The pathological state of "epileptic heart" induced by epilepsy has shattered the perception that epilepsy is an isolated neurological disorder, reflecting the synergistic damage between chronic epilepsy and cardiac bioelectrical activity as well as mechanical function. Autonomic nervous system dysfunction is the core mediating link, which regulates the expression of myocardial ion channels and induces risks such as arrhythmias. In the long term, it also drives structural remodeling and functional impairment including left atrial enlargement and myocardial fibrosis. This kind of damage is influenced by factors such as classification of epilepsy, disease duration, and antiepileptic drugs—for instance, patients with drug resistant epilepsy or those on long-term polypharmacy suffer more significant damage. This article systematically reviews recent research progress, summarizes consensus and controversies, provides a basis for the precision management of cardiovascular risks in epilepsy patients, and contributes to reducing the incidence of SUDEP and improving long-term quality of life.