Report on the Cardiovascular Comorbidities of Epilepsy: Advancing Sustainable Development Goal 3

Introduction: Aligning Neurological and Cardiac Care with Global Health Targets

In alignment with Sustainable Development Goal 3 (SDG 3), which aims to ensure healthy lives and promote well-being for all at all ages, this report examines the critical intersection of neurology and cardiology. Specifically, it addresses the relationship between epilepsy and cardiac conditions, a comorbidity that poses a significant challenge to achieving SDG Target 3.4: reducing premature mortality from non-communicable diseases. Understanding and managing the cardiovascular health of individuals with epilepsy is essential for improving patient outcomes, reducing mortality risks such as Sudden Unexpected Death in Epilepsy (SUDEP) and Sudden Cardiac Death (SCD), and advancing the global health agenda.

The Bidirectional Link Between Epilepsy and Heart Disease

A Compounded Risk Profile

Research indicates a strong, bidirectional relationship between neurologic and cardiac function. This connection presents a compounded health risk that complicates patient management and challenges the siloed approach to medical specialties. Achieving integrated care is fundamental to promoting the holistic well-being central to SDG 3.

• Individuals with epilepsy exhibit an increased risk for cardiovascular diseases, including hypertension, atrial fibrillation, and hyperlipidemia.
• Conversely, individuals with cardiovascular disease and its associated risk factors have a higher incidence of epilepsy, a risk that extends beyond stroke. Data from the Framingham Heart Study confirms hypertension as a standalone risk factor for late-onset epilepsy.
• Genetic factors can also predispose individuals to both conditions, such as channelopathies that affect electrical signaling in both the brain and the heart.

The “Epileptic Heart”: A Framework for Understanding Chronic Cardiac Damage

Mechanisms of Cardiac Injury

The concept of the “epileptic heart,” proposed by researchers Richard Verrier and Trudy Pang, posits that chronic seizures progressively damage the heart’s structure and function. This cumulative damage contributes directly to premature mortality, undermining the objectives of SDG 3.4. The primary mechanisms include:

1. Recurrent Hypoxemia: Seizures, particularly generalized tonic-clonic (GTC) seizures, reduce oxygen supply to the heart muscle.
2. Catecholamine Toxicity: The release of stress hormones like adrenaline during and after seizures can “stun” the heart, temporarily reducing its pumping efficiency (ejection fraction) and causing long-term damage.
3. Accelerated Atherosclerosis: Chronic epilepsy is associated with accelerated hardening of the arteries, a condition potentially exacerbated by certain antiseizure medications. Research suggests this can advance the heart’s biological age by 10 to 20 years.

Differentiating SUDEP and SCD

While both represent tragic outcomes, understanding their distinction is vital for targeted prevention strategies. People with epilepsy have a nearly threefold higher risk for SCD compared to the general population.

• Sudden Cardiac Death (SCD): Typically occurs in older individuals (40-75 years) and is the result of identifiable, pre-existing heart disease.
• Sudden Unexpected Death in Epilepsy (SUDEP): Occurs in a younger demographic (20-40 years) and is diagnosed when no definitive cardiac or other cause of death can be found during autopsy. The “epileptic heart” model suggests that chronic seizure-induced damage may lead to fatal arrhythmias that cause SCD in this population.

Improving Health Outcomes Through Enhanced Cardiovascular Risk Assessment

Essential Diagnostic Tools

To proactively manage cardiovascular risk and prevent premature mortality in line with SDG 3, a more integrated diagnostic approach is required. This involves moving beyond standard neurological assessments to include cardiac monitoring.

• Electrocardiogram (EKG): A routine 12-lead EKG can provide initial insights. For more comprehensive data, Holter monitors or wireless ambulatory patches can be used for multi-day monitoring.
• Echocardiography: This imaging tool can identify structural changes, such as myocardial stiffness or alterations to the left atrium, which increase the risk for arrhythmias like atrial fibrillation.

Key EKG Markers for Risk Stratification

Dr. Verrier highlights several EKG measures that are critical for identifying individuals at high risk:

• P Wave Irregularities: Abnormalities in the P wave’s duration or shape can signal a predisposition to atrial fibrillation, which affects up to 10% of people with epilepsy.
• Pathological Q Waves: Deep or wide Q waves may indicate a past, silent myocardial infarction. This is significant given the nearly fivefold increase in myocardial infarction among people with chronic epilepsy.
• ST Segment Changes: Changes in this segment, which can occur in up to 40% of seizures, reflect stress on the heart muscle.
• Prolonged QT Interval: A prolonged interval, found in approximately one-third of patients with drug-resistant epilepsy, indicates an increased susceptibility to life-threatening ventricular arrhythmias.
• Microvolt T-Wave Alternans: This advanced parameter measures beat-to-beat variability in the T wave. Levels above 47 microvolts (μv) indicate a high risk for fatal arrhythmias. Studies show that patients with drug-resistant epilepsy often have levels exceeding 60 μv, particularly following tonic-clonic seizures.

Cardiovascular Fitness as a Predictor of All-Cause Mortality

The Significance of Metabolic Equivalent of Task (METs)

Research by Dr. Guilherme Fialho and Dr. Katia Lin has demonstrated that cardiovascular fitness is a powerful predictor of mortality, more so than traditional risk factors. Their work reveals a critical health gap for people with epilepsy.

• In treadmill tests, individuals with temporal lobe epilepsy (TLE) had significantly lower fitness levels, averaging 1.7 METs lower than control groups.
• Each 1-MET increase in fitness is associated with a 12% or greater reduction in mortality risk. Therefore, a 1.7-MET deficit represents a substantial increase in all-cause mortality risk.
• This reduced fitness is linked to increased cardiac stiffness and autonomic dysfunction, highlighting that even patients considered “low risk” by standard measures may face elevated mortality risks.

Recommendations for an Integrated Care Model Aligned with SDG 3

A Call for Collaborative Health Management

Achieving the goals of SDG 3 requires a paradigm shift toward integrated care that addresses the complex needs of individuals with chronic, non-communicable diseases. For epilepsy, this means incorporating cardiac health into routine management.

1. Systematic Risk Screening: Clinicians should assess not only seizure frequency but also classic cardiovascular risk factors, including lipid profiles, and consider using EKG and echocardiography more routinely.
2. Prioritize High-Risk Patients: Individuals with refractory epilepsy, particularly those experiencing generalized tonic-clonic seizures, and those with multiple cardiovascular risk factors should be prioritized for comprehensive cardiac evaluation.
3. Referral to Cardiology: Patients identified as being in the highest risk category should be referred to a cardiologist for detailed assessment and co-management.
4. Promote Research and Education: Further clinical trials are needed to clarify the causal pathways and test interventions. Educating both patients and healthcare providers about the “epileptic heart” concept is crucial for empowering proactive health management.

Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being

  The entire article is centered on health, specifically the complex relationship between a neurological disorder (epilepsy) and cardiovascular diseases. It discusses disease prevalence, risk factors, mortality rates (SCD and SUDEP), and the need for improved diagnosis and treatment protocols. The core theme is ensuring healthy lives and promoting well-being by better understanding and managing the health risks associated with chronic non-communicable diseases.

What specific targets under those SDGs can be identified based on the article’s content?

1. Target 3.4: By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.

   The article directly addresses this target by focusing on mortality from non-communicable diseases (NCDs). Epilepsy is a chronic neurological NCD, and the article links it to an increased risk of cardiovascular diseases, another major group of NCDs. It highlights premature mortality in the form of Sudden Unexpected Death in Epilepsy (SUDEP), which typically affects younger individuals (ages 20-40), and Sudden Cardiac Death (SCD). The discussion on using tools like EKG and echocardiography for early risk assessment and referring high-risk patients to cardiology is a clear call for “prevention and treatment” to reduce this premature mortality.

2. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

   This target is relevant as the article advocates for expanding the “quality essential health-care services” available to people with epilepsy. It suggests that standard epilepsy care is insufficient and should be integrated with cardiovascular monitoring. The text proposes that services like “a 12-lead standard EKG,” “multi-day ambulatory monitor,” “echocardiography,” and referrals to cardiology should become part of routine care for high-risk patients. This implies a need to improve the coverage and quality of healthcare for this specific population to ensure they have access to the services required to manage their comprehensive health risks.

Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicator 3.4.1: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease.

   The article provides direct context for this indicator. It states that “People with epilepsy have close to a threefold risk for SCD [Sudden Cardiac Death], compared with the general population” and discusses mortality from SUDEP. It also notes that cardiovascular fitness, measured in METs, is a “powerful predictor of mortality.” Tracking the mortality rate from cardiovascular events specifically within the population of people with epilepsy would be a direct way to measure progress on Target 3.4, as discussed in the article.

2. Indicator 3.8.1: Coverage of essential health services.

   The article implicitly points to this indicator by listing several “essential health services” that are currently underutilized in epilepsy care but are crucial for assessing cardiovascular risk. Progress could be measured by tracking the coverage of these specific services among people with chronic or drug-resistant epilepsy. These services mentioned include:

   • Routine EKG monitoring
   • Echocardiography
   • Holter monitors or wireless ambulatory patch monitors
   • Treadmill testing for cardiovascular fitness (METs)
   • Lipid profile assessments
   • Formal referrals to cardiology specialists for high-risk patients

Table of SDGs, Targets, and Indicators

Source: newswise.com