Does a patient with heart failure on a novel anticoagulant (e.g. apixaban) who severely bit their tongue in their sleep need to be evaluated for possible seizure?

Evaluation for Seizure in a Heart Failure Patient with Tongue Bite on Novel Anticoagulant

Yes, a patient with heart failure on a novel anticoagulant who severely bit their tongue in their sleep should be evaluated for possible seizure, as tongue biting during sleep is a significant indicator of potential seizure activity. 1

Relationship Between Tongue Biting and Seizures

• Tongue biting, particularly when it occurs during sleep, is strongly associated with seizure activity, especially the tonic component of generalized seizures 1
• Patients with epilepsy are at particular risk of injury during seizures, with tongue biting being a specific risk during the tonic phase of generalized seizures 1
• In post-stroke patients (a population that overlaps with heart failure patients), the risk of seizures is >5%, making this a significant concern 1

Special Considerations for Patients on Novel Anticoagulants

• Patients on novel anticoagulants (NOACs) have an increased bleeding risk, making any trauma (including tongue biting) potentially more severe 1, 2
• The combination of heart failure, anticoagulation, and potential seizure activity represents a high-risk clinical scenario requiring prompt evaluation 3
• Seizure activity in anticoagulated patients poses a special risk due to the potential for traumatic injury during seizures 1

Evaluation Algorithm

1. Immediate assessment:

   • Detailed history of the tongue-biting episode (timing, severity, associated symptoms) 1
   • Examination of the tongue injury to assess severity 1
   • Neurological examination focusing on focal deficits 1

2. Diagnostic workup:

   • Electroencephalogram (EEG) to evaluate for seizure activity 1
   • Brain imaging (CT or MRI) to rule out structural lesions, especially important in anticoagulated patients 1
   • Laboratory tests including:
     • Complete blood count
     • Comprehensive metabolic panel
     • Anticoagulation levels if applicable 1

3. Medication review:

   • Assess for drug-drug interactions between antiepileptic drugs and NOACs 1
   • Several antiepileptic drugs (phenytoin, carbamazepine, phenobarbital) can reduce NOAC efficacy 1
   • Some antiepileptic drugs can cause thrombocytopenia or platelet dysfunction, further increasing bleeding risk 1

Management Considerations

• If seizure is confirmed, antiepileptic medication selection must consider interactions with NOACs 1
• Careful monitoring of both seizure control and anticoagulation status will be required 1
• Regular follow-up is essential as both conditions (heart failure and seizures) can worsen over time 1

Potential Pitfalls and Caveats

• Not all tongue biting is seizure-related, but severe tongue biting during sleep strongly suggests seizure activity 1
• Misattributing tongue biting to other causes may lead to delayed diagnosis of seizures 1
• Patients with heart failure and multiple comorbidities are at higher risk for adverse outcomes and require comprehensive evaluation 3, 4
• The combination of antiepileptic drugs and NOACs requires careful management due to potential interactions affecting both efficacy and safety 1