Epilepsy and Cardiac Arrhythmias: A State-of-the-Art Review

Epilepsy is an important cause of disability and mortality worldwide. It can be frequently misdiagnosed, and detailed history and relevant investigations are needed to differentiate epilepsy from syncope. Electroencephalogram is a key noninvasive assessment of neurological function, and the diagnostic yield is increased when performed for an extended period in the ambulatory setting with concurrent electrocardiogram and video monitoring. People living with epilepsy may be affected by a diverse range of ictal (seizure-associated) arrhythmias. The prevalence of detected arrhythmias in people living with epilepsy is anticipated to rise in the context of increasingly available wearable technology and improved survival. Ictal bradycardia and asystole sometimes observed in temporal lobe epilepsy may be associated with falls and injury that can be prevented by cardiac pacing; however, seizure control with medical therapy is still crucial. Sudden unexpected death in epilepsy is likely explained by a different mechanism, in particular central cardiorespiratory autonomic dysfunction sometimes associated with generalized tonic-clonic seizures. Channelopathies encompassing the heart-brain axis are increasingly recognized and may explain the overlap between certain epileptic and arrhythmogenic syndromes, with potential for targeted therapy in the future. The QT interval is prognostically significant in epilepsy, with various seizure types affecting the QT interval differently. Certain antiseizure medications may cause electrocardiogram abnormalities and arrhythmias although there remains limited clinical data. This State-of-the-Art Review describes our current understanding regarding the relationship between epilepsy and cardiac arrhythmias, as well as delineating areas of unmet need.