Cardiovascular Monitoring of Children and Adolescents Receiving Medication For Attention Deficit Hyperactivity Disorder (ADHD)
Medications called psychostimulants (examples are the medications marketed as Ritalin and Dexedrine) have been used to treat ADHD for decades, and generally are considered safe and effective. Other, newer medications (such as Strattera), more recently have been used alone or sometimes in combination with the psychostimulants to treat this very common problem that affects about 5% of school aged children.
All of the major medications used for the treatment of ADHD, however, have the potential to alter blood pressure and pulse rate. Some psychiatrists and other physicians have become concerned that these medications may contribute to a sudden stopping of the heart, which is called “cardiac arrest”. This concern is especially strong for children and adolescents who have a history of heart disease. Unfortunately, severe heart disease is not always detected before cardiac arrest occurs, which can be precipitated by taking particular medicines in children with heart problems.
Therefore, prior to beginning any of these medications, and periodically while taking all medications for ADHD, the prescribing physician should obtain a careful family and medical history and physical examination of the child to try to detect potential heart problems and risk factors for heart disease.
New recommendations from the American Heart Association and the American Academy of Pediatrics1,2 that have been endorsed by the American Academy of Child and Adolescent Psychiatry3, issued in April, 2008, say that it is reasonable for the physician who prescribes any of the current medications for ADHD to “consider” also obtaining an EKG prior to starting treatment because an EKG may detect serious a heart problem that is not detected through a careful history and physical examination.
OMH regards this as a reasonable recommendation. The addition of an EKG to taking a good family history and individual history of any heart problems in the child and performing a physical examination is a prudent step in trying to detect unsuspected heart problems. If a child already is on medication, obtaining an EKG also should be considered. EKG's are safe, relatively inexpensive in the current environment of very expensive medical tests, and not painful.
Obtaining an EKG also may help to put parents'/caretaker's and children's minds more at ease about taking medications that for many children offer considerable benefit in the context of a comprehensive treatment plan for this common and burdensome disorder.
Finally, parents/caregivers should bring this new American Heart Association and American Academy of Pediatrics recommendation to the attention of their children's physicians and psychiatrists for further discussion. Parents/ caregivers should always make sure that their child's physician knows about any medications and over the counter remedies the child is taking before any new medication for ADHD (or anything else) is prescribed. More information about these new recommendations can be found on line at the first two links below.
- Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL: 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 117:2407-2423, 2008, accessed May 21, 2008 at http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189473
- American Heart Association: Top ten things to know. Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs. Accessed May 21, 2008. http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189473
- Hendren RL: AAACAP endorses clarification statement on ECGs and ADHD. Personal electronic communication to AACAP members, with link to on line AHA clarification. Accessed May 16, 2008.