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ADHD Medications: Cardiovascular Monitoring

Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Medications for Attention Deficit/Hyperactivity Disorder: A Scientific
Statement From the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing
Circulation 2008;117;2407-2423; originally published online Apr 21, 2008;
http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.107.189473/DC1

Cardiovascular Monitoring and Stimulant Drugs for Attention-Deficit Hyperactivity Disorder - Policy Statement of the American Academy of Pediatrics
Published online on May 28, 2008
http://www.aap.org/new/ecg-adhd.htm

American Academy of Pediatrics/American Heart Association Clarification of Statement on Cardiovascular Evaluation and Monitoring of Children and Adolescents With Heart Disease Receiving Medications for ADHD
Published online on June 3, 2008
http://americanheart.mediaroom.com/index.php?s=43&item=422

In late April the American Heart Association (AHA) released new guidelines for children receiving stimulant medication for Attention Deficit Hyperactivity Disorder (ADHD) The AHA recommended that all children beginning treatment with stimulant medications, and those already on stimulant medication, should have an electrocardiogram (ECG) to search for occult heart disease that could place them at increased risk for sudden cardiac death. This recommendation caused anxiety in many parents and frustration in many psychiatrists and pediatricians.

The AHA recommendation has significant procedural and financial implications. It is estimated that 2.5 million children are receiving stimulant medication now. Obtaining an ECG on each one would entail significant costs. For some patients a further barrier was the suggestion that the ECG should be reviewed by a practitioner experienced in reading pediatric ECG.  This would limit the reading of these studies to pediatric cardiologists and a small subset of pediatricians.

Within a month the American Academy of Pediatrics (AAP) fired back. The AAP published its own policy statement on stimulants and ADHD on May 28, 2008. Highlights included. 

• Sudden Cardiac Death (SCD) in persons taking medications for ADHD is a rare event occurring at rates no higher than in the general population of children and adolescents
• Stimulant medication can cause mild elevations of blood pressure and heart rate but there is no evidence they increase the risk of SCD
• There is no evidence that the routine use of ECG screening before beginning medication for ADHD treatment would prevent SCD.
• Substantial evidence exists concerning the efficacy and safety of ADHD treatment with stimulant medications.
• Requiring an ECG before stimulant treatment could create a barrier to timely therapy. Limiting children’s access to effective treatment for ADHD could have serious implications, because there are substantial risks of not treating ADHD.

The AAP recommended that the cardiac evaluation of children taking stimulant medication should not change from their previous policy in 2000. The recommendations were as follows:

1. The AAP continues to recommend a careful assessment of all children, including those starting stimulants, using a targeted cardiac history (e.g., patient history of previously detected cardiac disease, palpitations, syncope, or seizures; a family history of sudden death in children or young adults; hypertrophic cardiomyopathy; long QT syndrome) and a physical examination, including a careful cardiac examination.

2. Given current evidence, the AAP encourages primary care and subspecialty physicians to continue currently recommended treatment for ADHD, including stimulant medications, without obtaining routine ECGs or routine subspecialty cardiology evaluations for most children before starting therapy with these medications.

To resolve confusion between the two professional societies the AAP and AHA issued a joint statement on June 3, 2008. The relevant portion is listed below:

• Obtaining a patient and family health history and doing a physical exam focused on cardiovascular disease risk factors are recommended by the AAP and AHA for assessing patients before treatment with drugs for ADHD.
• It is reasonable for a physician to consider obtaining an ECG as part of the evaluation of children being considered for stimulant drug therapy, but this should be at the physician’s judgment, and it is not mandatory to obtain one.
• Treatment of a patient with ADHD should not be withheld because an ECG is not done

Editorial Comment
The AAP statement of May 28, 2008 is reasonable guidelines that practitioners should embrace. Patients should be screened by history for potential cardiac risk factors and have a physical exam that focuses on cardiovascular system. Patients with known or suspected heart disease may need an ECG and further specialty evaluation.

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