Children and teens taking stimulants to treat attention
deficit hyperactivity disorder (ADHD) should be screened for hidden heart
problems, the American Heart Association now says.
In an updated consensus statement released today, the organization
recommends that in addition to a careful medical history and physical
examination, an electrocardiogram (ECG) be performed prior to starting any
child or teenager on stimulant medications. This represents a departure from
the previous scientific statement published about this topic in 1999.
More than 2.5 million children and teens in the U.S. take stimulants to
control their ADHD. With careful monitoring the drugs have been shown to be
safe even in those with known heart issues, cardiologist Victoria L. Vetter,
MD, of the Children's Hospital of Philadelphia tells WebMD.
Vetter led the American Heart Association (AHA) panel that wrote the
"We aren't trying to scare doctors away from using these drugs, which
are so important for the treatment of ADHD," Vetter says. "Most kids
can be treated, but very careful monitoring is important."
(Did your child's doctor order
these tests before prescribing ? If not, will you have them done now? Talk
with other parents on WebMD's
Children with ADD/ADHD message board.)
ADHD Drugs Raise Heart Rate, Blood Pressure
Stimulants like the ADHD drugs Ritalin, Adderall, Dexedrine, and Concerta
are known to increase heart rates and blood pressure, but the risk is not
considered significant in otherwise healthy children who take the drugs for
The FDA requires that the labeling on stimulants used in the treatment of
ADHD warn of a risk of sudden death in patients with heart problems. But the
incidence of cardiac events among children and teens taking the drugs is not
known because no registry exists to record these events, Vetter says.
In February 2005, Canada's drug regulatory agency briefly suspended the sale
of the ADHD drug Adderall based on U.S. reports of sudden deaths in
In March 2006, an FDA panel reported that between 1992 and early 2005, 11
sudden deaths in children had been attributed to medications such as Ritalin
and Concerta and 13 deaths were linked to amphetamines, such as Adderall or
Dexedrine. Three sudden deaths were reported in children taking the ADHD drug
Strattera, although Strattera is not a stimulant.
Studies suggest that ADHD is more common in children with heart problems
than in the general pediatric population. And the obesity epidemic has led to
an epidemic of high blood pressure among children and teens, Vetter says.
Since February 2007, the FDA has required that medications used to treat
ADHD be accompanied by information warning about the use of these drugs in
patients with heart problems. This has created a variety of dilemmas, including
how to determine if a child has heart disease.
Vetter says her own preliminary research suggests that as many as 2% of
children in the U.S. have undiagnosed heart problems that could be identified
by ECG screening.
"This is definitely an issue that needed to be addressed," she says.
The goal of the updated recommendations is to "allow treatment of this very
significant problem of ADHD while attempting to lower the risk of these
ECG Should Be Routine
The AHA panel's pretreatment recommendations include:
- Taking a thorough medical history prior to treatment, with special
attention given to symptoms that might indicate heart problems, such as heart
palpitations, high blood pressure, heart murmur, fainting or near-fainting
episodes, chest pain, or unexplained change in exercise
- Review of all current medications including prescription, over-the-counter
preparations, and health supplements.
- Careful evauation for a family history of sudden death, serious rhythm
abnormalities, heart muscle disorders (cardiomyopathy), or Marfan's
- A physical exam, including assessment of blood pressure and heart
- An ECG to identify or rule out heart problems. The electrocardiogram should
be read by a pediatric cardiologist or a doctor with expertise in reading
- Referral to a pediatric cardiologist if the pretreatment evaluation shows
cause for concern.
"We are not saying that if all these things can't be done, kids
shouldn't be put on medication," Vetter says. "A child who lives in
rural Kentucky may not have access to a pediatric ECG. We are going to have to
figure out how to address the access issue."
Furthermore, even if heart disease is identified, treatment may still be
used with careful monitoring. "It is reasonable to use stimulants with
caution in patients with known congenital heart disease and/or arrhythmias, if
these patients are stable and under the care of a pediatric cardiologist,"
the panel notes.
The AHA has also called for periodic cardiac evaluations of patients taking
ADHD drugs. The guideline states that blood pressure and pulse should be
evaluated during routine follow-up visits (every one to three months).
The guideline also recommends that a repeat ECG be considered after the age of
12 if the initial treatment ECG was obtained before 12 years of age.
Finally, patients currently taking stimulant medications who have not undergone
ECG testing in the past should have an ECG performed.
Panel members also called for the establishment of a registry to track
sudden cardiac deaths (SCD) in children, teens, and young adults.
"Such a registry, even if comprehensively maintained over a short period
of time, would allow a more accurate understanding of many questions related to
sudden cardiac death, including the potential association of stimulant drugs
and SCD," Vetter and colleagues write.
WebMD contacted the Pharmaceutical Research and Manufacturers of America
(PhRMA) about the AHA's new guidelines. In an email, PhRMA spokesman Jeff
Trewhitt says that PhRMA's medical staff is still reviewing the guidelines.
WebMD spoke with Robert H. Beekman, MD, chairman of the American Academy of
Pediatrics' section on cardiology and cardiac surgery, about the AHA's new
"The American Heart Association proposal is reasonable and represents
the cautious opinion of a number of national experts," says Beekman, who
works at Cincinnati Children's Hospital.
"There are concerns among some cardiologists, however, that widespread
screening with electrocardiograms may generate quite a few false-positive
findings, which could lead to a lot of parental concern and a lot of
expense," Beekman says. "I think it will be critical after a period of
time has passed for the American Heart Association to study the true impact of
this new recommendation."
Electrocardiogram readings "vary considerably among normal
children," Beekman explains. "What is normal is variable by age, by
race, by gender -- and there are common false-positives that turn out to be
misleading once somebody delves into them."
But Beekman notes that "in the face of a formal American Heart
Association policy statement that's published and released to the lay public,
it will be hard to not practice medicine in a fashion that's aligned with the
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With additional reporting by Miranda Hitti.
By Salynn Boyles
Reviewed by Elizabeth Klodas
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