Pathological evaluations of the hearts of 7 patients with epilepsy, aged 12 to 44 years, who died suddenly are reported from the Department of Neurosciences, New Jersey Medical School, Newark. Cardiac abnormalities were found in 5 epilepsy patients and in none of the hearts of a comparison non-epileptic group. Lesions were subendocardial, mainly irreversible perivascular and interstitial fibrosis, and reversible myocyte vacuolization. Seizures had been generalized and not more than 1 per month in the year prior to death. No patient had status epilepticus. Only 2 had therapeutic levels of AEDs at postmortem. Asphyxia was not the cause of death, and only 1 had neuropathological findings, a communicating hydrocephalus. Cardiac pathology was attributed to recurrent seizures and resulting coronary vasospasm with ischemia. 
COMMENT. Patients with epilepsy who die suddenly without apparent cause are likely to have a cardiac abnormality, causally related to prior recurrent seizures and vasospasm. Risk factors for sudden death in epilepsy include young age, especially African-American, ambulatory, a long history of infrequent seizures, predominantly generalized tonic-clonic, and subtherapeutic levels of AEDs.
Adolescents with a first tonic-clonic seizure and a normal EEG are candidates for a cardiac consultation and work-up to exclude a primary cardiac arrythmia, especially those involved in sports activities. The above study indicates that young patients with epilepsy may also require cardiac supervision to monitor possible coronary ischemic complications related to recurrent seizure activity. The necessity to maintain adequate AED levels in young, ambulatory and especially sports-orientated epilepsy patients is emphasized by these findings.