American Heart Association Calls for Electrocardiograms Before Kids Take ADHD Drugs
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Reviewed By Louise Chang, MD
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 consensus statement.
"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."
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 attention disorders.
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 children.
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 [medications]."
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 tolerance.
- Review of all current medications including prescription, over-the-counter preparations, and health supplements.
- Careful evaluation for a family history of sudden death, serious rhythm abnormalities, heart muscle disorders (cardiomyopathy), or Marfan's syndrome.
- A physical exam, including assessment of blood pressure and heart rhythm.
- 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 pediatric ECGs.
- 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 guidelines.
"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 policy."
SOURCES: American Heart Association Scientific Statement, April 21, 2008, Circulation, online edition. Victoria L. Vetter, MD, FAHC, chairwoman, consensus statement writing panel; professor of pediatrics, University of Pennsylvania; director of electrophysiology, Children's Hospital of Philadelphia. FDA Pediatric Advisory Committee Meeting, March 22, 2006. Robert H. Beekman, MD, chairman, section on cardiology and cardiac surgery, American Academy of Pediatrics; professor of pediatric cardiology, Cincinnati Children's Hospital Medical Center.
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