Advice re heart and ADHD (very long)

[Guest guest]

1. Children With ADHD Should Have ECG Before

Taking Stimulant Drugs

Authors and

Disclosures

Sue

Disclosure: Sue has disclosed no relevant financial relationships.

Laurie Barclay, MD

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial

relationships.

Brande

Disclosure: Brande has disclosed no relevant financial

information.

From Heartwire

— a professional news service of WebMD

April 22, 2008 — Children with

attention-deficit/hyperactivity disorder (ADHD) should receive careful cardiac

evaluation—including an electrocardiogram (ECG)—before starting treatment with

stimulant drugs, a new American Heart Association

statement recommends [1].

The statement, published online April

21, 2008 in Circulation, notes

that stimulant medications used to treat ADHD can increase heart rate and blood

pressure, and although these side effects are insignificant for most children

with ADHD, they are an important consideration for children who have certain

forms of congenital heart disease or arrhythmias with a predisposition for

sudden cardiac arrest. The statement says that these new recommendations

" are not intended to limit the appropriate use of stimulants in children

with ADHD, to label children with heart disease, or to limit their

participation in athletic activities but to add clarity to who has or does not

have heart disease and the extent of the risk. "

Some conditions

undetected by physical exam

It advises that 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, or syncope. All additional medications, including prescribed and

over-the-counter medications, should be determined, and a complete family

history should be obtained. Because " some of the cardiac conditions

associated with sudden cardiac death might not be detected on a routine

physical examination, we are suggesting that an ECG be added to increase the

likelihood of identifying significant cardiac conditions that might place the

child at risk, " the authors write.

Head of the statement-writing

committee, Dr Vetter

(University of Pennsylvania School of Medicine, Philadelphia), commented to heartwire:

" The FDA has issued medication guidelines for stimulant drugs used to

treat ADHD that state that you should tell your doctor if you have any heart

condition, but there are many children who have structural heart disease that

could lead to sudden cardiac death who don't know they have it until a

significant event occurs. It is possible that using a stimulant medication

could be a trigger for such an event. While there are patients who have had sudden

cardiac arrest and strokes on these drugs, there are no large studies that have

proven that the drugs have caused these events. However, it is thought that if

adrenergic stimulation is increased, something these drugs do, this could

trigger sudden cardiac arrest in susceptible patients. "

Vetter explained that the committee

has therefore recommended that physicians consider ordering an ECG to aid them

in deciding whether or not underlying heart disease is present before

prescribing these drugs for ADHD and, if there is any indication of heart

disease, the child should be referred to a pediatric cardiologist for a full

examination, because ECGs can give false-positive results.

She added that children with

underlying heart disease can still take drugs for ADHD if they are stable and

under the care of a pediatric cardiologist. " Even if an underlying

disorder is confirmed by the cardiologist, these children can still take

stimulant drugs, but they should be monitored very carefully. We know that many

children with structural heart disease have ADHD, and we still want them to

take the drugs because ADHD has a huge emotional and social impact on children

and affects the way they grow up and their ability to be successful. The drugs

do work in helping this; we don't want to limit people from getting these

medications. We just want them to be used as safely as possible, " Vetter

told heartwire.

Class 2a

recommendation

She stressed that if a child does not

have access to an ECG or to a pediatric cardiologist who can evaluate an ECG or

perform a cardiology consultation, this does not mean that they should not

receive treatment for ADHD. " This is a class 2a recommendation—we

feel it is useful, helpful, and reasonable, but it is has not been proven to be

of benefit. We recommend that doctors use family history, a physical exam, and

an ECG to make a decision about possible heart disease in children before

prescribing stimulant drugs and, although we feel that an ECG is reasonable and

helpful as a tool in identifying children with cardiac conditions that can lead

to sudden cardiac death, if, in the view of the physician, a child requires

immediate treatment with stimulant medications, this recommendation is not

meant to keep them from getting that treatment, " she said.

The statement adds that once

stimulant treatment begins, all children should have their heart health

monitored periodically, with a blood-pressure check one to three months after

starting medication and during routine follow-ups every six to 12 months

thereafter. Because some heart conditions do not appear until adolescence, it

is recommended that if the initial ECG was obtained when the child was younger

than 12 years of age, a repeat ECG should be done when the child is older than

12 years.

In 2003, an estimated 2.5 million

children in the US took medication for ADHD. Surveys indicate that ADHD affects

an estimated 4% to 12% of all school-aged children in the US, and it appears

more common in children with heart conditions. Studies report that, depending

on the specific cardiac condition, 33% to 42% of pediatric cardiac patients

have ADHD, Vetter said. The number of undiagnosed children with heart

conditions is unknown because routine heart screening is not performed.

However, Vetter said, in a recent pilot study, up to 2% of healthy school-aged

children had potentially serious undiagnosed cardiac conditions identified by

an ECG.

Source

1. Vetter VL,

Elia J, kson C, et al. Cardiovascular monitoring of children and

adolescents with heart disease receiving stimulant drugs. A scientific

statement from the American Heart Association Congenital Cardiac Defects

Committee of the Council on Cardiovascular Disease in the Young and the Council

on Cardiovascular Nursing. Circulation.

2008; published online April 21. DOI:10.1161/CIRCULATIONAHA.107.189473.

The complete contents of Heartwire,

a professional news service of WebMD, can be found at www.theheart.org,

a Web site for cardiovascular healthcare professionals.

Clinical Context

Concerns expressed by the US Food and

Drug Administration regarding potential cardiovascular risks for stimulant

medications used for ADHD, and requirements for specific heart-related labeling

and medication guides, have posed several dilemmas for the clinician intending

to prescribe stimulant medications to children with ADHD. These include how to

know if the child has heart disease, a heart problem, or heart defect and what

to do if these conditions are identified.

The goal of this statement from the

American Heart Association Congenital Cardiac Defects Committee of the Council

on Cardiovascular Disease in the Young and the Council on Cardiovascular

Nursing was to provide the clinician with some tools to help identify these

children, determine whether the use of stimulant medications is appropriate in

a particular child, and monitor and follow up on children receiving these

medications to lower the cardiovascular risks.

Study Highlights

Evaluation

of children with ADHD being considered for treatment with stimulant

medications should include patient history focusing on symptoms of

fainting or dizziness, particularly with exercise; seizures; rheumatic

fever; exercise-induced chest pain or shortness of breath; unexplained

change in exercise tolerance; palpitations, increased heart rate, or extra

or skipped beats; high blood pressure; significant heart murmur or heart

problems; and intercurrent viral illness with chest pains or palpitations.

Use of

medications and health supplements should be elicited.

Family

history should ask about sudden or unexplained death at an early age;

sudden cardiac death (SCD) or " heart attack " in relatives

younger than 35 years; sudden death during exercise; cardiac arrhythmias;

hypertrophic cardiomyopathy (HCM) or other cardiomyopathy (eg, dilated

cardiomyopathy, right ventricular cardiomyopathy); long-QT syndrome

(LQTS), short-QT syndrome, or Brugada's syndrome; Wolff-Parkinson-White

(WPW) or similar rhythm abnormalities; syncope or other event requiring

resuscitation in those younger than 35 years; and Marfan's syndrome.

Physical

examination should look for abnormal heart murmur, other cardiovascular

abnormalities, and physical features of Marfan's syndrome.

Baseline

ECG can often detect cardiovascular abnormalities (eg, HCM, LQTS, WPW

anomaly) if read by a pediatric cardiologist or a cardiologist or

clinician with expertise in reading pediatric ECGs.

A second

ECG may be useful after the child is older than 2 years if baseline ECG

was done at younger than 12 years or if new symptoms or family history

develops.

Pediatric

cardiology consult is recommended if the above evaluation shows any

significant findings.

Once

stimulant drugs are started, the clinician should monitor cardiovascular

status at each visit with physical examination and with questions

concerning potential cardiac symptoms and new family history.

Blood

pressure and pulse should be monitored every 1 to 3 months during routine

follow-up for all medications and more often during titration and weaning

of alpha-agonists.

Appropriate

referral and testing are indicated for any cardiac symptoms.

In

patients with congenital heart disease that is not repaired or repaired

but without current hemodynamic or arrhythmic concerns, or congenital

heart disease that is considered to be stable, it is reasonable to

consider the use of stimulant medication unless the patient's pediatric

cardiologist has specific concerns.

After

other methods of treatment of ADHD have been considered or used, it is

reasonable to use stimulants with caution in patients with:

Heart

condition associated with SCD

History

of arrhythmia requiring resuscitation, direct-current cardioversion or defibrillation,

or overdrive pacing

History

of arrhythmia associated with death or SCD

Previous

aborted SCD

Other

clinically significant, untreated, or uncontrolled arrhythmia

Corrected

QT interval on ECG of more than 0.46 second

Heart

rate or blood pressure more than 2 SD above means for age.

After

stimulant medications are started in such patients, these patients should

be carefully monitored.

If any

of the listed conditions are diagnosed during treatment, discontinuation

of the stimulant medication should be considered, at least until further

testing and treatment are performed.

Once

arrhythmias are treated and controlled, the patient can be restarted on

medication if the pediatric cardiologist approves.

Pearls for Practice

Evaluation

of children with ADHD being considered for treatment with stimulant

medications should include patient history focusing on cardiovascular

symptoms, use of medications and health supplements, family cardiovascular

history, physical examination focused on the cardiovascular system, and

baseline ECG. Pediatric cardiology consultation is recommended if the

evaluation shows any significant findings.

Once

stimulant drugs are started, the clinician should monitor cardiovascular

status at each visit with a physical examination, vital signs, and

questions concerning potential cardiac symptoms and new family history.

Appropriate referral and testing are indicated for any cardiac symptoms.