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Direk MÇ, Epcacan S, Özdemir AA, Uysal F, Okuyaz Ç. Effects of levetiracetam treatment on autonomic nervous system functions in pediatric epilepsy patients. Pediatr Int 2023; 65:e15636. [PMID: 37795856 DOI: 10.1111/ped.15636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study investigated the effects of levetiracetam (LEV) treatment on cardiac rhythm and heart rate variability. METHODS The study included two groups of patients diagnosed with non-lesional epilepsy who had not yet been treated and who presented to the outpatient pediatric neurology clinic at Van Training and Research Hospital, Van, Turkey, between 2019 and 2020. The heart rate variability (HRV) of 47 patients in the first group, before and at the 3rd month of treatment, and intravenous (IV) LEV loading in 13 patients in the second group was evaluated by Holter electrocardiography (ECG). RESULTS It was determined that the values of triangular index, standard deviation of the RR intervals over a 24-hour period (SDNN), standard deviation of all 5-minute mean RR intervals (SDANN), mean of standard deviations of all normal RR intervals (SDNNI), the percentage of RR intervals with >50-millisecond variation (PNN50), and the square root of mean squared differences of successive RR intervals (RMSSD). HRV of 47 patients under LEV treatment significantly increased in the 3rd month of treatment compared to baseline (p < 0.05). No difference was found in HRV between the intravenous loading and the control group (p > 0.05). CONCLUSIONS Our study suggests that the sympathovagal balance before treatment in the patient group is in favor of the sympathetic nervous system and that the sympathovagal imbalance improves after treatment. Our results show that LEV monotherapy and loading have no negative effect on HRV and potential cardiac arrhythmia risk in children with epilepsy.
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Affiliation(s)
| | - Serdar Epcacan
- Department of Pediatric Cardiology, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Asena Ayca Özdemir
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Fahrettin Uysal
- Department of Turkey Pediatric Cardiology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Çetin Okuyaz
- Department of Pediatric Neurology, Faculty of Medicine, Mersin University, Mersin, Turkey
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Sudden Unexpected Death in Epilepsy. Neurol Int 2022; 14:600-613. [PMID: 35893283 PMCID: PMC9326725 DOI: 10.3390/neurolint14030048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is a complex neurological condition with numerous etiologies and treatment options. In a subset of these patients, sudden unexpected death can occur, and to date, there are numerous explanations as to the pathophysiological mechanisms and how to mitigate these catastrophic outcomes. Approximately 2.3 million Americans have epilepsy, and nearly 150,000 people develop the condition each year. Sudden unexpected death in epilepsy (SUDEP) accounts for 2–18% of all epilepsy-related deaths and this is equivalent to one death in 1000 person-years of diagnosed epilepsy. It is more common in young adults aged 20–45. Seizures in the past year; the absence of terminal remission in the last five years; increased seizure frequency, particularly GTCS; and nocturnal seizures are the most potent modifiable risk factors for SUDEP. Patients not receiving any antiepileptic drug therapy are at higher risk of SUDEP. Patient education on medication compliance; care plans for seizure clusters (rescue medicines); epilepsy self-management programs; and lifestyle changes to avoid seizure-triggering factors, including avoiding excessive alcohol use and sleep deprivation, should be provided by health care providers. Continued research into SUDEP will hopefully lead to effective interventions to minimize occurrences. At present, aggressive control of epilepsy and enhanced education for individuals and the public are the most effective weapons for combating SUDEP. This narrative review focuses on updated information related to SUDEP epidemiology; pathophysiology; risk factor treatment options; and finally, a discussion of important clinical studies. We seek to encourage clinicians who care for patients with epilepsy to be aggressive in controlling seizure activity and diligent in their review of risk factors and education of patients and their families about SUDEP.
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Heart Rate Variability Analysis for Seizure Detection in Neonatal Intensive Care Units. Bioengineering (Basel) 2022; 9:bioengineering9040165. [PMID: 35447725 PMCID: PMC9031489 DOI: 10.3390/bioengineering9040165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 12/03/2022] Open
Abstract
In Neonatal Intensive Care Units (NICUs), the early detection of neonatal seizures is of utmost importance for a timely clinical intervention. Over the years, several neonatal seizure detection systems were proposed to detect neonatal seizures automatically and speed up seizure diagnosis, most based on the EEG signal analysis. Recently, research has focused on other possible seizure markers, such as electrocardiography (ECG). This work proposes an ECG-based NSD system to investigate the usefulness of heart rate variability (HRV) analysis to detect neonatal seizures in the NICUs. HRV analysis is performed considering time-domain, frequency-domain, entropy and multiscale entropy features. The performance is evaluated on a dataset of ECG signals from 51 full-term babies, 29 seizure-free. The proposed system gives results comparable to those reported in the literature: Area Under the Receiver Operating Characteristic Curve = 62%, Sensitivity = 47%, Specificity = 67%. Moreover, the system’s performance is evaluated in a real clinical environment, inevitably affected by several artefacts. To the best of our knowledge, our study proposes for the first time a multi-feature ECG-based NSD system that also offers a comparative analysis between babies suffering from seizures and seizure-free ones.
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Hamdy RM, Abdel-Tawab H, Abd Elaziz OH, Sobhy El attar R, Kotb FM. Evaluation of Heart Rate Variability Parameters During Awake and Sleep in Refractory and Controlled Epileptic Patients. Int J Gen Med 2022; 15:3865-3877. [PMID: 35422653 PMCID: PMC9004725 DOI: 10.2147/ijgm.s354895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/25/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Rehab M Hamdy
- Department of Cardiology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
- Correspondence: Rehab M Hamdy, Department of Cardiology, Faculty for Medicine (for Girls), Al-Azhar University, Cairo, Egypt, Tel +201003022726, Email
| | - Hayam Abdel-Tawab
- Department of Neurology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
| | - Ola H Abd Elaziz
- Department of Cardiology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
| | - Rasha Sobhy El attar
- Department of Neurology, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
| | - Fatma M Kotb
- Department of Internal Medicine, Faculty of Medicine (for Girls), Al-Azhar University, Cairo, Egypt
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Zhuravlev D, Lebedeva A, Lebedeva M, Guekht A. Current concepts about autonomic dysfunction in patients with epilepsy. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:131-138. [DOI: 10.17116/jnevro2022122031131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hamdy RM, Elaziz OHA, El attar RS, Abdel-Tawab H, Kotb FM. Evaluation of QT dispersion in epileptic patients and its association with SUDEP risk. Epilepsy Res 2022; 180:106860. [DOI: 10.1016/j.eplepsyres.2022.106860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/06/2022] [Accepted: 01/16/2022] [Indexed: 11/03/2022]
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Abstract
PURPOSE OF REVIEW Epilepsy is associated with autonomic dysfunction. Here, we provide an up-to-date review on measures of interictal autonomic function, focusing on heart rate variability (HRV), baroreflex sensitivity (BRS) and electrodermal activity (EDA). RECENT FINDINGS Resting HRV, BRS and EDA are altered in patients with epilepsy compared with healthy controls. A larger body of work is available for HRV compared with BRS and EDA, and points to interictal HRV derangements across a wide range of epilepsies, including focal, generalized, and combined generalized and focal epilepsies. HRV alterations are most pronounced in temporal lobe epilepsy, Dravet syndrome and drug-resistant and chronic epilepsies. There are conflicting data on the effect of antiseizure medications on measures of interictal autonomic function. However, carbamazepine has been associated with decreased HRV. Epilepsy surgery and vagus nerve stimulation do not appear to have substantial impact on measures of interictal autonomic function but well designed studies are lacking. SUMMARY Patients with epilepsy, particularly those with longstanding uncontrolled seizures, have measurable alterations of resting autonomic function. These alterations may be relevant to the increased risk of premature mortality in epilepsy, including sudden unexpected death in epilepsy, which warrants investigation in future research.
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do Nascimento Vinholes L, Sousa da Silva A, Marinho Tassi E, Corrêa Borges de Lacerda G. Heart rate variability in frontal lobe epilepsy: Association with SUDEP risk. Acta Neurol Scand 2021; 143:62-70. [PMID: 32749695 DOI: 10.1111/ane.13330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Frontal lobe epilepsy (FLE) may impair autonomic heart rate modulation. Decreased heart rate variability (HRV) may enhance risk of sudden death. Our objective was to describe whole day and wakefulness/sleep HRV parameters from FLE patients in comparison with those of healthy controls and correlate HRV parameters to SUDEP-7 scores. METHODS Ten patients with FLE and 15 healthy controls underwent a 24-hour electrocardiogram holter. The SUDEP-7 score was calculated for patients. Subgroups were identified according to active epilepsy, number of generalized seizures, cognitive deficit, medication load, and time-length of epilepsy. Time-domain SDNN, SDNNi, SDANN, rMSDD, and pNN50 and frequency-domain LF, HF, and LF/HF parameters were analyzed. Wilcoxon and Spearman correlation tests were used. A P < .05 was considered significant. RESULTS Patients SDNN, SDNNi, rMSSD, and pNN50 were decreased in 24-hour recordings. Although a tendency for a protective effect of sleep was seen for both patients and controls, intragroup comparisons of sleeping/waking states revealed a significant increase in sleep rMSSD (P = .046) and pNN50 (P = .041) only for controls. All 24-hour time-domain parameters and LF were inversely and significantly correlated to SUDEP-7, particularly SDANN (ρ = -0.896, P = .00019), known to deteriorate with diminished physical activity and decreased in patients with more generalized seizures. Wakefulness parameters did not correlate to SUDEP-7, whereas correlations to sleep parameters were very strong, particularly with rMSSD (ρ = -0.945, P = .00012). Cognitive deficit was associated with decreased pNN50, sleep pNN50, and LH. CONCLUSION HRV is impaired in patients with FLE. Low HRV scores are associated with increased risk for SUDEP as measured by the SUDEP-7 score.
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Affiliation(s)
| | - Alexandre Sousa da Silva
- Mathematics and Statistical Department Universidade Federal do Estado do Rio de Janeiro (UniRio) Rio de Janeiro Brazil
| | - Eduardo Marinho Tassi
- Cardiology Department Universidade Federal do Estado do Rio de Janeiro (UniRio) Rio de Janeiro Brazil
| | - Glenda Corrêa Borges de Lacerda
- Neurology Post‐Graduation Program Neurology Department Universidade Federal do Estado do Rio de Janeiro (UniRio) Rio de Janeiro Brazil
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Baysal-Kirac L, Serbest NG, Şahin E, Dede HÖ, Gürses C, Gökyiğit A, Bebek N, Bilge AK, Baykan B. Analysis of heart rate variability and risk factors for SUDEP in patients with drug-resistant epilepsy. Epilepsy Behav 2017; 71:60-64. [PMID: 28549245 DOI: 10.1016/j.yebeh.2017.04.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/08/2017] [Accepted: 04/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac problems have been suggested as causes of sudden unexpected death in epilepsy (SUDEP). Our aim was to investigate possible associations of cardiac autonomic functions based on heart rate variability (HRV) parameters with risk factors of SUDEP in patients with drug-resistant epilepsy. METHODS Forty-seven patients with drug-resistant seizures and 45 healthy control subjects were enrolled in the study. Interictal time domain parameters of HRV were evaluated with 24-hour Holter recordings. Potential SUDEP risk in patients with epilepsy was estimated using an inventory of seven validated SUDEP risk factors (The SUDEP-7 inventory). RESULTS When compared with the healthy controls, all time domain measures (SDNN-24, SDNN-index, SDANN-index, RMSSD and pNN50) were significantly suppressed in the patient group. Scores of the SUDEP-7 inventory ranged from 1 to 9 with a median 4 out of a maximum possible risk score of 10. Maximum heart rate value in 24-hour Holter recordings and epilepsy duration were correlated with the SUDEP-7 scores (r=0.3, p=0.03). We found no significant association with HRV measures and SUDEP-7 risk factors. One patient diagnosed with Dravet syndrome died of SUDEP, which was autopsy confirmed; his SUDEP-7 inventory score was 7, HRV measures were significantly diminished, and his maximum heart rate (HR) was 208beats/min (maximum HR is between 104 and 188beats/min in normal subjects). CONCLUSION Patients with drug-resistant epilepsy present with significantly lower HRV measures, which may increase the risk for sudden cardiac death. Increased heart rate and diminished HRV measures may constitute one of the possible mechanisms underlying SUDEP and should be diagnosed in patients with epilepsy.
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Affiliation(s)
- Leyla Baysal-Kirac
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Nail Güven Serbest
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Fatih, 34093 Istanbul, Turkey.
| | - Erdi Şahin
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Hava Özlem Dede
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Candan Gürses
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Ayşen Gökyiğit
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Nerses Bebek
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
| | - Ahmet Kaya Bilge
- Istanbul University, Istanbul Faculty of Medicine, Department of Cardiology, Fatih, 34093 Istanbul, Turkey.
| | - Betül Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology and Clinical Neurophysiology, Fatih, 34093 Istanbul, Turkey.
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Tomson T, Surges R, Delamont R, Haywood S, Hesdorffer DC. Who to target in sudden unexpected death in epilepsy prevention and how? Risk factors, biomarkers, and intervention study designs. Epilepsia 2016; 57 Suppl 1:4-16. [PMID: 26749012 DOI: 10.1111/epi.13234] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 11/28/2022]
Abstract
The risk of dying suddenly and unexpectedly is increased 24- to 28-fold among young people with epilepsy compared to the general population, but the incidence of sudden unexpected death in epilepsy (SUDEP) varies markedly depending on the epilepsy population. This article first reviews risk factors and biomarkers for SUDEP with the overall aim of enabling identification of epilepsy populations with different risk levels as a background for a discussion of possible intervention strategies. The by far most important clinical risk factor is frequency of generalized tonic-clonic seizures (GTCS), but nocturnal seizures, early age at onset, and long duration of epilepsy have been identified as additional risk factors. Lack of antiepileptic drug (AED) treatment or, in the context of clinical trials, adjunctive placebo versus active treatment is associated with increased risks. Despite considerable research, reliable electrophysiologic (electrocardiography [ECG] or electroencephalography [EEG]) biomarkers of SUDEP risk remain to be established. This is an important limitation for prevention strategies and intervention studies. There is a lack of biomarkers for SUDEP, and until validated biomarkers are found, the endpoint of interventions to prevent SUDEP must be SUDEP itself. These interventions, be they pharmacologic, seizure-detection devices, or nocturnal supervision, require large numbers. Possible methods for assessing prevention measures include public health community interventions, self-management, and more traditional (and much more expensive) randomized clinical trials.
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Affiliation(s)
- Torbjörn Tomson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Robert Delamont
- Department of Clinical Neurophysiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Dale C Hesdorffer
- GH Sergievsky Center and Department of Epidemiology, Columbia University, New York, New York, U.S.A
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Can heart rate variability in children with epilepsy be used to predict seizures? Seizure 2014; 23:357-62. [DOI: 10.1016/j.seizure.2014.01.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/27/2014] [Accepted: 01/30/2014] [Indexed: 11/22/2022] Open
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Malik GA, Smith PEM. Increasing awareness of sudden unexpected death in epilepsy. Expert Rev Neurother 2014; 13:1371-82. [DOI: 10.1586/14737175.2013.861741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Cardiac functions of voltage-gated Ca(2+) channels: role of the pharmacoresistant type (E-/R-Type) in cardiac modulation and putative implication in sudden unexpected death in epilepsy (SUDEP). Rev Physiol Biochem Pharmacol 2014; 167:115-39. [PMID: 25280639 DOI: 10.1007/112_2014_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Voltage-gated Ca(2+) channels (VGCCs) are ubiquitous in excitable cells. These channels play key roles in many physiological events like cardiac regulation/pacemaker activity due to intracellular Ca(2+) transients. In the myocardium, the Cav1 subfamily (L-type: Cav1.2 and Cav1.3) is the main contributor to excitation-contraction coupling and/or pacemaking, whereas the Cav3 subfamily (T-type: Cav3.1 and Cav3.2) is important in rhythmically firing of the cardiac nodal cells. No established cardiac function has been attributed to the Cav2 family (E-/R-type: Cav2.3) despite accumulating evidence of cardiac dysregulation observed upon deletion of the Cav2.3 gene, the only member of this family so far detected in cardiomyocytes. In this review, we summarize the pathophysiological changes observed after ablation of the E-/R-type VGCC and propose a cardiac mechanism of action for this channel. Also, considering the role played by this channel in epilepsy and its reported sensitivity to antiepileptic drugs, a putative involvement of this channel in the cardiac mechanism of sudden unexpected death in epilepsy is also discussed.
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Dericioglu N, Demirci M, Cataltepe O, Akalan N, Saygi S. Heart rate variability remains reduced and sympathetic tone elevated after temporal lobe epilepsy surgery. Seizure 2013; 22:713-8. [DOI: 10.1016/j.seizure.2013.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 11/29/2022] Open
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Tobaldini E, Nobili L, Strada S, Casali KR, Braghiroli A, Montano N. Heart rate variability in normal and pathological sleep. Front Physiol 2013; 4:294. [PMID: 24137133 PMCID: PMC3797399 DOI: 10.3389/fphys.2013.00294] [Citation(s) in RCA: 176] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 09/26/2013] [Indexed: 01/15/2023] Open
Abstract
Sleep is a physiological process involving different biological systems, from molecular to organ level; its integrity is essential for maintaining health and homeostasis in human beings. Although in the past sleep has been considered a state of quiet, experimental and clinical evidences suggest a noteworthy activation of different biological systems during sleep. A key role is played by the autonomic nervous system (ANS), whose modulation regulates cardiovascular functions during sleep onset and different sleep stages. Therefore, an interest on the evaluation of autonomic cardiovascular control in health and disease is growing by means of linear and non-linear heart rate variability (HRV) analyses. The application of classical tools for ANS analysis, such as HRV during physiological sleep, showed that the rapid eye movement (REM) stage is characterized by a likely sympathetic predominance associated with a vagal withdrawal, while the opposite trend is observed during non-REM sleep. More recently, the use of non-linear tools, such as entropy-derived indices, have provided new insight on the cardiac autonomic regulation, revealing for instance changes in the cardiovascular complexity during REM sleep, supporting the hypothesis of a reduced capability of the cardiovascular system to deal with stress challenges. Interestingly, different HRV tools have been applied to characterize autonomic cardiac control in different pathological conditions, from neurological sleep disorders to sleep disordered breathing (SDB). In summary, linear and non-linear analysis of HRV are reliable approaches to assess changes of autonomic cardiac modulation during sleep both in health and diseases. The use of these tools could provide important information of clinical and prognostic relevance.
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Affiliation(s)
- Eleonora Tobaldini
- Division of Medicine and Pathophysiology, Department of Biomedical and Clinical Sciences "L. Sacco," L. Sacco Hospital, University of Milan Milan, Italy
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Terra VC, Cysneiros R, Cavalheiro EA, Scorza FA. Sudden unexpected death in epilepsy: from the lab to the clinic setting. Epilepsy Behav 2013; 26:415-20. [PMID: 23402930 DOI: 10.1016/j.yebeh.2012.12.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/17/2012] [Indexed: 11/30/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is defined as sudden, unexpected, witnessed or unwitnessed, non-traumatic, and non-drowning death in a patient with epilepsy. Sudden unexpected death in epilepsy is probably the most common cause of epilepsy-related deaths. Many predisposing and initiating factors may coexist and contribute to SUDEP, but the mechanisms are poorly understood. Cardiac and respiratory deregulation seems to have a major role in SUDEP. Here, we review several advances in understanding the mechanisms involved in SUDEP.
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Affiliation(s)
- Vera C Terra
- Departamento de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil.
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Lotufo PA, Valiengo L, Benseñor IM, Brunoni AR. A systematic review and meta-analysis of heart rate variability in epilepsy and antiepileptic drugs. Epilepsia 2012; 53:272-82. [PMID: 22221253 DOI: 10.1111/j.1528-1167.2011.03361.x] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Epilepsy is associated with near-fatal and fatal arrhythmias, and sudden unexpected death in epilepsy (SUDEP) is partly related to cardiac events. Dysfunction of the autonomous nervous system causes arrhythmias and, although previous studies have investigated the effects of epilepsy on the autonomic control of the heart, the results are still mixed regarding whether imbalance of sympathetic, vagal, or both systems is present in epilepsy, and also the importance of anticonvulsant treatment on the autonomic system. Therefore, we aimed to investigate epilepsy and its treatment impact on heart rate variability (HRV), assessed by sympathetic and parasympathetic activity expressed as low-frequency (LF) and high-frequency (HF) power spectrum, respectively. METHOD We performed a systematic review from the first date available to July 2011 in Medline and other databases; key search terms were "epilepsy"; "anticonvulsants"; "heart rate variability"; "vagal"; and "autonomous nervous system." Original studies that reported data and/or statistics of at least one HRV value were included, with data being extracted by two independent authors. We used a random-effects model with Hedges's g as the measurement of effect size to perform two main meta-analyses comparing LF and HF HRV values in (1) epilepsy patients versus controls; (2) patients receiving versus not receiving treatment; and (3) well-controlled versus refractory patients. Secondary analyses assessed other time- and frequency-domain measurements (nonlinear methods were not analyzed due to lack of sufficient data sets). Quality assessment of each study was verified and also meta-analytic techniques to identify and control bias. Meta-regression for age and gender was performed. KEY FINDINGS Initially, 366 references were identified. According to our eligibility criteria, 30 references (39 studies) were included in our analysis. Regarding HF, epilepsy patients presented lower values (g -0.69) than controls, with the 95% confidence interval (CI) ranging from -1.05 to -0.33. No significant differences were observed for LF (g -0.18; 95% CI -0.71 to 0.35). Patients receiving treatment presented HF values to those not receiving treatment (g -0.05; 95% CI -0.37 to 0.27), with a trend for having higher LF values (g 0.1; 95% CI -0.13 to 0.33), which was more pronounced in those receiving antiepileptic drugs (vs. vagus nerve stimulation). No differences were observed for well-controlled versus refractory patients, possibly due to the low number of studies. Regression for age and gender did not influence the results. Finally, secondary time-domain analyses also showed lower HRV and lower vagal activity in patients with epilepsy, as shown by the standard deviation of normal-to-normal interval (SDNN) and the root mean square of successive differences (RMSSD) indexes, respectively. SIGNIFICANCE We confirmed and extended the hypothesis of sympathovagal imbalance in epilepsy, as showed by lower HF, SDNN, and RMSSD values when compared to controls. In addition, there was a trend for higher LF values in patients receiving pharmacotherapy. As lower vagal (HF) and higher sympathetic (LF) tone are predictors of morbidity and mortality in cardiovascular samples, our findings highlight the importance of investigating autonomic function in patients with epilepsy in clinical practice. Assessing HRV might also be useful when planning therapeutic interventions, as some antiepileptic drugs can show hazardous effects in cardiac excitability, potentially leading to cardiac arrhythmia.
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Affiliation(s)
- Paulo A Lotufo
- Clinical Research Center, University Hospital, University of São Paulo, São Paulo, Brazil
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