Individuals with chronic epilepsy have elevated P‐wave heterogeneity comparable to patients with atrial fibrillation

Abstract

ObjectiveIdentification of epilepsy patients with elevated risk for atrial fibrillation (AF) is critical given the heightened morbidity and premature mortality associated with this arrhythmia. Epilepsy is a worldwide health problem affecting nearly 3.4 million people in the United States alone. The potential for increased risk for AF in patients with epilepsy is not well appreciated, despite recent evidence from a national survey of 1.4 million hospitalizations indicating that AF is the most common arrhythmia in people with epilepsy.MethodsWe analyzed inter‐lead heterogeneity of P‐wave morphology, a marker reflecting arrhythmogenic nonuniformities of activation/conduction in atrial tissue. The study groups consisted of 96 patients with epilepsy and 44 consecutive patients with AF in sinus rhythm before clinically indicated ablation. Individuals without cardiovascular or neurological conditions (n = 77) were also assessed. We calculated P‐wave heterogeneity (PWH) by second central moment analysis of simultaneous beats from leads II, III, and aVR (“atrial dedicated leads”) from standard 12‐lead electrocardiography (ECG) recordings from admission day to the epilepsy monitoring unit (EMU).ResultsFemale patients composed 62.5%, 59.6%, and 57.1% of the epilepsy, AF, and control subjects, respectively. The AF cohort was older (66 ± 1.1 years) than the epilepsy group (44 ± 1.8 years, p < .001). The level of PWH was greater in the epilepsy group than in the control group (67 ± 2.6 vs. 57 ± 2.5 μV, p = .046) and reached levels observed in AF patients (67 ± 2.6 vs. 68 ± 4.9 μV, p = .99). In multiple linear regression analysis, PWH levels in individuals with epilepsy were mainly correlated with the PR interval and could be related to sympathetic tone. Epilepsy remained associated with PWH after adjustments for cardiac risk factors, age, and sex.SignificancePatients with chronic epilepsy have increased PWH comparable to levels observed in patients with AF, while being ~20 years younger, suggesting an acceleration in structural change and/or cardiac electrical instability. These observations are consistent with emerging evidence of an “epileptic heart” condition.

Aborted sudden cardiac death in a young patient with epilepsy and the Gorlin Goltz syndrome

“…Recently, individuals with epilepsy were found to have increased atrial electrical dispersion (measured as P-wave heterogeneity). Importantly, P-wave heterogeneity in PWE reached levels similar to a 20-year older cohort of individuals with paroxysmal AF waiting for an ablation procedure [19] .…”

“…Structural myocardial changes may predispose to cardiac electrical heterogeneity, dispersion and arrhythmias. Elevated T-wave alternans, T and P-wave heterogeneity and heightened risk for life-threatening ventricular arrhythmias, have been shown in PWE [17] , [18] , [19] . Additionally, cardiac arrhythmogenic genes may also be present in PWE and several antiseizure medications (ASMs) can trigger cardiac abnormalities due to ion channel effects [20] , [21] .…”

Next step of ‘epileptic heart’

“…As indicated by Dr Fialho and other researchers, 3 , 4 there is an increased prevalence of electrical alterations in people with epilepsy, including P-wave heterogeneity, T-wave alternans, and QT prolongation, which might be predictive of the risk of sudden cardiac death. These findings suggested that the index reflecting the cardiac electrical instability could be used in the clinical routine monitoring of people with epilepsy.…”

The epileptic heart: Cardiac comorbidities and complications of epilepsy. Atrial and ventricular structure and function by echocardiography in individuals with epilepsy – From clinical implications to individualized assessment

“…A previous report on P-wave heterogeneity (PWH) measured in electrocardiography, a marker of atrial electrical dispersion, found that individuals with epilepsy have PWH levels similar to a more than 20 years older population with AF. AF is the most prevalent sustained arrhythmia in adults, and it is commonly associated with structural heart disease, including heart failure [59] . Early signs of impaired atrial mechanics and altered anatomy evaluated by echocardiography can predict heart failure and future AF risk [60] .…”