Cardiogenic syncope and epilepsy: how not to make a mistake in the diagnosis. Clinical case and current of the issue status

Authors: E.V. Gordeeva1 2, N.V. Kizhvatova1 2, E.D. Kosmacheva1 2, L.V. Timchenko1, V.A. Porkhanov1 2

Company: 1 Scientific Research Institution – Professor S.V. Ochapovsky Region Clinical Hospital No 1, Krasnodar, 350086, Russian Federation
2 Kuban State Medical University, Krasnodar, 350063, Russian Federation

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Type:  Case reports


For citation: Gordeeva E.V., Kizhvatova N.V., Kosmacheva E.D., Timchenko L.V., Porkhanov V.A. Cardiogenic syn- cope and epilepsy: how not to make a mistake in the diagnosis. Clinical case and current of the issue status. Creative Cardiology. 2020; 14 (2): 178–87 (in Russ.). DOI: 10.24022/1997-3187-2020-14-2-178-187

Received / Accepted:  12.05.2020 / 21.05.2020

Keywords: syncope cardiogenic syncope rhythm disturbances epilepsy sudden death

Full text:  



Syncopal conditions accompanied by convulsive syndrome are fairly frequent clinical situations that require a thorough examination and differential diagnosis of epilepsy with other, including cardiac, diseases that cause cerebral hypoperfusion. Risk stratification is fundamental in the management, and assessment of high-risk clinical symptoms should be carried out both at the first visit and at repeated contact with patient, provided that the symptoms persist. Here we present a clinical case of a transient complete atrioventricular block that manifested itself in the form of a loss of consciousness, accompanied by convulsive attack, which caused misdiagnosis of epilepsy and prolonged ineffective administration of anticonvulsants. The symptoms were eliminated by the implantation of a pacemaker. The discussion provides an algorithm for the differential diagnosis of syncope accompanied by seizures and cardiogenic syncope. In turn, an epileptic seizure can be accompanied by both benign, reversible rhythm disturbances, often sinus tachycardia, and prognostically unfavorable ones: ventricular fibrillation and bradycardia / asystole. It is considered that fatal cardiac arrhythmia is a cause of sudden death in epilepsy. The article presents the possible mechanisms for the development of such complications and the principles of patient management.


  1. Sheldon R., Rose S., Connolly S., Ritchie D., Koshman M.-L., Frenneaux M. Diagnostic criteria for vasovagal syncope based on a quantitative history. Eur. Heart J. 2006; 27: 344–50. DOI: 10.1093/eurheartj/ehi584
  2. Da Silva R.M.F.L. Syncope: epidemiology, etiology, and prognosis. Front. Physiol. 2014; 5: 471. DOI: 10.3389/fphys.2014.00471
  3. Nei M., Sperling M.R., Mintzer S., Ho R.T. Long-term cardiac rhythm and repolarization abnormalities in refractory focal and generalized epilepsy. Epilepsia. 2012; 53 (8): e137–40. DOI: 10.1111/j.1528-1167.2012.03561.x
  4. Shmuely S., Bauer P.R., van Zwet E.W., Van Dijk J.G., Thijs R.D. Differentiating motor phenomena in tilt-induced syncope and convulsive seizures. Neurology. 2018; 90: e1339. DOI: 10.1212/WNL.0000000000005301.
  5. S, ahin I., Karabulut A., Kızkapan F., Okuyan E. Epileptic seizures secondary to high degree atrioventricular block without escape rhythm. Türk. Kardiyol. Dern. Ars,. Arch. Turk. Soc. Cardiol. 2014; 42 (7): 655–7. DOI: 10.5543/tkda.2014.20050
  6. Xu Y., Nguyen D., Mohamed A. et al. Frequency of a false positive diagnosis of epilepsy: a systematic review of observational studies. Seizure. 2016; 41: 167–74.
  7. Rangel I., Freitas J., Sousa A., Correia A.S., Lebreiro A., Paiva M. et al. Tilt table testing in patients with suspected epilepsy. Eur. Heart J. 2012; 33: 828.
  8. Freitas J.P., Rangel I., Maciel M.J., RochaGoncalves F. Misdiagnosis epilepsy. Role of tilt table testing. Europace. 2013; 15: ii115.
  9. Zaidi A., Clough P., Cooper P., Scheepers B., Fitzpatrick A.P. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J. Am. Coll. Cardiol. 2000; 36: 181–4.
  10. Bergfeldt L. Differential diagnosis of cardiogenic syncope and seizure disorders. Heart. 2003; 89 (3): 353–8. DOI: 10.1136/heart.89.3.353
  11. Sheldon R. How to differentiate syncope from seizure. Cardiol. Clin. 2015; 33 (3): 377–85. DOI: 10.1016/j.ccl.2015.04.006
  12. Ungar A., Ceccofiglio A., Pescini F. et al. Syncope and epilepsy coexist in 'possible' and 'drug-resistant' epilepsy (Overlap between Epilepsy and Syncope Study – OESYS). BMC. Neurol. 2017; 17 (1): 45. DOI: 10.1186/s12883-017-0822-5
  13. Colman N., Nahm K., Ganzeboom K. et al. Epidemiology of reflex syncope. Clin. Auton. Res. 2004; 14 (Suppl. 1): i9–17. DOI: 10.1007/s10286-004-1003-3
  14. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur. Heart J. 2018; 39 (21): 1883–948. DOI: 10.1093/eurheartj/ehy037
  15. Van der Lende M., Surges R., Sander J.W., Thijs R.D. Cardiac arrhythmias during or after epileptic seizures. J. Neurol. Neurosurg. Psychiatry. 2016; 87 (1): 69–74. DOI: 10.1136/jnnp-2015-310559
  16. Thurman D.J., Logroscino G., Beghi E. et al. The burden of premature mortality of epilepsy in highincome countries: a systematic review from the mortality task force of the international league against epilepsy. Epilepsia. 2017; 58: 17–26. DOI: 10.17749/2077-8333.2017.9.4.050-063
  17. Rubleva Yu.V., Mironov M.B., Krasilshchikova T.M., Burd S.G. The effect of epileptic seizures on heart rate and conduction: literary revolution. Epilepsy and paroxysmal conditions. 2017; 9 (4): 50–63 (in Russ.)
  18. Espinosa P.S., Lee J.W., Tedrow U.B. et al. Sudden unexpected near death in epilepsy: malignant arrhythmia from a partial seizure. Neurology. 2009; 72: 1702–03.
  19. Reeves A.L., Nollet K.E., Klass D.W. et al. The ictalbradycardia syndrome. Epilepsia. 1996; 37: 983–7.
  20. Manolis Th.A., Manolis A.A., Melita H. Sudden unexpected death in epilepsy: the neuro-cardiorespiratory connection. DOI: 10.1016/j.seizure. 2018.12.007
  21. Paton J.F., Boscan P., Pickering A.E. et al. The yin and yang of cardiac autonomic control: vago-sympathetic interactions revisited. Brain. Res. Rev. 2005; 49: 555–5. DOI: 10.1016/j.brainresrev. 2005.02.005
  22. Ryvlin P. Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study. Lancet Neurol. 2013; 12: 966–77. DOI: 10.1016/S14744422(13)70214-X
  23. Kennebäck G., Bergfeldt L., Vallin H. et al. Electrophysiologic effects and clinical hazards of carbamazepine treatment for neurologic disorders in patients with abnormalities of the cardiac conduction system. Am. Heart J. 1991; 121: 1421–9.
  24. Velagapudi P., Turagam M., Laurence T., Kocheril. Cardiac arrhythmias and sudden unexpected death in epilepsy (SUDEP). Pacing Clin. Electrophysiol. 2012; 35 (3): 363–70. DOI: 10.1111/j.15408159.2011.03276.x

About Authors

Elena V. Gordeeva, Cand. Med. Sc., Functional Diagnostician of Region Clinical Hospital # 1, Assistant Professor of Kuban State Medical University,
Natal’ya V. Kizhvatova, Cand. Med. Sc., Head of Cardiology Department # 3 of Region Clinical Hospital # 1, Associate Professor of Department of Therapy # 1 of Kuban State Medical University,
Elena D. Kosmacheva, Dr. Med. Sc., Professor, Deputy Chief Physician of Region Clinical Hospital # 1, Chief Cardiologist of the Southern Federal District and Krasnodar Territory, Head of Therapy Department # 1 of Kuban State Medical University,
Lyudmila V. Timchenko, Head of Department,
Vladimir A. Porkhanov, Dr. Med. Sc., Professor, Academician of RAS, Chief Physician of Region Clinical
Hospital # 1, Honored Doctor of the Russian Federation, Chief Thoracic Surgeon of the Krasnodar Territory, Chief of Chair of Oncology with a Course of Thoracic Surgery of Kuban State Medical University,

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery