American Heart Association Recommends Screening for Heart Disease in Children Getting Drugs for ADHD

The American Heart Association (AHA) has just recommended specific screening for heart problems for children and adolescents before they get stimulant drugs for treating attention deficit hyperactivity disease (ADHD).

Public Citizen applauds the AHA’s recommendations, but points out that these specific, much-needed recommendations should have come from the Food and Drug Administration (FDA).

Although the FDA had made general recommendations aimed at preventing sudden cardiac death by screening for children with heart problems in the past, specific details were not provided by the agency.

These screening recommendations have the potential to affect a wide population: the FDA has estimated that 2.5 million children are being treated with drugs for ADHD. FDA advisory committee member Dr. Steve Nissen of the Cleveland Clinic expects appropriate warnings to help slow the rise of the use of ADHD drugs in children and adolescents.

In response to criticism of a previous FDA advisory committee recommendation for a black box warning concerning cardiovascular risks, Dr. Nissen rejected concerns that warnings regarding serious cardiovascular risks associated with ADHD drugs would discourage patients from receiving treatment:

I strongly disagree. I cannot accept the paternalistic notion that patients and caregivers are better off without information about drug risks. The presence of a black-box warning and a mandatory patient guide would probably stimulate useful discussions among patients, parents, and physicians about risks, benefits, and alternative therapies. An appropriate warning might also slow the exponential growth in the use of amphetamines and similar stimulants, which has reached epidemic proportions in the United States, resulting in the treatment of nearly of nearly 10 percent of preadolescent boys.

The following information, which explains the reasoning and details of the decision to recommend heart screening, comes from the AHA recommendations.

Why screen for heart problems in children with ADHD?

ADHD may be more prevalent in children with heart disease than in the general pediatric population. Part of the AHA concern derived from a total of 27 sudden cardiac deaths reported to the FDA in children using one of the stimulant drugs (see box below) used to treat ADHD.

On average, there is an increase in heart rate of one to two beats per minute and an increase in systolic and diastolic blood pressures of three to four millimeters. In general, these cardiac side effects have been thought to be clinically insignificant for most children with ADHD, but there may be a potential for severe adverse events in some children with certain forms of congenital heart disease or arrhythmias with a predisposition for sudden cardiac arrest.

The intention of these recommendations is to provide the physician with some tools to help identify children with heart disease and make determinations about the use of stimulant medications and the follow-up of children on these medications. The goal is to allow treatment of this very significant problem of ADHD while attempting to lower the risk of these products.

For Children Newly Diagnosed with ADHD

After a diagnosis of ADHD has been made but before therapy with a stimulant or other medication is initiated, a thorough evaluation should be performed with special attention to symptoms that can indicate a cardiac condition such as palpitations, near syncope (fainting), or syncope (discussed later). All additional medications used, including prescribed and over-the-counter medications, should be determined, and a complete family history should be obtained, especially for conditions known to be associated with sudden cardiac death (SCD). Detection of these symptoms or conditions should warrant an evaluation by a pediatric cardiologist before initiation of therapy.

Patients should undergo a thorough physical examination for high blood pressure, cardiac murmurs, physical findings associated with Marfan syndrome (a condition that affects connective tissue), and signs of irregular heart rhythms.

Some of the cardiac conditions associated with SCD might not be detected on a routine physical examination. Therefore, we are suggesting that an ECG (electrocardiogram) be added to increase the likelihood of identifying significant cardiac conditions that might place the child at risk. We recognize that the ECG cannot identify all children with these conditions but will increase the probability.

What to look for in an evaluation

Details of questions concerning the patient’s history included a history of fainting or dizziness (particularly with exercise); seizures; rheumatic fever; chest pain or shortness of breath with exercise; unexplained, noticeable change in exercise tolerance; palpitations, increased heart rate or extra or skipped heart beats; history of high blood pressure; history of heart murmur other than innocent or functional murmur or history of other heart problems; viral illness with chest pains or palpitations; current medications (prescribed and over the counter); and health supplements (nonprescribed).

The family history should include questions concerning sudden or unexplained death in someone young; SCD or “heart attack” in members less than 35 years of age; sudden death during exercise; cardiac arrhythmias (irregular heartbeats); an event requiring resuscitation in young members less than 35 years of age, including syncope (fainting) requiring resuscitation; Marfan syndrome.

The physical examination should include an evaluation of the child for the presence of abnormal heart murmur; other cardiovascular abnormalities, including hypertension and irregular or rapid heart rhythm; and physical findings suggestive of Marfan syndrome.

A baseline ECG, which often can identify cardiovascular abnormalities, is reasonable to obtain. It can be useful and can increase the sensitivity of the screening process, especially if there are suspicions of high-risk conditions.

ECGs should be read by a pediatric cardiologist or a cardiologist or physician with expertise in reading pediatric electrocardiograms. Once medication is started, if the initial ECG was obtained before the child was 12 years of age, a repeat ECG may be useful after the child is 12 years of age.

Patients Currently Taking Stimulants

For children already taking methylphenidate, amphetamine or other stimulant agents, it is reasonable for the doctor to obtain a history, review the physical examination and order an ECG if these were not previously done as outlined above if deemed necessary.

At the time of public disclosure of these new AHA guidelines, Dr. Victoria Vetter, a pedriatic cardiologist and senior author of the guidelines stated that: “a screening of about 1,100 healthy children found that about 2 percent of them had some kind of heart problem. We thought it was reasonable to include the electrocardiogram as a tool for the pediatrician, the psychiatrist so that this would help identify additional children who have heart disease.”

What You Can Do

Pediatric and adolescent patients currently taking drugs for ADHD should be screened for heart problems using the AHA guidelines to evaluate whether the drug treatment is appropriate for the patient.