Cardiovascular disease risk, awareness, and treatment in people with epilepsy

Samuel W Terman,Carole E Aubert,Chloe E Hill,Jeremy Skvarce,James F Burke,Scott Mintzer

doi:10.1016/j.yebeh.2021.107878

Abstract

ObjectiveTo evaluate whether cardiovascular risk, risk awareness, and guideline concordant treatment differ in individuals with versus without epilepsy. MethodsThis was a retrospective cross-sectional study using the National Health and Nutrition Examination Survey. We included participants ≥18 years for 2013–2018. We classified participants as having epilepsy if reporting ≥1 medication treating seizures. We calculated 10-year atherosclerotic cardiovascular disease (ASCVD) risk using the revised pooled cohort equation. We compared unadjusted and adjusted risk for participants with versus without epilepsy. We then assessed hypertension and diabetes disease awareness and control, plus statin guideline-concordance. We assessed mediators for both ASCVD risk and cardiovascular disease awareness. ResultsOf 17,961 participants, 154 (0.9%) had epilepsy. Participants with epilepsy reported poorer diet (p = 0.03), fewer minutes of moderate-vigorous activity per day (p < 0.01), and increased frequency of cardiovascular conditions (e.g. coronary heart disease, myocardial infarction, stroke). There was no difference in control of individual examination and laboratory risk factors between groups (A1c, systolic blood pressure, diastolic blood pressure, high-density lipoprotein, low-density lipoprotein, total cholesterol). However, epilepsy was associated with 52% (95% confidence interval [CI]: 0–130%) increase in ASCVD risk, which became nonsignificant after adjusting for health behaviors. No single studied variable (income, Patient Health Questionnaire-9 (PHQ-9), diet, smoking) had a significant indirect effect. Participants with epilepsy reported increased hypertension awareness which was trivially but significantly mediated by having a routine place of healthcare (indirect effect: 1% absolute increase (95% CI: 0–1%), and they reported increased rates of hypertension treatment and guideline-concordant statin therapy. Participants with versus without epilepsy reported similar rates of blood pressure control and diabetes awareness, treatment, and control. ConclusionsParticipants with epilepsy had increased ASCVD risk, despite similar or better awareness, treatment, and control of individual risk factors such as diabetes and hypertension. Our results suggest that epilepsy is associated with numerous health behaviors leading to cardiovascular disease, though the causal pathway is complex as these variables (income, depression, diet, exercise, smoking) generally served as confounders rather than mediators.

Highlights

While clinicians focus attention on sudden unexplained death in patients with epilepsy (SUDEP), large cohorts suggest that cardiovascular diseases cause up to 30–45% of deaths in people with epilepsy [1,2,3,4,5,6,7,8,9,10]
Our results suggest that epilepsy is associated with numerous health behaviors leading to cardiovascular disease, though the causal pathway is complex as these variables generally served as confounders rather than mediators
This hypothesis was informed by several pieces of prior evidence: previous cross-sectional surveys documented 1) increased rates of self-reported diabetes, hypertension, coronary disease, and stroke [12,13,14,15], 2) worse health behaviors [21,22], 3) disparities in access to care which could interfere with adequate risk factor control [19], and 4) certain enzyme-inducing antiseizure medications may elevate lipids in people with epilepsy [25]

Summary

Introduction

While clinicians focus attention on sudden unexplained death in patients with epilepsy (SUDEP), large cohorts suggest that cardiovascular diseases cause up to 30–45% of deaths in people with epilepsy [1,2,3,4,5,6,7,8,9,10]. Previous cross-sectional surveys have documented increased rates of diabetes, coronary heart disease, hypertension, and stroke in patients with epilepsy [12,13,14,15]. Such studies were limited by self-reported outcomes which could misclassify patients. In the general population it has been documented that only $50–70% of patients with hypertension or diabetes are aware of their diagnosis, and just 10–30% demonstrate risk factor control [17,18] These issues may be even more problematic in epilepsy because of possible disparities in access or adherence [19]. Additional possible mediators between epilepsy and cardiovascular risk may include poorer health behaviors [20,21,22], lower socioeconomic status [19,23,24], or lipid-elevating enzyme-inducing antiseizure medications [25,26]

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