University of Virginia Health System

Children Using Stimulants for ADHD May Need Heart Check

The American Heart Association (AHA) has issued recommendations that call for cardiovascular screening before prescribing stimulant treatment for all children diagnosed as having attention-deficit hyperactivity disorder (ADHD).

"This is new, and it is a shift in our policy," says Dr. Victoria L. Vetter of the University of Pennsylvania School of Medicine.

"But we're not recommending that every child in the country have these heart screenings, rather that they be used as a reasonable tool for this small, particular group of children about to take ADHD medications so we can ensure the treatment proceeds as safely as possible," she says.

The recommendations were published in Circulation, a journal of the AHA.

Medical History and Exam Provide Answers

The following steps are recommended:

• The taking of a detailed patient and family medical history, particularly regarding heart disease
• A full physical exam, including blood pressure and heartbeat monitoring
• An electrocardiogram (ECG) 
• A consultation with a pediatric cardiologist prior to treatment if evidence of heart disease is uncovered

After treatment begins, the AHA says children should continue to have blood pressure checkups once every one to three months, as well as routine health checkups every six to 12 months.

The AHA notes that ADHD is the most common neurobehavioral disorder among American children.

Estimates show that between 4 percent and 12 percent of American school-age children have the condition.

More than 2.5 million children in the U.S. are being prescribed ADHD medications, the AHA says.

According to the National Institutes of Health (NIH), the most-effective ADHD medications typically belong to the "stimulant" class of drugs, which includes amphetamines, methylphenidates and dextroamphetamines.

Some of the names under which these drugs are marketed include Adderall®, Concerta®, Dexedrine®, Focalin®, Ritalin®, Ritalin SR® or LA® and Metadate ER® or CD®.

The new recommendations refer to all these stimulants, as well as to a newer drug known as Strattera®, which was recently approved by the U.S. Food and Drug Administration (FDA) as a non-stimulant treatment for ADHD.

Though ADHD stimulants increase a child's heart rate and blood pressure, the NIH noted that no evidence has indicated that these medications are addictive, and side effects do not typically pose any danger for most healthy children.

However, children with underlying heart disease who take stimulants for ADHD appear to face an increased risk for sudden cardiac arrest, the AHA notes.

This risk association is particularly troublesome for young ADHD patients, because heart disease often goes undiagnosed in children and may be present without noticeable symptoms.

The AHA also pointed to a number of studies that suggest that between 33 percent and 42 percent of pediatric heart patients also have ADHD.

FDA data collected from 1999 through 2004 revealed that 19 children following an ADHD prescription regimen had died suddenly, while 26 experienced heart complications such as stroke, heart attack or heart palpitations.

Caution Should Be Noted

Vetter notes that, in 2005, the Canadian equivalent of the FDA - Health Canada - decided to place a ban on Adderall, an amphetamine-based ADHD medication designed for kids older than 3.

The Canadian decision was based on a review of FDA records concerning 12 reported deaths among American children taking ADHD medications.

Vetter points out that the Canadian decision was based on an assessment of collected data based on reports from families (sometimes in the absence of autopsy records), rather than a complete scientific analysis.

"But the reality is that we were faced with some kids who had ADHD who suddenly died," she says. "And a lot of them were exercising at the time, which is when most of the kids who have electrical malfunctions of the heart would have a sudden cardiac death. So we have to assume they experienced a cardiac death."

In February 2007, the FDA ordered makers of ADHD medications to develop guidelines alerting patients to the heart risks associated with their treatments.

"But it's not that these are dangerous medicines," Vetter says. "But by adding the ECG, and by being aware of possible heart disease, and monitoring the kids once you prescribe the medications, one can go ahead and treat the ADHD. And these kids can be very happy."

Dr. Andrew Adesman of Schneider Children's Hospital agrees that the point of expanded screenings is to identify a child's underlying heart complication, not to look for problems with the stimulants themselves.

"Serious cardiac complications from stimulant medications are very rare," says Adesman. "But because there are concerns on the part of parents and some physicians, routine ECG screenings will provide greater reassurance for the vast majority of patients for whom ADHD medications are being considered."

For more information about ADHD, pediatric heart conditions and other children's health issues, visit www.uvachildrenshospital.com. 

Always consult your child's physician for more information.