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Children with ADHD should get heart tests before given stimulant drugs 4-22-08
The American Heart Association on April 21 issued a statement to recommend
that children with attention deficit hyperactivity disorder (ADHD) should get
careful assessment for their cardiac condition using an electrocardiogram (ECG)
before treatment with stimulant drugs.
The recommendation is also valid for children who are currently receiving
stimulant therapy, but have not received the cardiac evaluation. The AHA said
side effects of ADHD drugs are insignificant, but they may have an impact on
children with certain heart abnormalities.
The 18-page statement titled Cardiovascular Monitoring of Children and
Adolescents with Heart Disease Receiving Stimulant Drugs was published online in
Circulation: Journal of the American Heart Association.
According to the AHA, what drove the organization to issue such a statement are
the concerns over potential cardiovascular effects of psychotropic drugs,
especially tricyclic antidepressants. The concerns have emerged since 1999, but
no specific cardiovascular monitoring with an ECG has been recommended for the
use of stimulant medications. What also prompted the statement are warnings from
the Food and Drug Administration about ADHD drugs and public concerns for the
drug safety.
Stimulant medications used to treat ADHD have been known to increase heart rate
and blood pressure, which could increase cardiac events. One study led by
Samuels JA, Franco K, Wan F, Sorof JM. from The University of Texas Health
Science Center at Houston reported in 2006 showed evidence for a possible
negative cardiovascular effect of stimulant medications in children with ADHD.
And the authors suggested that this potential cardiovascular risk should be
balanced against the beneficial behavioral effects of this class of medication.
In their report published in Pediatr Nephrol. 2006 Jan;21(1):92-5. Epub 2005 Oct
28., they said children receiving stimulant therapy had significantly higher
diastolic blood pressure and waking diastolic blood pressure during a 24-hour
monitoring period. Both total heart rate and the rate-pressure product were also
higher, meaning that using the ADHD drugs increases heart risk in pediatric
patients.
Certain heart conditions such as erratic heart rhythm increase the risk for
sudden cardiac death (SCD) and use of ADHD drugs have been associated with
increased risk of sudden cardiac deaths. A report published in 2006 by
Langendijk P. N. and Wilde A. A. from Academisch Medisch Centrum/Universiteit
van Amsterdam showed that the U.S. Adverse Event Reporting System documented 25
cases of sudden death based on WHO criteria with the use of amphetamines and
methylphenidate, stimulant drugs used to treat attention deficit hyperactivity
disorder (ADHD). Most the cases were children aged less than 18 years.
The authors said sudden death in children is often caused by fatal arrhythmias
due to congenital heart disease such as long QT syndrome and hypertrophic
cardiomyopathy. The article was titled Medication for ADHD and the risk of
cardiovascular mortality and published in the Aug 5, 2006 issue of Nederlands
Tijdschrift voor Geneeskunde.
The AHA said doctors perform routine physical exams and review the patient and
family history to determine the risk of health problems before starting new
treatments, but such examinations are not sufficient to detect the cardiac
conditions associated with SCD because many of these conditions do not result in
symptoms and even if there is any the subtle symptoms such as palpitations,
fainting or chest pain can be vague or elusive. But an ECG can have the job
done.
Based on these arguments, the AHA recommends an ECG should be used to evaluate
cardiac conditions in children with ADHD before any treatment with stimulant
drugs. This can help doctors to identify heart rhythm abnormalities that could
potentially lead to sudden cardiac death. The AHA receives donations from
pharmaceutical firms and medical device manufacturers, the organization states
on its website.
The authors for the statement said children who are found to have a heart
condition should be referred to a pediatric cardiologist. Those who are deemed
to have no problem and start taking ADHD drugs should be checked periodically
for blood pressure within one to three months and then every six to 12 months.
Further, if the initial ECG is taken before age 12, the statement says it may be
useful to repeat the ECG test after the children is over 12 years.
Victoria L. Vetter, M.D at the University of Pennsylvania School of Medicine in
Philadelphia, lead author of the statement, said 33 to 42 percent of pediatric
cardiac patients have ADHD. Early surveys showed an estimated 4 to 12 percent of
all school children suffered ADHD and about 2.5 million children took
medications for the condition in 2003.