spontaneous death. Our results suggest that the highly accumulated burden of convulsive stress results in a hypoxic heart insult, where P-gp expression may play a depolarizing role in cardiomyocyte membranes and in the development of the ECG changes, such as QT interval prolongation, that could be related with SUDEP. We postulate that this mechanism could explain, in part, the higher SUDEP risk in patients with RE or SE.

Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures

Background

Generalized tonic-clonic seizures (GTCS) frequently lead to emergency inpatient referrals. Laboratory blood values are routinely performed on admission to detect underlying causes and metabolic or cardiac complications. Our goal was to assess the nature and frequency of complications occurring in association with GTCS.

Methods

We retrospectively extracted data from emergency protocols and discharge letters of adult patients admitted to the Department of Epileptology between 01/2010 and 06/2015. Inclusion criteria were diagnosis of GTCS and admission via emergency services. Exclusion criteria were status epilepticus prior to admission to hospital and non-generalized seizures.

Results

A total of 223 patients (of 986 screened cases) were included. Overall, 1.8% required intubation while 1.3% had less severe respiratory problems. In 5.6% of patients, a transient hypoxemia was measured. Hypertensive urgencies affected 7.8% of the patients, sinus tachycardia occurred in 41.2%. Troponin I (cTNI) was determined in 75 patients and was increased in 12% of these cases. Occurrence of elevated cTNI levels was significantly correlated with patient’s age. Four patients were diagnosed with NSTEMI and one patient with STEMI. Creatine kinase (CK) was increased in 59.4% of the patients, with <5-fold increases in 47%, <10-fold in 5.8% and >10-fold increases in 4.3%. Rhabdomyolysis with an >50 fold increase in CK was detected in 1.9% of patients. Prolonged disturbances of consciousness affected 5% of cases while agitation, delirium, and psychotic episodes occurred in 6.3%. Minor traumatic injuries affected 45.7% of patients.

Conclusions

Troponin elevations in association with GTCS are one of the more common complications after emergency admissions especially in older patients. In our selected patient population, serious complications such as intracranial hemorrhage, myocardial infarction and acute renal failure occurred in <1% of GTCS only.

The heart of epilepsy: Current views and future concepts

Cardiovascular (CV) comorbidities are common in people with epilepsy. Several mechanisms explain why these conditions tend to co-exist including causal associations, shared risk factors and those resulting from epilepsy or its treatment. Various arrhythmias occurring during and after seizures have been described. Ictal asystole is the most common cause. The converse phenomenon, arrhythmias causing seizures, appears extremely rare and has only been reported in children following cardioinihibitory syncope. Arrhythmias in epilepsy may not only result from seizure activity but also from a shared genetic susceptibility. Various cardiac and epilepsy genes could be implicated but firm evidence is still lacking. Several antiepileptic drugs (AEDs) triggering conduction abnormalities can also explain the co-existence of arrhythmias in epilepsy. Epidemiological studies have consistently shown that people with epilepsy have a higher prevalence of structural cardiac disease and a poorer CV risk profile than those without epilepsy. Shared CV risk factors, genetics and etiological factors can account for a significant part of the relationship between epilepsy and structural cardiac disease. Seizure activity may cause transient myocardial ischaemia and the Takotsubo syndrome. Additionally, certain AEDs may themselves negatively affect CV risk profile in epilepsy. Here we discuss the fascinating borderland of epilepsy and cardiovascular conditions. The review focuses on epidemiology, clinical presentations and possible mechanisms for shared pathophysiology. It concludes with a discussion of future developments and a call for validated screening instruments and guidelines aiding the early identification and treatment of CV comorbidity in epilepsy.

Heart-type fatty acid-binding protein as a predictor of cardiac ischemia in intractable seizures in children

BACKGROUND

Children with intractable epilepsy have chronic dysfunction of the autonomic nervous system causing myocardial ischemia. Heart-type fatty acid-binding protein (H-FABP) is a sensitive biomarker for myocardial ischemia.

AIMS

We aimed to evaluate serum levels of H-FABP during seizures compared to their interictal levels and healthy controls and changes in heart rate (HR) and HR variability (HRV) in epileptic children with intractable seizures.

MATERIALS AND METHODS

We included 30 epileptic seizures in 25 children with intractable epilepsy and 30 matched controls. They were subjected to video-electroencephalography monitoring simultaneously with Holter electrocardiogram and measurement of H-FABP.

RESULTS

Mean serum levels of H-FABP were increased significantly in patients either in the ictal or interictal periods compared to that in the controls (P < 0.001 and P< 0.01, respectively). There is no significant difference in serum levels of the H-FABP in the ictal and interictal periods. The basal time domain measures of HRV were significantly lower in the patient group compared to the control group.

CONCLUSION

H-FABP might suggest a degree of myocardial ischemia in intractable epilepsy. HRV is impaired in patients with refractory seizures.

Cardiac and autonomic mechanisms contributing to SUDEP

Sudden unexpected death in epilepsy is likely caused by a cascade of events affecting the vegetative nervous system leading to cardiorespiratory failure and death. Multiple genetic, electrophysiological, neurochemical, and pharmacological cardiac alterations have been associated with epilepsy, which can affect autonomic regulation of the heart and predispose patients to sudden unexpected death in epilepsy. These cardiac and autonomic changes are more frequently seen in patients with longstanding and medication refractory epilepsy and may be a prerequisite for sudden unexpected death in epilepsy. Cardiac changes are also observed within the immediate periictal period in patients with and without preexisting cardiac pathology and could be the tipping point in the cascade of events compromising autonomic, respiratory, and cardiac function during an epileptic convulsion. Better understanding if and how these cardiac alterations can make a particular individual with epilepsy more susceptible to sudden unexpected death in epilepsy will hopefully lead us to more effective preventative strategies.

Continuous cardiac troponin I release in Fabry disease

BACKGROUND

Fabry disease (FD) is a rare lysosomal storage disorder also affecting the heart. The aims of this study were to determine the frequency of cardiac troponin I (cTNI) elevation, a sensitive parameter reflecting myocardial damage, in a smaller cohort of FD-patients, and to analyze whether persistent cTNI can be a suitable biomarker to assess cardiac dysfunction in FD.

METHODS

cTNI values were determined at least twice per year in 14 FD-patients (6 males and 8 females) regularly followed-up in our centre. The data were related to other parameters of heart function including cardiac magnetic resonance imaging (cMRI).

RESULTS

Three patients (21%) without specific vascular risk factors other than FD had persistent cTNI-elevations (range 0.05-0.71 ng/ml, normal: <0.01). cMRI disclosed late gadolinium enhancement (LGE) in all three individuals with cTNI values ≥0.01, while none of the 11 patients with cTNI <0.01 showed a pathological enhancement (p<0.01). Two subjects with increased cTNI-values underwent coronary angiography, excluding relevant stenoses. A myocardial biopsy performed in one during this procedure demonstrated substantial accumulation of globotriaosylceramide (Gb3) in cardiomyocytes.

CONCLUSION

Continuous cTNI elevation seems to occur in a substantial proportion of patients with FD. The high accordance with LGE, reflecting cardiac dysfunction, suggests that cTNI-elevation can be a useful laboratory parameter for assessing myocardial damage in FD.

Effect of antiepilepsy drug therapy on ventricular function in children with epilepsy: a tissue Doppler imaging study

Impaired cardiac myocardial function may contribute to the risk for sudden unexpected death of a patient with epilepsy. This study aimed to investigate the effect of antiepilepsy drugs (AEDs) on cardiac function in pediatric epileptic patients using standard and tissue Doppler imaging (TDI) echocardiography. This hospital-based, prospective cross-sectional study investigated 52 epileptic children (mean age 9.3 ± 3.1 years) treated with AEDs (duration 2.4-10.0 years) and 36 healthy children (mean age 9.5 ± 4.0 years). In the epilepsy group, standard echocardiography showed increased left ventricular (LV) end-diastolic and end-systolic diameters, an increased LV mass index, and preserved ejection fraction. The patients also exhibited increased mitral peak A-wave velocity and mitral E-wave deceleration time as well as a decreased mitral E/A ratio. The E/Em ratio was significantly higher in the epilepsy group (5.6 ± 1.2) than in the control group (5.2 ± 1.1) (p = 0.016). In the epilepsy group, TDI showed an increased isovolumetric relaxation time and myocardial performance index (MPI). It also exhibited decreased early diastolic velocity (Em) and a decreased mitral annular displacement index in these patients. There were positive correlations between the LV lateral wall MPI (r = 0.231), septal MPI (r = 0.223), and LV mass index (p < 0.05) but no correlation with the duration of AED treatment. The authors detected subclinical ventricular dysfunction associated with AEDs at a preclinical stage. They suggest that TDI can be useful for determining the short- and long-term cardiac effects of AEDs.

Serum levels of cardiac troponin I in patients with status epilepticus and healthy cardiovascular system

BACKGROUND AND AIMS

Status epilepticus (SE) is accompanied by acute and intense activation of the sympathetic nervous system, which might result in myocyte damage. However, there is insufficient evidence to assess cardiac biomarkers in SE patients. As a highly specific and sensitive biomarker of acute myocardial infarction, serum concentration of cardiac troponin I (cTnI) has been assessed in this study in a sample of SE patients without evidence of previous cardiovascular diseases.

METHODS

In this analytical cross-sectional study, a total number of 30 patients with SE and no history of baseline cardiovascular disorders, aged between 12 and 60 years have been evaluated. Baseline, demographic characteristics and laboratory measurements including cTnI, creatine kinase (CPK) and CPK-MB were recorded for all of patients. cTnI was quantified using ELISA method with the precision of 0.01 ng/mL.

RESULTS

All cases had a cardiac troponin level <0.01 ng/mL except for one 60- year-old female with a history of seizure 3 years prior. The last seizure was 60 days prior and the patient had a reported cTnI level as 0.04 ng/mL, within normal limits. The mean serum levels of CPK and CK-MB were 202.20 (SD = 14.46) μg/l and 14.54 (SD = 1.49) ng/mL, respectively.

CONCLUSIONS

This investigation is one of the few to evaluate serum concentration of cTnI in generalized convulsive SE patients where no detectable elevation was observed in serum concentration of cTnI following SE episode. However, it is very important to take into account that all recruited SE patients included in this study had a healthy cardiovascular system.

Cardiac Troponin I elevation after epileptic seizure

Background

Cardiac troponin-I (cTNI) is highly specific biomarker to prove myocardial damage, e.g. in acute coronary syndrome (ACS). However, it occurs in other conditions as well. We therefore analysed cTNI increase in patients after generalized convulsive seizure.

Methods

Consecutive patients admitted with acute generalized convulsive seizure were included in case of cTNI measurement on admission. Among 898 selected cases, 53 patients were referred secondary to our department; in 845 cases cTNI measurements on admission were available. In case of multiple admissions (81 cases), only the first admission entered our analysis. In 17 patients elevated cTNI was determined due to ACS; in one patient a myocarditis was found. 5 patients suffered of relevant renal insufficiency. Finally 741 patients were included in the analysis. A cTNI cut-off level of ≥ 0.1 ng/ml was considered. Factors associated with a cTNI increase were analysed subsequently.

Results

The mean age of the study population (n = 741) was 47.8 years (SD ± 18.6), 40.9% were female. In 50 patients (6.7%) a cTNI elevation of unknown origin was found; no obvious cardiac involvement could be detected in these patients who all remained asymptomatic. A vascular risk profile (including at least hypertension, hypercholesterolemia or diabetes) (OR = 3.62; CI: 1.59 to 8.21; p = 0.001) and elevated creatine kinase on admission (OR = 2.36; CI: 1.26 to 4.39; p = 0.002) were independent factors associated with cTNI release.

Conclusion

cTNI release occurs in patients with generalized convulsive seizure with predominance in patients with vascular risk profile.

Type 2 myocardial infarction following generalized tonic-clonic seizure

Myocardial infarction is diagnosed when blood levels of biomarkers are increased in the clinical setting of acute myocardial ischemia. Among the biomarkers, troponin I is the preferred biomarker indicative of myocardial necrosis. It is tissue specific for the heart. Myocardial infarction is rarely reported following seizure. We report a case of elevated troponin I in a patient after an episode of generalized tonic-clonic seizure. The diagnosis was type 2 myocardial infarction.

Cardiac arrhythmias and sudden unexpected death in epilepsy (SUDEP)

Sudden unexpected death in epilepsy (SUDEP) is a major clinical problem in epilepsy patients in the United States, especially those with chronic, uncontrolled epilepsy. Several pathophysiological events contributing to SUDEP include cardiac arrhythmias, respiratory dysfunction, and dysregulation of systemic or cerebral circulation. There is a significant body of literature suggesting the prominent role of cardiac arrhythmias in the pathogenesis of SUDEP. There is evidence to say that long-standing epilepsy can cause physiological and anatomical autonomic instability resulting in life-threatening arrhythmias. Tachyarrhythmias, bradyarrhythmias, and asystole are commonly seen during ictal, interictal, and postictal phase in epilepsy patients. It is unclear if these rhythm disturbances need attention as some of them may be just benign findings. Evidence regarding prolonged cardiovascular monitoring or the benefit of pacemaker/defibrillator implantation for primary or secondary prevention in epilepsy patients is limited. Awareness regarding pathophysiology, cardiac effects, and management options of SUDEP will become useful in guiding more individualized treatment in the near future. (PACE 2011; 1-8).

Persistent increase in cardiac troponin I in Fabry disease: a case report

BACKGROUND

Hypertrophic cardiomyopathy is a frequent manifestation in Fabry disease (FD) - an X-linked lysosomal storage disorder caused by reduced activity of the enzyme α-galactosidase A. In FD an elevation of specific cardiac biomarkers, such as cardiac troponin I (cTNI) has been reported in case of clinical manifestation suggestive of myocardial ischemia. In diagnosing acute myocardial infarction cTNI is considered the most reliable parameter.

CASE PRESENTATION

In the referred case we present a 59 years old female patient with the diagnosis of FD presenting with persistently increased cTNI level (lowest value 0.46 ng/ml, highest value 0.69 ng/ml; normal range <0.05 ng/ml) over a period of 5 months lacking cardiac clinical signs. Since renal insufficiency did not explain the degree of cTNI elevation, this was interpreted as a result of cardiac involvement in FD. Cardiac MRI showed marked left ventricular hypertrophy and focal late Gadolinium enhancement.

CONCLUSIONS

Our case report demonstrates a persistent cTNI release in FD with cardiac involvement. Proving the persistence in a symptom free interval, it might be related to a direct damage of myocytes. In FD cTNI could serve as a beneficial long term parameter providing new perspectives for screening strategies.

Cardiac changes in epilepsy

Epilepsy and seizures can have a dramatic effect on the autonomic nervous system by involvement of the central autonomic control centers. The peri-ictal changes can lead to short-term alteration of cardiac functions in patients with seizures, and are partially hemispheric specific. Changes in heart rhythm, conduction and even subtle signs of ischemia have been reported. Ictal asystole and the lock-step phenomenon during seizures play an important role in the pathophysiology of SUDEP. In patients with longlasting epilepsy and multiple seizures, there are now convincing arguments for a chronic dysfunction of the autonomic nervous system. In this sense, heart rate variability can be considered as a biomarker of autonomic dysfunction in epilepsy. Early recognition of these short- and long-term cardiac effects will become useful in predicting seizures and in guiding more individualized treatment in the near future.

Prevention and reversal by cocaine esterase of cocaine-induced cardiovascular effects in rats

The present study is the first to utilize bacterial cocaine esterase (CocE) to increase elimination of a lethal dose of cocaine and evaluate its cardioprotective effects. Rats received one of 5 treatments: CocE 1 min after saline; CocE 1 min after a lethal i.p. dose of cocaine; saline 1 min after a lethal i.p. dose of cocaine; CocE immediately after observing a cocaine-induced convulsion; and CocE 1 min after observing a cocaine-induced convulsion. Measures were taken of ECG, blood pressure, and cardiac troponin I (cTnI). The specificity of CocE against cocaine was determined by evaluating its actions against the cocaine analogue, WIN-35,065-2, which lacks an ester attack point for CocE. In addition, CocE's effects were compared with those of midazolam, a benzodiazepine often used to manage cocaine overdose. Whereas CocE alone had negligible cardiovascular effects, it blocked or reversed cocaine-induced QRS complex widening, increased QTc interval, ST elevation, bradycardia, and hypertension. When administered 1 min after cocaine, CocE inhibited myocardial damage; however, administered 1 min after a cocaine-induced convulsion (approximately 40s before cocaine-induced death), CocE did not block cTnI release, but did restore cardiac function. Midazolam blocked convulsions, but exhibited inadequate protection against cocaine-induced cardiotoxicity. The majority of rats given cocaine plus midazolam died. CocE did not prevent the lethal cardiovascular effects of WIN-35,065-2. In all likelihood, CocE rapidly and specifically reduced the body burden of cocaine and inhibited or reversed the cardiovascular consequences of high-dose cocaine. These results support CocE as a potential therapeutic avenue in cocaine overdose.

Sudden unexpected death in epilepsy: risk factors and potential pathomechanisms

Sudden unexpected death in epilepsy (SUDEP) is the most common cause of death directly related to epilepsy, and most frequently occurs in people with chronic epilepsy. The main risk factors for SUDEP are associated with poorly controlled seizures, suggesting that most cases of SUDEP are seizure-related events. Dysregulation in cardiac and respiratory physiology, dysfunction in systemic and cerebral circulation physiology, and seizure-induced hormonal and metabolic changes might all contribute to SUDEP. Cardiac factors include bradyarrhythmias and asystole, as well as tachyarrhythmias and alterations to cardiac repolarization. Altered electrolytes and blood pH, as well as the release of catecholamines, modulate cardiac excitability and might facilitate arrhythmias. Respiratory symptoms are not uncommon during seizures and comprise central apnea or bradypnea, and, less frequently, obstruction of the airways and neurogenic pulmonary edema. Alterations to autonomic function, such as a reduction in heart rate variability or disturbed baroreflex sensitivity, can impair the body's capacity to cope with challenging situations of elevated stress, such as seizures. Here, we summarize data on the incidence of and risk factors for SUDEP, and consider the pathophysiological aspects of chronic epilepsy that might lead to sudden death. We suggest that SUDEP is caused by the fatal coexistence of several predisposing and triggering factors.

Cardiac effects of seizures

Seizures frequently affect the heart rate and rhythm. In most cases, seizure-related cardiac changes are transient and do not appear to cause clinically significant abnormalities for the patient. Great interest in this area of research has been generated because of a possible connection with sudden unexpected death in epilepsy (SUDEP). While there are clear, but rare complications from seizure-related cardiac arrhythmias, such as ictal asystole that causes syncope, the overall risk of seizures on cardiac status and any potential connection between seizures and SUDEP still remain uncertain.

Epilepsy and hormones: a critical review

Especially during growth, puberty, and menopause, profound changes including maturation of the growth hormone, sex steroid, and thyroid axes, as well as alterations in lipid homeostasis, cardiac integrity, and other enzyme systems, occur physiologically. With epilepsy, however, things are often changing, and there may be a complicated interplay between hormones, epilepsy, and antiepileptic drugs (AEDs). On the one hand, epilepsy itself possibly elicits diverse effects on different enzyme systems including sex steroids, the neuro-cardio-endocrine axis, and bone health. On the other hand, different AEDs are known to induce neuroendocrine changes (e.g., lipid metabolism) that may have deleterious consequences on health and well-being later in life. It is important for physicians and epileptologists to have in mind and to consider the endocrine effects induced by epilepsy itself or by a certain AED when starting antiepileptic therapy, especially when it is expected that long-term treatment will be necessary.

Alterações cardiovasculares e morte súbita nas epilepsias

A epilepsia é a doença neurológica crônica grave mais comum e o fenômeno da morte súbita nas epilepsias (SUDEP) é a causa direta de morte mais importante nesta doença. A causa da SUDEP ainda é desconhecida, no entanto, alterações cardiovasculares têm sido sugeridas como os mecanismos mais comuns. Sendo assim, enfatizamos nesta revisão a relação existente entre SUDEP e alterações cardiovasculares.

Níveis cardíacos de troponina I em pacientes com epilepsia do lobo temporal refratária após cortico-amígdalo-hipocampectomia

OBJETIVOS: A morte súbita em epilepsia (SUDEP) é a principal causa de morte entre os pacientes com epilepsia. Alterações morfológicas e funcionais do coração estão relacionadas com a SUDEP. Nesse sentido, o objetivo deste estudo foi avaliar a concentração de troponina I, um importante marcador de lesão do miocárdio, em pacientes com epilepsia do lobo temporal de difícil controle e que foram submetidos à ressecção cirúrgica e que não obtiveram sucesso com esta abordagem terapêutica. METODOLOGIA: Onze pacientes participaram do estudo e todos continuaram a apresentar crises após o tratamento cirúrgico. Os valores de troponina I indicativos de lesão seriam aqueles maiores de 1 ng/ml e o valor mínimo detectável pelo kit utilizado em nosso estudo foi de 0,15 ng/ml. RESULTADOS: Apenas três pacientes apresentaram níveis de troponina I detectáveis. Em relação aos níveis detectáveis de troponina I, não encontramos nenhuma relação com sexo, idade e lateralidade da lesão. CONCLUSÕES: APESAr de não termos encontrado resultados positivos em nosso estudo, o papel do coração na SUDEP não pode ser descartado, já que algumas lesões, embora não sendo capazes de alterar os níveis séricos de troponina I, podem ser suficientes na gênese de focos arritmogênicos.

Elevations of troponin in patients with epileptic seizures? What do they mean?

Cardiac troponin concentrations are important sensitive and specific markers for myocardial injury in clinical medicine. Troponin (TnT) elevations have been noted in some series in the setting of acute neurologic disease. We have previously reported that solitary seizures do not evoke elevations in TnT. The importance of this negative finding is exemplified by a patient who arrived at our clinic following a new onset seizure and in whom the cardiac TnT level was observed to rise. Triggered by this observation and by the knowledge that seizures alone would not do this, a subsequent targeted cardiologic workup documented what was believed to be an extension of a previously unrecognized myocardial infarction, with a seizure as its clinical presentation. Elevations of troponin should not be considered to be due to isolated seizures. This case illustrates the importance of having data concerning the response of troponin in various emergency and clinical situations.

Finding the missing link between ictal bradyarrhythmia, ictal asystole, and sudden unexpected death in epilepsy

Basic science studies of the human brain have supported the cortical representation of cardiovascular responses, including heart rate variability. Clinical observations of ictal bradyarrhythmia may be mechanistically explained by the influence of the central autonomic network, although the localization and lateralization issues need to be considered in the light of patterns of seizure spread, hand dominance, and presence of lesions. Ictal bradyarrhythmia also offers a mechanistic explanation of sudden unexpected death in epilepsy (SUDEP), though it may explain only some but not all cases of SUDEP. The missing links are (1) clinical evidence of common factors shared by patients with ictal bradyarrhythmia and patients who die from SUDEP, (2) evidence of arrhythmia as a risk factor for SUDEP from epidemiological studies, and, (3) determination of the importance of ictal bradyarrhythmia in SUDEP with respect to other proposed mechanisms including apnea and intrinsic cardiac abnormalities. There remains a need to review the seizure mechanisms in cases of SUDEP and to step up the amount of concurrent ECG/intracranial EEG analysis in both ictal bradyarrhythmia and SUDEP cases.

Sudden unexpected death in epilepsy: from mechanisms to prevention

PURPOSE OF REVIEW

To discuss the pathophysiology and potential prevention of sudden unexpected death in epilepsy.

RECENT FINDINGS

Long-term electrocardiogram monitoring over several months has detected ictal asystole in three out of 20 (15%) patients with refractory epilepsy, suggesting that high-risk ictal arrhythmias occur in a greater proportion of patients with refractory epilepsy than previously thought. In case-control studies, sudden unexpected death in epilepsy was found to be associated with frequent generalized tonic-clonic seizures and greater ictal maximal heart rate, especially during nocturnal attacks. Conversely, supervision at night was associated with a lower risk of occurrence. The impact of epilepsy surgery on the risk of death and sudden unexpected death in epilepsy remains unclear, with comparable long-term survival in an epilepsy surgery cohort compared with a matched population of patients with refractory epilepsy who did not undergo surgery. Previous results may have been partly confounded by the association observed between preoperative decreased heart rate variability and poor postoperative seizure outcome.

SUMMARY

Ictal arrhythmias may represent a more prevalent cause of sudden unexpected death in epilepsy than previously thought. No clear recommendations have emerged from the literature regarding the most appropriate therapeutic strategies to prevent the event, apart from the supervision at night of patients with refractory epilepsy.

Cardiovascular manifestations of autonomic epilepsy

Cardiovascular autonomic manifestations of seizures occur frequently in the epileptic population. Common manifestations include alterations in heart rate and rhythm, blood pressure, ECG changes and chest pain. The neuroanatomical and neurophysiological underpinnings of these autonomic manifestations are not been fully elucidated. Diagnostic confusion may arise when ictal symptoms are confined to the autonomic nervous system; conversely, such symptoms in association with convulsions or altered consciousness are more readily recognized as concomitant ictal features. Awareness of the diverse autonomic manifestations of epilepsy will enhance diagnosis and lead to more effective therapy of these patients.

Seizures and syncope: anatomic basis and diagnostic considerations

Although pathophysiologically distinct, syncope and seizures share clinical characteristics which may make diagnosis difficult. Adding to diagnostic complexity are the facts that seizures and syncope may coexist in the same patient, syncope may be associated with seizure-like motor manifestations, and seizures may be complicated by cardiac arrhythmia and syncope. Combined EEG/ECG telemetry is sometimes necessary to establish the correct diagnosis. These techniques also provide an opportunity to study the role of certain cortical regions in the modulation of cardiac function. There is an increasing understanding of the central autonomic pathways involved in the genesis of the cardiovascular changes that occur during epileptic seizures. This article reviews the use of EEG/ECG telemetry in the evaluation of syncope and seizures, and the neuroanatomic circuitry involved in the production of the cardiovascular manifestations of seizures.

Is there progress in the autopsy diagnosis of sudden unexpected death in adults?

Sudden death is now currently described as natural unexpected death occurring within 1h of new symptoms. Most studies on the subject focused on cardiac causes of death because most of the cases are related to cardiovascular disease, especially coronary artery disease. The incidence of sudden death varies largely as a function of coronary heart disease prevalence and is underestimated. Although cardiac causes are the leading cause of sudden death, the exact incidence of the other causes is not well established because in some countries, many sudden deaths are not autopsied. Many risk factors of sudden cardiac death are identified: age, gender, heredity factors such as malignant mutations, left ventricular hypertrophy and left ventricle function impairment. The role of the police surgeon in the investigation of sudden death is very important. This investigation requires the interrogation of witnesses and of the family members of the deceased. The interrogation of physicians of the rescue team who attempted resuscitation is also useful. Recent symptoms before death and past medical history must be searched. Other sudden deaths in the family must be noted. The distinction between sudden death at rest and during effort is very important because some lethal arrhythmia are triggered by catecholamines during stressful activity. The type of drugs taken by the deceased may indicate a particular disease linked with sudden death. Sudden death in the young always requires systematic forensic autopsy performed by at least one forensic pathologist. According to recent autopsy studies, coronary artery disease is still the major cause of death in people aged more than 35 years. Cardiomyopathies are more frequently encountered in people aged less than 35 years. The most frequent cardiomyopathy revealed by sudden death is now arrhythmogenic right ventricular cardiomyopathy also known simply as right ventricular cardiomyopathy (RVC). The postmortem diagnosis of cardiomyopathies is very important because the family of the deceased will need counseling and the first-degree relatives may undergo a possible screening to prevent other sudden deaths. In each case of sudden death, one important duty of the forensic pathologist is to inform the family of all autopsy results within 1 month after the autopsy. Most of the recent progress in autopsy diagnosis of sudden unexpected death in the adults comes from molecular biology, especially in case of sudden death without significant morphological anomalies. Searching mutations linked with functional cardiac pathology such as long-QT syndrome, Brugada syndrome or idiopathic ventricular fibrillation is now the best way in order to explain such sudden death. Moreover, new syndromes have been described by cardiologists, such as short-QT syndrome and revealed in some cases by a sudden death. Molecular biology is now needed when limits of morphological diagnosis have been reached.

Avaliação de parâmetros cardíacos em animais com epilepsia: possível causa de morte súbita?

Dentre as causas de morte súbita nas epilepsias (SUDEPE), as disfunções cardíacas têm sido uma área de interesse. Sendo assim, o objetivo de nosso estudo foi avaliar a freqüência cardíaca (FC) (in vivo e in vitro) e a pressão ventricular (PV) in vitro de ratos com epilepsia induzida pela pilocarpina. Ratos machos, adultos, da raça Wistar (n=6) receberam pilocarpina para a indução do status epilepticus. Ratos controles (n=6) receberam solução salina ao invés de pilocarpina. Nossos resultados mostram diferenças significantes na freqüência cardíaca in vivo entre os grupos estudados. Em contraste, não encontramos diferenças entre os grupos nos experimentos in vitro. Nossos resultados sugerem que sob a influência do sistema nervoso central, o coração pode apresentar alterações funcionais que aumentam a probabilidade de ocorrência de morte súbita nas epilepsias.