Cardiac Evaluations Recommended for Children Taking ADHD Medications

It's not uncommon anymore for a child to be diagnosed with attention deficit hyperactivity disorder (ADHD), but doctors should be doing follow-up testing for possible heart problems prior to beginning drug therapy. ADHD is a disorder affecting 4 to 8 percent of American children aged 4 to 17. Symptoms include lack of attention and disorganized or impulsive behavior. Stimulant drugs, such as Ritalin, Adderall, Dexedrine, and Concerta help patients with ADHD to stay focused and control their behavior. Government estimates show that over 2.5 million chldren and teens as well as about as 1.5 million adults in the United States take stimulant drugs to control ADHD.

The American Heart Association (AHA) is now recommending that an electrocardiogram (ECG) be performed prior to starting any child or teenager on stimulant medications. In addition, ADHD patients should undergo a physical examination and a family medical history should be obtained.

Cardiologist Victoria L. Vetter, MD, of the Children's Hospital of Philadelphia, led the American Heart Association panel that wrote the consensus statement and said that with careful monitoring, the drugs have been shown to be safe for patients with known heart issues. She stated that the AHA is not trying to scare doctors away from prescribing these drugs that are so important for the treatment of ADHD and that "Most kids can be treated, but very careful monitoring is important."

ADHD medications elevate heart rate and blood pressure. For most children, this does not pose a problem. But for patients with a heart condition, it increases the risk of sudden cardiac arrest (an erratic heartbeat that causes the heart to stop pumping blood through the body) as well as other heart problems. According to studies, ADHD is more common in children with heart problems than in the general pediatric population and the spread of obesity has led to high blood pressure among children and teens. Dr. Vetter said that a screening of about 1,100 healthy children found that approximately 2 percent of them had some kind of heart problem.

Since February, 2007, the FDA has required that a warning of the risk of sudden death in patients with heart problems be included on the labeling of ADHD-treating stimulants. According to Dr. Vetter, the incidence of cardiac events among children and teens taking the drugs is not known because no registry exists to record these events. The sale of Adderall was temporarily suspended in February of 2005 based on U.S. reports of sudden deaths in children, and in March of 2006 an FDA panel reported that a number of sudden deaths in children had occurred between 1992 and early 2005. Eleven of the deaths were from medications such as Ritalin and Concerta and 13 others were linked to medications such as Adderall or Dexedrine. Three sudden deaths were caused by the drug Strattera, which is not a stimulant.

The Cardiac Checklist for ADHD from the American Heart Association includes:

• Patient history, with special attention to palpitations, high blood pressure, heart murmur, fainting, chest pain or difficulties during exercise.
• Family history of sudden death, serious rhythm abnormalities, heart muscle disorders or Marfan's syndrome.
• A review of current medications (prescription, over-the-counter, and supplements).
• A physical that includes checking blood pressure and a screening for abnormal heartbeats.
• An electrocardiogram (ECG) to check the electrical function of the heart.
• A consultation with a pediatric cardiologist to discuss any important findings.

The AHA has also called for the establishment of a registry to track sudden cardiac deaths in children, teens, and young adults. In addition, patients taking ADHD medications should have periodic checks of blood pressure and pulse rates as well as a repeat ECG after the age of 12 if the initial treatment ECG was obtained before 12 years of age. If patients are currently taking stimulant medications and have not undergone ECG testing, it is recommended for them to have an ECG performed.

There is a debate among experts regarding the use of the ECG to screen such a large number of patients for the detection of what is considered to be a rare condition and whether it is worth the costs for patient families and physicians alike to undertake such a project. However, the testing done in combination with a detailed checkup may help to avoid rare cases of sudden cardiac arrest in children who take the stimulant medications.