Cardiac evaluation recommended in children with ADHD before treatment with stimulant drugs


Children with attention deficit hyperactivity disorder ( ADHD ) should get careful cardiac evaluation and monitoring, including an electrocardiogram ( ECG ), before treatment with stimulant drugs.

The scientific statement on Cardiovascular Monitoring of Children and Adolescents with Heart Disease Receiving Stimulant Drugs is published in Circulation: Journal of the American Heart Association ( AHA ).

In 1999, concerns over potential cardiovascular effects of psychotropic drugs, especially tricyclic antidepressants, but including stimulants, prompted an American Heart Association Scientific Statement: Cardiovascular Monitoring of Children and Adolescents Receiving Psychotropic Drugs. However, no specific cardiovascular monitoring was recommended for the use of stimulant medications. Warnings from the FDA ( Food and Drug Administration ) about stimulant medications and public concern for the safety of using them have prompted the current statement.

Studies have shown that stimulant medications like those used to treat ADHD can increase heart rate and blood pressure. These side effects are insignificant for most children with ADHD; however, they’re an important consideration for children who have a heart condition. Certain heart conditions increase the risk for sudden cardiac death ( SCD ), which occurs when the heart rhythm becomes erratic and doesn’t pump blood through the body.

Doctors usually use a physical exam and the patient and family history to detect the risk for or presence of health problems before beginning new treatments, including prescribing medication. But some of the cardiac conditions associated with sudden cardiac death may not be noticed in a routine physical exam. Many of these conditions are subtle and do not result in symptoms or have symptoms that are vague such as palpitations, fainting or chest pain.

That’s why the statement writing group recommends adding an ECG to pre-treatment evaluations for children with ADHD. An ECG measures the heart’s electrical activity and can often identify heart rhythm abnormalities such as those that can lead to sudden cardiac death.

If heart problems are suspected after the evaluation, children should be referred to a pediatric cardiologist. Once stimulant treatment begins, children should have their heart health monitored periodically, with a blood pressure check within one to three months, then again at routine follow-ups every six to 12 months.

If the initial ECG was taken before age 12 years, it may be useful to do a repeat ECG after the child is over age 12 years.

Widespread use of ECGs to detect heart abnormalities, including screenings for competitive athletes, is not routinely recommended by the American Heart Association. However, the ECG screening in this specific population of children prescribed ADHD medication may be medically indicated.

In 2003, an estimated 2.5 million children took medication for ADHD. Surveys indicate that ADHD affects an estimated 4 percent to 12 percent of all school-aged children in the United States, and it appears more common in children with heart conditions. Studies report that, depending on the specific cardiac condition, 33 percent to 42 percent of pediatric cardiac patients have ADHD. The number of undiagnosed children with heart conditions is unknown as routine heart screening is not performed; a recent pilot study indicated that up to 2 percent of healthy school aged children had potentially serious undiagnosed cardiac conditions identified by an ECG.

Data from the FDA showed that between 1999 and 2004, 19 children taking ADHD agents died suddenly and 26 children experienced cardiovascular events such as stroke, cardiac arrest and heart palpitations. Since February 2007, the FDA has required all manufacturers of drug products approved for ADHD treatment to develop Medication Guidelines to alert patients to possible cardiovascular risks.

Future studies are necessary to assess the true risk of sudden cardiac death in association with stimulant drugs in children and adolescents with and without heart disease, Vetter said. However, studying SCD associated with drugs is difficult because the government’s reporting system is voluntary, which means local data on these types of deaths isn’t always reported nationally.

Source: American Heart Association, 2008

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