The American Heart Association recommends the routine administration of an
electrocardiogram (ECG) for all children with attention deficit/hyperactivity
disorder who are prescribed stimulant treatment to minimize the risk of sudden
cardiac death (SCD).
The recommendation is part of a scientific statement released by a group
commissioned by the American Heart Association (AHA) and published online in
the journal Circulation in April.
In addition to recommending a routine ECG, the statement also outlines
specific steps to inquire about family history and to conduct a thorough
physical examination for signs of potential heart defects or diseases such as
hypertrophic cardiomyopathy, long-QT syndrome, and Wolff-Parkinson-White
syndrome. AHA experts believe that routine ECG screening is "medically
indicated and of reasonable cost."
Child and adolescent psychiatrists interviewed by Psychiatric News
disagreed with aspects of this sweeping recommendation for ECG screening.
"At this point, there is no evidence that such widespread screening
would actually enhance safety or reduce the risk of rare but potentially
serious heart-related problems," David Fassler, M.D., a pediatric
psychiatrist and a clinical professor of psychiatry at the University of
Vermont, told Psychiatric News. "This recommendation is not
consistent with the FDA's assessment or with the current guidelines of other
medical organizations, including the American Academy of Child and Adolescent
Psychiatry [AACAP] and the American Academy of Pediatrics."
Fassler is also APA secretary-treasurer.
In a recent retrospective study of 55,000 ADHD patients aged 3 to 20,
researchers at the University of Florida found that the use of stimulants was
linked to a small increase in cardiac side effects, such as increased blood
pressure and palpitation that led to emergency-room and doctor-office visits.
But the study showed no increased risk of cardiac deaths or cardiac-related
hospitalizations (Psychiatric News, February 1).
Steven Pliszka, M.D., a professor of psychiatry and chief of the Division
of Child and Adolescent Psychiatry at the University of Texas Health Sciences
Center in San Antonio, also does not think routine ECG screening is
"If you look at the rates of SCD in available studies, there is no
evidence of a higher risk in children with ADHD than the general pediatric
population," he told Psychiatric News. He pointed out that
thousands of participants in many clinical trials received ECG screening
before enrollment, and the cases of heart disease in these children were"
The AHA experts acknowledged in their statement that "there are no
clinical studies or data indicating that children with most types of
congenital heart disease are at significant risk for SCD while on these
medications" and "no widely accepted recommendations or standards
of care for cardiac monitoring on stimulant medications." Nevertheless,
they urge physicians to conduct a thorough evaluation before prescribing
stimulants for treating children and adolescents with ADHD, so that previously
unknown cardiac risk factors are more likely to be
However, the current AACAP guideline, a practice-parameter document on ADHD
issued in 2007, states that "no evidence currently indicates a need for
routine cardiac evaluation (i.e., electrocardiography, echocardiography)
before starting any stimulant treatment in otherwise healthy
"There is no evidence that children with ADHD are more likely to have
heart disease. Nor is there evidence that taking stimulants causes heart
diseases that increase the risk of SCD," Pliszka pointed out. "In
clinical trials of various stimulants, where ECG screening was used at
enrollment, cardiac risk factors have been extremely rare."
Pliszka is the lead author of the AACAP guideline, but he stressed that the
opinions he expressed to Psychiatric News are his own and do not
represent AACAP's official response to the AHA's statement. He suggested that
clinicians treating ADHD focus on doing a thorough medical history and
examination, including questions about family history of cardiac problems and
patients' signs of cardiovascular risk factors, before starting them on
What should physicians do if they detect signs or symptoms of heart
conditions? The AHA statement recommends a consult visit with a pediatric
cardiologist and evaluation involving the patient's family and other treating
physicians to weigh the risks of prescribing versus not prescribing
stimulants. The AACAP guideline recommends detailed cardiovascular evaluations
including ECG and other tests if the patient has a medical history or possible
signs of heart disease.
The Food and Drug Administration (FDA) has mandated a boxed warning in the
label of Adderall (mixed amphetamine salts) but not methylphenidate, which
states that "misuse of amphetamine may cause sudden death and serious
cardiovascular adverse events." The warnings section of the labels of
all stimulants advises that "stimulant products generally should not be
used in children or adolescents with known serious structural cardiac
abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other
serious cardiac problems."
In addition, the AHA statement calls for the establishment of a registry
for SCD in children, adolescents, and young adults to collect risk factors and
clinical details in a standardized and systematic manner.
Fassler agreed with this suggestion. "There is a need for more
large-scale, long-term research on stimulants and other medications used to
treat child and adolescent psychiatric disorders," he noted.
The FDA and the Agency for Healthcare Research and Quality are conducting a
study that is expected to clarify the risk of SCD and other cardiovascular
adverse effects, if any, connected to stimulants (Psychiatric News,
October 19, 2007).
On the basis of current clinical evidence, "I do not see any
convincing argument to alter the practice recommended by the current AACAP
guidelines," said Pliszka.
"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" is posted at<circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189473v1>."
Practice Parameter for the Assessment and Treatment of Children and
Adolescents With Attention-Deficit/Hyperactivity Disorder" is posted at<www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf>.▪