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Expert Interview Epilepsy Introducing New Guidelines on Sudden Unexpected Death in Epilepsy An Expert Interview with Cynthia L Harden Department of Neurology, Mount Sinai Health System, New York, NY, US Cynthia L Harden Cynthia L Harden, MD, received her medical degree at the University of Wisconsin. She trained in internal medicine at Mount Sinai St Luke’s Hospital and neurology at Mount Sinai Hospital, both in New York City, and in clinical neurophysiology at Albert Einstein College of Medicine in the Bronx. She served most of her career at Weill Cornell College of Medicine, where she became Professor of Neurology. Dr Harden serves as Chair of the Guideline Development, Dissemination and Implementation Subcommittee of the American Academy of Neurology (AAN). In 2016, she was also elected Chair of AAN’s Epilepsy Section for a 2-year term. Keywords Epilepsy, guidelines, sudden unexpected death, SUDEP Disclosure: Cynthia L Harden has nothing to declare in relation to this article. This is an expert interview and as such, has not undergone the journal's standard peer review process. No funding was received in the publication of this article. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: June 12, 2017 Published Online: July 24, 2017 Citation: US Neurology, 2017;13(2):65–6 Corresponding Author: Cynthia L Harden, Mount Sinai Health System, Mount Sinai Beth Israel Phillips Ambulatory Care Center, 10 Union Square East, Suite 5D, New York, NY 10003, US. E: TOU CH MED ICA L MEDIA N ew guidelines from the American Academy of Neurology (AAN) and the American Epilepsy Society on sudden unexpected death in epilepsy (SUDEP) were presented at the 69th Annual AAN Meeting held in Boston, MA, US, May 28–22, 2017 in parallel with their publication in Neurology. 1 In an expert interview, Dr Cynthia L Harden of Mount Sinai discusses SUDEP, why the new guidelines were needed and the key recommendations. Q. What is the incidence of SUDEP? Based on moderate confidence in the evidence from three Class I studies, SUDEP risk in children with epilepsy is 0.22/1,000 patient-years (95% confidence interval [CI] 0.16–0.31). 1 Based on low confidence in the evidence, due to considerable imprecision across five Class I studies, SUDEP risk increases in adults to 1.2/1,000 patient-years (95% CI 0.64–2.32). 1 These rates were derived according to the AAN guideline process, as follows: in the comprehensive analysis of the literature, the authors included reports that met AAN criteria to be categorized as Class I, which means they are less likely to have selection bias than reports determined to be Class II-IV. 2 The Class I articles surveyed a population-representative group of people with epilepsy, and captured at least 80% of the deaths in the study population, and of the deaths, at least 80% were systematically evaluated for death due to SUDEP. A random-effects meta-analysis was performed across age groups, due to variation in SUDEP incidence rates across studies. The three papers in children had close agreement as to the SUDEP incidence per 1,000 epilepsy patient-years, therefore the confidence in the evidence is “moderate”, meaning that future studies are unlikely to change this incidence rate. The five papers in adults with epilepsy had more variation in their findings, resulting in the confidence in the evidence as “low”, meaning that future studies may change this SUDEP incidence rate. These rates are based on an accurate documentation of the SUDEP diagnosis, so that the SUDEP occurrences were either “definite”, meaning an autopsy was performed, or “probable”, meaning that the SUDEP criteria were met, but no autopsy was performed. Overall, the incidence appears to increase after age 18. Patients over age 55 were often excluded in the reports since competing causes of death e.g., cardiovascular-related, could not be reliably excluded in this mature age group. These results suggest that ongoing research to accurately capture SUDEP diagnoses at the point of contact with the medical examiner, is still needed. 65