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Baltos JA, Casillas-Espinosa PM, Rollo B, Gregory KJ, White PJ, Christopoulos A, Kwan P, O'Brien TJ, May LT. The role of the adenosine system in epilepsy and its comorbidities. Br J Pharmacol 2024; 181:2143-2157. [PMID: 37076128 DOI: 10.1111/bph.16094] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/09/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023] Open
Abstract
Epilepsy is one of the most serious and common chronic neurological conditions, characterised by recurrent hypersynchronous electrical activity in the brain that lead to seizures. Despite over 50 million people being affected worldwide, only ~70% of people with epilepsy have their seizures successfully controlled with current pharmacotherapy, and many experience significant psychiatric and physical comorbidities. Adenosine, a ubiquitous purine metabolite, is a potent endogenous anti-epileptic substance that can abolish seizure activity via the adenosine A1 G protein-coupled receptor. Activation of A1 receptors decreases seizure activity in animal models, including models of drug-resistant epilepsy. Recent advances have increased our understanding of epilepsy comorbidities, highlighting the potential for adenosine receptors to modulate epilepsy-associated comorbidities, including cardiovascular dysfunction, sleep and cognition. This review provides an accessible resource of the current advances in understanding the adenosine system as a therapeutic target for epilepsy and epilepsy-associated comorbidities. LINKED ARTICLES: This article is part of a themed issue Therapeutic Targeting of G Protein-Coupled Receptors: hot topics from the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists 2021 Virtual Annual Scientific Meeting. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v181.14/issuetoc.
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Affiliation(s)
- Jo-Anne Baltos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Pablo M Casillas-Espinosa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ben Rollo
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Karen J Gregory
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- ARC Centre for Cryo-Electron Microscopy of Membrane Proteins, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Paul J White
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Arthur Christopoulos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
- Neuromedicines Discovery Centre, Monash University, Melbourne, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lauren T May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Mayer J, Mbizvo GK, Bucci T, Marson A, Lip GYH. Association of antiseizure medications and adverse cardiovascular events: A global health federated network analysis. Epilepsia 2024; 65:1264-1274. [PMID: 38411304 DOI: 10.1111/epi.17922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE A diagnosis of epilepsy has been associated with adverse cardiovascular events (CEs), but the extent to which antiseizure medications (ASMs) may contribute to this is not well understood. The aim of this study was to compare the risk of adverse CEs associated with ASM in patients with epilepsy (PWE). METHODS A retrospective case-control cohort study was conducted using TriNetX, a global health federated network of anonymized patient records. Patients older than 18 years, with a diagnosis of epilepsy (International Classification of Diseases, 10th Revision code G40) and a medication code of carbamazepine, lamotrigine, or valproate were compared. Patients with cardiovascular disease prior to the diagnosis of epilepsy were excluded. Cohorts were 1:1 propensity score matched (PSM) according to age, sex, ethnicity, hypertension, heart failure, atherosclerotic heart disease, atrial and cardiac arrythmias, diabetes, disorders of lipoprotein metabolism, obesity, schizophrenia and bipolar disorder, medications, and epilepsy classification. The primary outcome was a composite of adverse CEs (ischemic stroke, acute ischemic heart disease, and heart failure) at 10 years. Cox regression analyses were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) following 1:1 PSM. RESULTS Of 374 950 PWE included; three cohorts were established after PSM: (1) carbamazepine compared to lamotrigine, n = 4722, mean age 37.4 years; (2) valproate compared to lamotrigine, n = 5478, mean age 33.9 years; and (3) valproate compared to carbamazepine, n = 4544, mean age 37.0 years. Carbamazepine and valproate use were associated with significantly higher risk of composite cardiovascular outcome compared to lamotrigine (HR = 1.390, 95% CI = 1.160-1.665 and HR = 1.264, 95% CI = 1.050-1.521, respectively). Valproate was associated with a 10-year higher risk of all-cause death than carbamazepine (HR = 1.226, 95% CI = 1.017-1.478), but risk of other events was not significantly different. SIGNIFICANCE Carbamazepine and valproate were associated with increased CE risks compared to lamotrigine. Cardiovascular risk factor monitoring and careful follow-up should be considered for these patients.
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Affiliation(s)
- Josephine Mayer
- Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre, National Health Service Foundation Trust, Liverpool, UK
| | - Gashirai K Mbizvo
- Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre, National Health Service Foundation Trust, Liverpool, UK
| | - Tommaso Bucci
- Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of General and Specialized Surgery, Sapienza University of Rome, Rome, Italy
| | - Anthony Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
- Department of Neurology, The Walton Centre, National Health Service Foundation Trust, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
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Peltola J, Surges R, Voges B, von Oertzen TJ. Expert opinion on diagnosis and management of epilepsy-associated comorbidities. Epilepsia Open 2024; 9:15-32. [PMID: 37876310 PMCID: PMC10839328 DOI: 10.1002/epi4.12851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/25/2023] [Indexed: 10/26/2023] Open
Abstract
Apart from seizure freedom, the presence of comorbidities related to neurological, cardiovascular, or psychiatric disorders is the largest determinant of a reduced health-related quality of life in people with epilepsy (PwE). However, comorbidities are often underrecognized and undertreated, and clinical management of comorbid conditions can be challenging. The focus of a comprehensive treatment regimen should maximize seizure control while optimizing clinical management of treatable comorbidities to improve a person's quality of life and overall health. A panel of four European epileptologists with expertise in their respective fields of epilepsy-related comorbidities combined the latest available scientific evidence with clinical expertise and collaborated to provide consensus practical advice to improve the identification and management of comorbidities in PwE. This review provides a critical evaluation for the diagnosis and management of sleep-wake disorders, cardiovascular diseases, cognitive dysfunction, and depression in PwE. Whenever possible, clinical data have been provided. The PubMed database was the main search source for the literature review. The deleterious pathophysiological processes underlying neurological, cardiovascular, or psychiatric comorbidities in PwE interact with the processes responsible for generating seizures to increase cerebral and physiological dysfunction. This can increase the likelihood of developing drug-resistant epilepsy; therefore, early identification of comorbidities and intervention is imperative. The practical evidence-based advice presented in this article may help clinical neurologists and other specialist physicians responsible for the care and management of PwE.
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Affiliation(s)
- Jukka Peltola
- Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
- Department of NeurologyTampere University HospitalTampereFinland
| | - Rainer Surges
- Department of EpileptologyUniversity Hospital BonnBonnGermany
| | - Berthold Voges
- Department of Neurology, Epilepsy Center HamburgProtestant Hospital AlsterdorfHamburgGermany
| | - Tim J. von Oertzen
- Medical FacultyJohannes Kepler UniversityLinzAustria
- Department of Neurology 1, Neuromed CampusKepler University HospitalLinzAustria
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Wang J, Huang P, Yu Q, Lu J, Liu P, Yang Y, Feng Z, Cai J, Yang G, Yuan H, Tang H, Lu Y. Epilepsy and long-term risk of arrhythmias. Eur Heart J 2023; 44:3374-3382. [PMID: 37602368 PMCID: PMC10499547 DOI: 10.1093/eurheartj/ehad523] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 06/26/2023] [Accepted: 08/03/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND AND AIMS Previous evidence has mainly supported transient changes in cardiac function during interictal or peri-ictal phases in people with epilepsy, but the long-term risk of cardiac arrhythmias is poorly described. This study aimed to assess the long-term association of epilepsy with cardiac arrhythmias, considering the potential role of genetic predisposition and antiseizure medications (ASMs) in any associations observed. METHODS This population-based study evaluated UK Biobank data for individuals recruited between 2006 and 2010. Cox proportional hazards models and competing risk models were used to examine the association of epilepsy history with the long-term incidence risk of cardiac arrhythmias and arrhythmias subtypes. Polygenic risk scores (PRS) were calculated to investigate the effect of genetic susceptibility. The role of ASMs was also evaluated by integrating observational and drug target Mendelian randomization (MR) evidence. RESULTS The study included 329 432 individuals, including 2699 people with epilepsy. Compared with those without epilepsy, people with epilepsy experienced an increased risk of all cardiac arrhythmias [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.21-1.53], atrial fibrillation (HR 1.26, 95% CI 1.08-1.46), and other cardiac arrhythmias (HR 1.56, 95% CI 1.34-1.81). The associations were not modified by genetic predisposition as indicated by PRS. Competing and sensitivity analyses corroborated these results. Individuals with epilepsy using ASMs, especially carbamazepine and valproic acid, were at a higher risk for cardiac arrhythmias. This observation was further supported by drug target MR results (PSMR < .05 and PHEIDI > .05). CONCLUSION This study revealed the higher risk of cardiac arrhythmias persists long term in people with epilepsy, especially among those using carbamazepine and valproic acid. These findings highlight the need for regular heart rhythm monitoring and management in people with epilepsy in order to reduce the risk of further cardiovascular complications.
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Affiliation(s)
- Jie Wang
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
- Department of Cardiology, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Peiyuan Huang
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Qingwei Yu
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
- Department of Neurosurgery, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan 410008, China
| | - Jun Lu
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Pinbo Liu
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Yiping Yang
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Zeying Feng
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Jingjing Cai
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
- Department of Cardiology, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Guoping Yang
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Hong Yuan
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
- Department of Cardiology, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Haibo Tang
- Department of Metabolic and Bariatric Surgery, The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Yao Lu
- Clinical Research Center, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
- Department of Cardiology, The Third Xiangya Hospital, Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
- Faculty of Life Sciences & Medicine, King's College London, 150 Stamford Street, London SE1 9NH, UK
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The Anti-Epileptic Drugs Lamotrigine and Valproic Acid Reduce the Cardiac Sodium Current. Biomedicines 2023; 11:biomedicines11020477. [PMID: 36831014 PMCID: PMC9953282 DOI: 10.3390/biomedicines11020477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
Anti-epileptic drugs (AEDs) are associated with increased risk of sudden cardiac death. To establish whether gabapentin, lamotrigine, levetiracetam, pregabalin, and valproic acid reduce the Nav1.5 current, we conducted whole-cell patch-clamp studies to study the effects of the five AEDs on currents of human cardiac Nav1.5 channels stably expressed in HEK293 cells, and on action potential (AP) properties of freshly isolated rabbit ventricular cardiomyocytes. Lamotrigine and valproic acid exhibited inhibitory effects on the Nav1.5 current in a concentration-dependent manner with an IC50 of 142 ± 36 and 2022 ± 25 µM for lamotrigine and valproic acid, respectively. In addition, these drugs caused a hyperpolarizing shift of steady-state inactivation and a delay in recovery from inactivation. The changes on the Nav1.5 properties were reflected by a reduction in AP upstroke velocity (43.0 ± 6.8% (lamotrigine) and 23.7 ± 10.6% (valproic acid) at 1 Hz) and AP amplitude; in contrast, AP duration was not changed. Gabapentin, levetiracetam, and pregabalin had no effect on the Nav1.5 current. Lamotrigine and valproic acid reduce the Nav1.5 current density and affect its gating properties, resulting in a decrease of the AP upstroke velocity. Gabapentin, levetiracetam, and pregabalin have no effects on the Nav1.5 current.
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Restrepo JA, MacLean R, Celano CM, Huffman JC, Januzzi JL, Beach SR. The assessment of cardiac risk in patients taking lamotrigine; a systematic review. Gen Hosp Psychiatry 2022; 78:14-27. [PMID: 35763920 DOI: 10.1016/j.genhosppsych.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The Food and Drug Administration (FDA) warned about lamotrigine's arrhythmogenicity based on in vitro data. This systematic review investigates lamotrigine's effect on cardiac conduction and risk of sudden cardiac death (SCD) in individuals with and without cardiovascular disease. METHODS We searched Web of Science and PubMed from inception through August 2021. We included studies measuring electrocardiogram (ECG) changes, laboratory abnormalities, or SCD among patients taking lamotrigine. Studies examining sudden unexpected death in epilepsy were excluded for scope. Two reviewers assessed articles and extracted data. We used the Effective Public Healthcare Panacea Project tool to evaluate confidence in evidence. RESULTS Eight randomized controlled trials, 9 nonrandomized observational studies, and 24 case reports were identified, with >3054 total participants, >1606 of whom used lamotrigine. One randomized trial of older patients found an average QRS increase of 3.5 +/- 13.1 ms. Fifteen studies reported no changes in ECG parameters. Case reports documented QRS widening (13), Brugada syndrome (6), QTc prolongation (1) and SCD (2), though many ingested toxic quantities of lamotrigine and/or other medications. CONCLUSIONS Evidence is insufficient to support the breadth of the FDA warning concerning lamotrigine's cardiac risk. Lamotrigine at therapeutic doses may be associated with modest, non-dangerous QRS widening.
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Affiliation(s)
- Judith A Restrepo
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Rachel MacLean
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jeffery C Huffman
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Baim Institute for Clinical Research, 930 Commonwealth Avenue #3, Boston, MA 02215, United States of America
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Eroglu TE, Folke F, Tan HL, Torp-Pedersen C, Gislason GH. Risk of out-of-hospital cardiac arrest in patients with epilepsy and users of antiepileptic drugs. Br J Clin Pharmacol 2022; 88:3709-3715. [PMID: 35293630 PMCID: PMC9542728 DOI: 10.1111/bcp.15313] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022] Open
Abstract
Aims A few studies suggested that epilepsy and antiepileptic drugs with sodium channel‐blocking properties were independently associated with out‐of‐hospital cardiac arrest (OHCA). However, these findings have not yet been replicated. Methods Using Danish registries, we conducted a nested case–control study in a cohort of individuals between 1 June 2001 and 31 December 2015. Cases were defined as OHCA from presumed cardiac causes, and were matched with non‐OHCA‐controls based on sex, and age on the date of OHCA. Exposure of interest was epilepsy or antiepileptic drug use. To study the association between individual antiepileptic drug use and the rate of OHCA, we compared each antiepileptic drug with valproic acid. Cox regression with time‐dependent covariates was conducted to calculate hazard ratio (HR) and 95% confidence interval (CI). Results We identified 35 195 OHCA‐cases and 351 950 matched non‐OHCA controls. Epilepsy (cases: 3.58%, controls: 1.60%) was associated with increased rate of OHCA compared with the general population (HR: 1.76, 95%CI: 1.64–1.88) when common OHCA risk factors were taken into account. When we studied antiepileptic drug use, we found that 2 antiepileptic drugs without sodium channel blockage, clonazepam (HR: 1.88, 95%CI: 1.45–2.44) and pregabalin (HR: 1.33, 95%CI: 1.05–1.69), were associated with OHCA, whereas none of the antiepileptic drugs with sodium channel blockage were associated with OHCA. Conclusion Epilepsy is associated with increased rate of OHCA. Our findings do not support a possible association between antiepileptic drugs with sodium channel‐blocking properties and OHCA.
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Affiliation(s)
- Talip E Eroglu
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Amsterdam UMC, Academic Medical Center, University of Amsterdam, Department of Experimental and Clinical Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Fredrik Folke
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,Copenhagen University Hospital - Copenhagen Emergency Medical Services, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanno L Tan
- Amsterdam UMC, Academic Medical Center, University of Amsterdam, Department of Experimental and Clinical Cardiology, Heart Centre, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
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Vossler DG. Stroke and Ischemic Heart Disease With Enzyme-inducing Antiseizure Medications: Time to Change Prescribing Habits. Epilepsy Curr 2022; 22:120-122. [PMID: 35444497 PMCID: PMC8988723 DOI: 10.1177/15357597211070392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Importance: Enzyme-inducing antiseizure medications (eiASMs) have been hypothesized to be associated with long-term risks of cardiovascular disease. Objective: To quantify and model the putative hazard of cardiovascular disease secondary to eiASM use. Design, Setting, and Participants: This cohort study covered January 1990 to March 2019 (median [IQR] follow-up, 9 [4-15], years). The study linked primary care and hospital electronic health records at National Health Service hospitals in England. People aged 18 years or older diagnosed as having epilepsy after January 1, 1990, were included. All eligible patients were included with a waiver of consent. No patients were approached who withdrew consent. Analysis began January 2021 and ended August 2021. Exposures: Receipt of 4 consecutive EI ASMs (carbamazepine, eslicarbazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, rufinamide, or topiramate) following an adult-onset (age >/=18 years) epilepsy diagnosis or repeated exposure in a weighted cumulative exposure model. Main Outcomes and Measures: Three cohorts were isolated, 1 of which comprised all adults meeting a case definition for epilepsy diagnosed after 1990, 1 comprised incident cases diagnosed after 1998 (hospital linkage date), and 1 was limited to adults diagnosed with epilepsy at 65 years or older. Outcome was incident cardiovascular disease (ischemic heart disease or ischemic or hemorrhagic stroke). Hazard of incident cardiovascular disease was evaluated using adjusted propensity-matched survival analyses and weighted cumulative exposure models. Results: Of 10,916,166 adults, 50,888 (.6%) were identified as having period-prevalent cases (median [IQR] age, 32 [19-50] years; 16 584 [53%] female), of whom 31,479 (62%) were diagnosed on or after 1990 and were free of cardiovascular disease at baseline. In a propensity-matched Cox proportional hazards model adjusted for age, sex, baseline socioeconomic status, and cardiovascular risk factors, the hazard ratio for incident cardiovascular disease was 1.21 (95% CI, 1.06-1.39) for those receiving eiASMs. The absolute difference in cumulative hazard diverges by more than 1% and greater after 10 years. For those with persistent exposure beyond 4 prescriptions, the median hazard ratio increased from a median (IQR) of 1.54 (1.28-1.79) when taking a relative defined daily dose of an eiASM of 1 to 2.38 (1.52-3.56) with a relative defined daily dose of 2 throughout a maximum of 25 years' follow-up compared with those not receiving an eiASM. The hazard was elevated but attenuated when restricting analyses to incident cases or those diagnosed when older than 65 years. Conclusions and Relevance: The hazard of incident cardiovascular disease is higher in those receiving eiASMs. The association is dose dependent and the absolute difference in hazard seems to reach clinical significance by approximately 10 years from first exposure.
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Abstract
INTRODUCTION Patients with severe epilepsy are at increased risk of cardiovascular disease and arrhythmias. Although antiseizure medications (ASMs) may have indirect protective effects against cardiovascular events by reducing seizure frequency and hence sudden death in epilepsy, some of them exert cardiotoxic effects. AREAS COVERED Patients with epilepsy, mainly those with severe forms, are at higher risk of cardiac disease because their heart can have structural alterations and electrical instability as a consequence of repeated seizures. Some ASMs have direct protective effects through anti-inflammatory, antioxidant, hypotensive, and lipid-reducing properties. Antiseizure medications can also have toxic cardiac effects including both long-term consequences, such as the increased risk of atherogenesis and subsequent cardiovascular disease due to the influence on lipid profile and pro-inflammatory milieu, and immediate effects as the increased risk of potentially fatal arrhythmias due to the influence on ion channels. Sodium channel blocking ASMs may also affect cardiac sodium channels and this effect is particularly observed in subjects with genetic mutations in cardiac ion channels. Fenfluramine cause valvulopathies in obese subjects and this effect need to be evaluated in epilepsy patients. EXPERT OPINION For the selection of treatment, cardiotoxic effects of ASMs should be considered; cardiac monitoring of treatment is advisable.
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Affiliation(s)
- Gaetano Zaccara
- Department of Eidemiology, Regional Health Agency of Tuscany, Firenze, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (Sabes-asdaa), Merano-Meran, Italy
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Verrier RL, Pang TD, Nearing BD, Schachter SC. The Epileptic Heart: Concept and clinical evidence. Epilepsy Behav 2020; 105:106946. [PMID: 32109857 DOI: 10.1016/j.yebeh.2020.106946] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/07/2020] [Accepted: 01/23/2020] [Indexed: 12/18/2022]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is generally considered to result from a seizure, typically convulsive and usually but not always occurring during sleep, followed by a sequence of events in the postictal period starting with respiratory distress and progressing to eventual cardiac asystole and death. Yet, recent community-based studies indicate a 3-fold greater incidence of sudden cardiac death in patients with chronic epilepsy than in the general population, and that in 66% of cases, the cardiac arrest occurred during routine daily activity and without a temporal relationship with a typical seizure. To distinguish a primarily cardiac cause of death in patients with epilepsy from the above description of SUDEP, we propose the concept of the "Epileptic Heart" as "a heart and coronary vasculature damaged by chronic epilepsy as a result of repeated surges in catecholamines and hypoxemia leading to electrical and mechanical dysfunction." This review starts with an overview of the pathophysiological and other lines of evidence supporting the biological plausibility of the Epileptic Heart, followed by a description of tools that have been used to generate new electrocardiogram (EKG)-derived data in patients with epilepsy that strongly support the Epileptic Heart concept and its propensity to cause sudden cardiac death in patients with epilepsy independent of an immediately preceding seizure.
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Affiliation(s)
- Richard L Verrier
- Harvard Medical School, Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine and Department of Neurology, Boston, MA United States of America.
| | - Trudy D Pang
- Harvard Medical School, Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine and Department of Neurology, Boston, MA United States of America
| | - Bruce D Nearing
- Harvard Medical School, Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine and Department of Neurology, Boston, MA United States of America
| | - Steven C Schachter
- Harvard Medical School, Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine and Department of Neurology, Boston, MA United States of America
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Hulbert J, Elger CE, Meyer R, Surges R. Antiepileptic Drugs Impair Shortening of Isolated Cardiomyocytes. Front Neurol 2017; 8:133. [PMID: 28421035 PMCID: PMC5376916 DOI: 10.3389/fneur.2017.00133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/21/2017] [Indexed: 11/28/2022] Open
Abstract
Background Most antiepileptic drugs (AEDs) inhibit seizure generation by acting on voltage-dependent ion channels. Voltage-dependent sodium and calcium channels are commonly expressed in brain and heart, suggesting that AEDs may have considerable cardiodepressive effects, thereby facilitating sudden cardiac death as a potential cause of sudden unexpected death in epilepsy. Here, we investigated the effects of carbamazepine (CBZ), lamotrigine (LTG), and levetiracetam (LEV) alone and in combination on the shortening properties of isolated ventricular cardiomyocytes of wild-type mice. Methods Properties of murine cardiomyocytes were determined by recording the sarcomere shortening with a video imaging system before, during, and after administration of AEDs in different concentrations and combinations. We assessed (i) the number of successful shortenings during continuous electrical stimulation (electromechanical coupling) and (ii) the shortening amplitude as well as other shortening-related properties upon repetitive electrical stimulation at 4 Hz. Data are given as mean ± SEM. Results At 100 μM, CBZ (10 cells), LTG (11 cells), and LEV (11 cells) alone had no effect on the electromechanical coupling but reversibly reduced shortening amplitudes by 15 ± 4, 24 ± 3, and 11 ± 3%, respectively. Increasing the LTG concentration to 250 (21 cells) and 500 μM (4 cells) reversibly inhibited the electromechanical coupling in 62 and 100% of the experiments. Importantly, simultaneous application of CBZ, LTG, and LEV at 100 μM also impaired the electromechanical coupling in 8 of 19 cardiomyocytes (42%) and reduced the shortening amplitude by 21 ± 4%. Conclusion Our data show that AEDs reversibly impair cardiac excitation and contraction. Importantly, the blocking effect on electromechanical coupling appears to be additive when different AEDs are simultaneously applied. The translational value of these experimental findings into clinical practice is limited. Our results, however, suggest that rationale AED therapy may be important with respect to cardiac side effects and potential facilitation of serious cardiac dysfunction especially when AEDs are used in combination or at very high doses.
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Affiliation(s)
- Johanna Hulbert
- Institute of Physiology II, University Hospital Bonn, Bonn, Germany
| | | | - Rainer Meyer
- Institute of Physiology II, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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