Cardiovascular risks and implications of epilepsy: The epileptic heart

The “Epileptic Heart” refers to progressive cardiac dysfunction in people with epilepsy (PWE), driven by recurrent seizures, anti-seizure medication (ASM), and autonomic dysregulation. Although originally introduced as a pathophysiological construct, its clinical application remains insufficiently developed. In this review, we propose clinical strategies for incorporating the concept into routine care, including a clinical workflow for cardiovascular screening in PWE to facilitate diagnosis and risk assessment in everyday practice. We also propose a novel conceptual framework—the Epileptic Heart Risk Index (EHRI)—to guide cardiovascular risk evaluation in PWE, integrating seizure burden, autonomic imbalance, ASM profile, and comorbid cardiovascular conditions to support stratification in clinical practice. In addition, we highlight promising future directions such as wearable biosensors for continuous monitoring and risk prediction, neuroimaging biomarkers of autonomic dysfunction, and tailored therapies—including vagus nerve stimulation (VNS)—that may reduce cardiovascular mortality in epilepsy.