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EDITORIAL
Because scientists are unable to explain the unexplained, screening for cardiovascular abnormalities is a good method to protect against sudden unexpected death in patients with epilepsy
Fulvio A ScorzaI,
Corresponding author
scorza.nexp@epm.br

Tel.: 55 11 5549 2064
, Ricardo M AridaII, Esper A CavalheiroI, Maurício Rocha e SilvaIII
I Universidade Federal de São Paulo, Escola Paulista de Medicina (UNIFESP/EPM), Disciplina de Neurologia Experimental, São Paulo/SP, Brazil.
II Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Departamento de Fisiologia, São Paulo/SP, Brazil.
III Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brazil.
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="para10" class="elsevierStylePara elsevierViewall">According to Professor Gutgesell&#44; sudden and unexpected deaths in young athletes and celebrities elicit intense media coverage&#44; often accompanied by the questions&#44; &#8220;Why did he die&#63;&#8221; and &#8220;Why could not this have been prevented&#63;&#8221; &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41;&#46; Interestingly&#44; these two important questions are also asked by the relatives of patients with epilepsy who die suddenly&#46; In the field of epilepsy&#44; how can we elucidate these issues&#63;</p><p id="para20" class="elsevierStylePara elsevierViewall">Regarding the first question&#44; in the vernacular of the epilepsy world&#44; the patient suffered what is called &#8220;sudden unexplained death in epilepsy&#8221; &#40;SUDEP&#41;&#46; SUDEP is a leading cause of mortality in patients with epilepsy &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41; and is defined as sudden&#44; unexpected&#44; witnessed or unwitnessed&#44; non-traumatic&#44; and non-drowning deaths in patients with epilepsy&#46; It occurs with or without evidence of a seizure&#44; excluding documented <span class="elsevierStyleItalic">status epilepticus</span>&#44; when the post-mortem examination does not reveal a toxicological or anatomical cause of death &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&#46; The reported incidence of SUDEP is variable&#44; largely due to the differences in patient populations&#44; study designs&#44; and the criteria used for defining the condition &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41;&#46; In fact&#44; results from a US population-based study indicate that the risk of sudden death in people with epilepsy is estimated to be as much as 20 times higher than that of the general population &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&#46; In general terms&#44; SUDEP is responsible for 7&#46;5&#37; to 17&#37; of all deaths in patients with epilepsy and has an incidence between 1&#58;500 and 1&#58;1&#44;000 patient-years among affected adults &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41;&#46; Concerning risk factors&#44; a number of associated factors have been reported&#44; but the results are not consistent between studies&#46; To date&#44; several studies have identified factors that potentially correlate with an elevated risk of SUDEP&#44; such as the refractoriness of the epileptic condition&#44; presence of generalized tonic-clonic seizures&#44; early onset of epilepsy&#44; antiepileptic medication &#40;polytherapy with antiepileptic drugs&#41;&#44; young age&#44; and duration of the seizure disorder &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#44;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#41;&#46; Although the cause of SUDEP is still unknown&#44; one of the main mechanisms of SUDEP is autonomic dysregulation &#40;i&#46;e&#46;&#44; cardiac abnormalities during and between seizures&#41; &#40;<a class="elsevierStyleCrossRefs" href="#bib6">6&#8211;8</a>&#41;&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">To address the second question &#40;&#8220;Why could not this have been prevented&#63;&#8221;&#41;&#44; although progress has been made relating to SUDEP over the last decade&#44; it remains somewhat of a &#8216;black box&#39; phenomenon &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&#46; Thus&#44; predicting and preventing SUDEP are challenging tasks &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&#46; Although we still are unable to prevent the onset of epilepsy or to reverse an established clinical picture&#44; preventive measures in clinical practice have been proposed to minimize the occurrence of SUDEP&#58; 1&#41; good seizure control&#59; 2&#41; stress reduction&#59; 3&#41; participation in physical activities and sports&#59; 4&#41; supervision at night&#59; 5&#41; educating family members regarding cardiopulmonary resuscitation &#40;CPR&#41; techniques and the basics of defibrillator use&#59; and 6&#41; dietary management &#40;i&#46;e&#46;&#44; omega-3 supplementation&#41; &#40;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#41;&#46; However&#44; we agree with Shorvon and Tomson &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41; that because there are no data on the effectiveness of any particular clinical strategy&#44; these suggestions are merely speculative&#46; However&#44; based on the reported evidence&#44; we believe that reducing the occurrence of tonic-clonic seizures&#44; exercising caution when changing antiepileptic drugs&#44; and improving post-ictal surveillance are likely to be beneficial &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">From a cardiovascular perspective and because the mechanism for the occurrence of SUDEP in people with uncontrolled seizures could be of cardiac origin&#44; &#40;<a class="elsevierStyleCrossRefs" href="#bib6">6&#8211;8</a>&#41; it seems obvious that a true convergence of clinical neurology and cardiology should be adopted to attempt to minimize the occurrence of sudden cardiac death in individuals with epilepsy&#46; Thus&#44; some primary and secondary preventive measures should be evaluated in people with refractory epilepsy&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">Similar to individuals in the general population&#44; all people with epilepsy should regularly take part in important primary preventive measures&#46; We must remember that because sudden cardiac arrest is often linked with coronary artery disease&#44; the same factors that put a patient at risk of coronary artery disease may also put them at risk for sudden cardiac arrest&#46; These factors include a family history of coronary artery disease&#44; smoking&#44; high blood pressure&#44; high blood cholesterol&#44; obesity&#44; diabetes&#44; and a sedentary lifestyle&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Concerning secondary preventive measures&#44; individuals with epilepsy that are also at a high risk for SUDEP should receive additional tests&#46; Because identifying cardiovascular abnormalities may help prevent episodes of cardiac arrest&#44; the recommended tests include blood tests &#40;lipid&#44; enzymatic&#44; hormone&#44; and electrolyte profiling&#41; and electrocardiography&#46; In addition&#44; imaging tests are suggested to screen for cardiac dysfunction&#44; such as chest X-rays&#44; nuclear scans&#44; and echocardiograms&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">Finally&#44; we completely support the suggestion &#40;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#41; that if there is a reasonable chance of preventing SUDEP&#44; it must be discussed with patients with epilepsy who are at the highest risk of SUDEP&#46; With this goal in mind&#44; the physician can explain possible strategies that people with epilepsy and their families can take to reduce their SUDEP risk&#46; As all of the risk factors&#44; mechanisms&#44; and specific methods to prevent SUDEP are not yet completely understood&#44; caution remains prudent and necessary&#46;</p></span>"
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos