Consider ECG for children prescribed attention-deficit/hyperactivity meds

June 2008

Due to the possibility of sudden cardiac death or other serious cardiac events, the American Heart Association recently issued a statement that states it is “reasonable to consider adding an electrocardiogram to the history and physical examination” for children before prescribing stimulant medication to treat their attention-deficit/hyperactivity disorder.

The statement from the AHA defines potential cardiac effects of medications commonly used to treat ADHD, and recommends pediatricians factor these into their decisions. The statement included a review of data that show children with heart conditions have a higher incidence of ADHD.

Both the AHA and the AAP recommend obtaining a patient and family health history and doing a physical examination focused on cardiovascular disease risk factors when assessing patients before prescribing medications to treat ADHD.

The AHA statement recommends that it is reasonable, though not mandatory, to consider an ECG for children who did not receive one prior to treatment. If the initial ECG was given when the child was younger than 12 years, a second ECG may be useful after the child is older than 12 years, according to the statement.

“Children can have undiagnosed heart conditions without showing symptoms,” Victoria L. Vetter, MD, head of the AHA statement writing committee and professor of pediatrics at the University of Pennsylvania School of Medicine in Philadelphia, said in a press release. “Furthermore, a child’s body changes constantly, with some conditions not appearing until adolescence.”

After the AHA issued its initial statement in the online version of Circulation, April 21, that included consideration of an ECG, AAP officials issued a response that it may not be feasible to refer all patients with an ADHD diagnosis for an electrocardiogram given the limited number of cardiology specialists and technicians available to provide these services. AAP officials agreed with the AHA’s guidelines that inability to obtain this test should not preclude providing needed treatment to any child.

Shortly after the AAP response, the AHA amended its statement, clarifying that obtaining an ECG is reasonable but not mandatory and should be at the discretion of the physician, and, “If possible, ECGs should be read by a pediatric cardiologist or a cardiologist or physician with expertise in reading pediatric electrocardiograms.”

ADHD and CVD risk

Between 1999 and 2004, 19 children prescribed ADHD medications were reported to the FDA voluntary reporting system to have died suddenly, and 26 children were reported to have experienced cardiovascular events, including heart palpitations, strokes and cardiac arrests, according to data from FDA officials.

Two percent of healthy children had serious cardiac conditions that were identified by an ECG, according to findings from a pilot study presented at the AHA 2007 Scientific Sessions.

The efficacy and cost-effectiveness of ECG screening are debatable. An ECG screening program for newborns in Italy has been conducted, as has the screening of high school and professional athletes in both Europe and the United States.

These programs have produced mixed results regarding the capability of the procedure to detect the likelihood of cardiac events, particularly sudden cardiac death. AHA officials said they believe that the use of an ECG in addition to the history and physical will increase the probability of identification of children who are predisposed to sudden cardiac death and other cardiac events.

Medications that treat ADHD have not been shown to cause heart conditions nor have they been demonstrated to cause sudden cardiac death. “However, some of these medications can increase or decrease heart rate and blood pressure,” according to a press release issued by the AHA and AAP. “Although these side effects are not usually considered dangerous, they should be monitored in children with heart conditions as the physician feels necessary.”

For more information:

• Vetter V, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs. A scientific statement from the American Heart Association council on cardiovascular disease in the young congenital cardiac defects committee and the council on cardiovascular nursing. Circulation. http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.107.189473/DC.
• Subcommittee on ADHD and Committee on Quality Improvement. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001;108:1033-1044.