Case Presentation: A 24-year-old black male with a history of generalized epilepsy first diagnosed one year ago presented to the Emergency Department (ED) after one episode of a witnessed generalized tonic-clonic seizure. Upon arrival at the ED, he was at his baseline mental state. However, just moments later, he had another refractory generalized tonic-clonic seizure witnessed by the medical staff. He received intravenous (IV) lorazepam during this episode and was loaded with IV Levetiracetam. Upon arrival to the ED, his blood pressure (BP) and heart rate (HR) were within normal range. However, after the second episode of seizure, his BP and HR increased to 157/95 mmHg and 180 bpm, respectively. On physical exam, he was diaphoretic, lethargic and minimally arousable. ECG confirmed Afib with a ventricular rate of 190 bpm along with ST-segment depressions in the inferior and anterolateral leads. His serum cardiac biomarkers were normal. Initial boluses of diltiazem were ineffective in rate control, and a continuous drip was initiated. Within 16 hours, the patient was alert and back to his baseline mental state. An EEG showed no further epileptic activity. An MRI of the brain showed no structural abnormalities. The patient was restarted on oral Levetiracetam. Interestingly, the patient also converted to normal sinus rhythm within 20 hours. ECG showed resolution of ST-segment depressions. A transthoracic echocardiogram showed no significant abnormalities. He was started on low dose metoprolol and has maintained normal rhythm. He was not started on systemic anti-coagulation.
Discussion: Peri-ictal changes in autonomic function are well known, with both parasympathetic and sympathetic systems being affected. Sinus tachycardia occurs in more than 85% of complex partial and tonic-clonic seizures (1). Despite the fact that atrial fibrillation (AFib) is a common type of atrial arrhythmia, it has rarely been associated with epilepsy (2). Sudden unexpected death in epilepsy (SUDEP) is uncommon and not well studied, but the most highly relevant category of mortality in this population. Interestingly, cardiovascular effects are probably not the major cause of SUDEP (3,4). Therefore, ST-segment changes seen during epilepsy may be due to microvascular ischemia in the setting of higher maximal heart rates. It is unclear whether seizure-related Afib requires specific treatment. Adequate treatment of epilepsy is the optimal strategy to prevent cardiovascular sequelae. The increased mortality and morbidity and the potential impairment of cardiac function prompt discussion regarding treatment with neuro-hormonal blockade and systemic anti-coagulation. Episodes of atrial arrhythmias are usually self-limited and often do not require prophylactic rate or rhythm control. There are no clinical data to support long-term medical therapy.
Conclusions: In conclusion, although atrial arrhythmias and specifically sinus tachycardia are commonly associated with epileptic seizures, atrial fibrillation has infrequently been reported. Variations in autonomic tone induced by peri-ictal seizure discharges are hypothesized to be causal in arrhythmia generation. It is unclear whether seizure-related atrial fibrillation requires specific treatment. However, the best prevention remains to be the adequate treatment of epilepsy.