AHA Recommends ECGs for Hyperactive Children

Children with attention deficit hyperactivity disorder (ADHD) should receive a cardiac evaluation including electrocardiogram (ECG) before treatment with stimulant drugs, the American Heart Association (AHA) has recommended. [Lancet Neurol 2008 Jum;7(6):494-499]

The scientific statement, Cardiovascular Monitoring of Children and Adolescents with Heart Disease Receiving Stimulant Drugs, recommended that it was both "sensible and useful" to obtain ECGS as part of the evaluation of children considered for stimulant drug therapy. [Lancet Neurol 2008 Jum;7(6):494-499]

The report recognized that there are no clinical trials on the topic; no widely accepted recommendations of standards of care for cardiac monitoring of those on stimulant medications; and that it is now known if the risk of sudden cardiac death (SCD) on stimulants is higher than in the general population.[Lancet Neurol 2008 Jum;7(6):494-499]

"However the recent information and warnings regarding cardiac disease warrant reconsideration of the previous approach," it read

"After ADHD is diagnosed, but before therapy with a stimulant or other medication is begun, we suggest that an ECG be added to the pre-treatment evaluation to increase the likelihood of identifying cardiac conditions that may place the child at risk for sudden death," said Dr. Victoria Vetter, head of the statement writing committee and professor of pediatrics at the University of Pennsylvania School of Medicine in Philadelphia, US.(Proc Biol Sci 2008 Aug 02)

Vetter also said doctors should evaluate children and adolescents already taking these medications if they were not evaluated when they started the treatment.

"Once stimulant treatment begins, children should have their heart health monitored periodically, with a blood pressure check within 1 to 3 months, then again at routine follow-ups every 6 to 12 months," she said.

Dr. Kenneth Ng, a cardiologist at Singapore's Novena Heart Centre, agreed with the research findings.

"It is quite practical to screen all ADHD children who need to be on medication. Such an evaluation will take less than 15 minutes including an ECG. The only issue is cost," he said, noting that in the private sector in Singapore, the evaluation would cost about S$140.

"There is no conclusive evidence that stimulant drugs used to treat ADHD increase the risk of a cardiac event in children," added Ng. "From epidemiological studies [however], it seems that the drugs pose some risk, especially in children who already have some underlying heart disease, although the actual number of children dying suddenly is very small."

The statement from the AHA was prompted by warnings from the US Food and Drug Administration (FDA) about stimulant medications and public concern.

Studies have shown that stimulant medications like those used to treat ADHD can increase heart rate and blood pressure. These side effects are insignificant for most children with ADHD; however, they're an important consideration for children who have a heart condition.(Proc Biol Sci 2008 June 10)

The statement writing group recommended adding an ECG to pre-treatment evaluations for children with ADHD as some cardiac conditions associated with SCD may not be noticed in a routine physical exam.

Data from the FDA showed that between 1999 and 2004, 19 children taking ADHD medications died suddenly and 26 children experienced cardiovascular events such as strokes, cardiac arrests and heart palpitations. Since February 2007, the FDA has required all manufacturers of drug products approved for ADHD treatment to develop medication guidelines to alert patients to possible cardiovascular risks.

The AHA called for randomized, double-blind, placebo controlled studies to assess the true risk of SCD in association with stimulant drugs in children and adolescents with and without heart disease.