Pediatricians Split on Heart Tests Before Kids' ADHD Meds

MONDAY Jan. 16, 2012 -- Some pediatricians continue to do electrocardiograms (EKGs) on children before starting them on medication for attention-deficit hyperactivity disorder, new research suggests, even though many experts say the latest evidence shows it isn't really necessary.

Several years ago, reports of sudden death, heart attack and stroke among children and adults taking stimulants to treat ADHD caused alarm among parents and health care providers about the safety of the medications.

The reports prompted Canadian health authorities to briefly pull Adderall from the market in 2005, while the U.S. Food and Drug Administration now requires that ADHD drugs carry a "black box" label warning about potential heart risks.

Further research suggested that the risk may only be to children who had underlying heart defects, such as some congenital abnormalities and arrhythmias. On Adderall, for example, the warnings now read: "Sudden death has been reported in association with CNS [central nervous system] stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities or other serious heart problems."

A few years ago, the American Heart Association stated that it would be "reasonable" to give kids EKGs, which look for abnormalities in the heart's electrical activity, before starting them on stimulant medication.

But in 2008, the American Academy of Pediatrics (AAP) issued a policy statement saying that routine EKGs prior to starting kids on ADHD medications wasn't necessary.

"A lot of pediatricians started doing EKGs, and then when the AAP said it didn't agree with that, pediatricians scaled back," explained Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Steven & Alexandra Cohen Children's Medical Center of New York.

And two major recent studies have found no hearts risk associated with ADHD medications. In a study published last November in the New England Journal of Medicine, researchers concluded that medications such as Ritalin, Adderall and Concerta don't raise the risk of sudden death, heart attack or stroke in children and young adults.

In the study, researchers from Vanderbilt University and colleagues analyzed data on 1.2 million children and young adults aged 2 to 24 enrolled in four large health plans around the United States.

And a study published last December in the Journal of the American Medical Association analyzed data on more than 150,000 young and middle-aged adults taking one of several ADHD drugs and found no added risk of heart attack, sudden cardiac death or stroke, even among people with a family history of heart disease.

"The recent data suggests there is no increase in sudden cardiac death or any need for cardiac monitoring, provided there is no history of heart disease in the patient and no family history of heart disease," said Dr. Victor Fornari, a professor of psychiatry at Hofstra North Shore-LIJ School of Medicine, in New York.

The current research, published in the February issue of Pediatrics, surveyed 525 U.S. pediatricians about their ADHD prescribing practices.

The vast majority of physicians said they did a routine medical history and physical before putting kids on stimulants to treat ADHD.

Less than half (48 percent) did a more in-depth cardiac history and physical, which is recommended by the AAP.

About 15 percent also ordered an EKG to look for abnormal heart rhythms. The most common reason for continuing to do EKGs was that it was the "prevailing practice" where they worked.

"Pediatricians have a very variable attitude toward the safety and efficacy of these medications," Fornari said. "Even though there is no evidence base to suggest continued cardiac screening, there persists this lingering attitude among physicians that 'I'm not comfortable unless I do it'."

And even many children with underlying heart issues are safely taking ADHD medications, Adesman said.

"Most children with underlying heart problems are likely still eligible to be treated with stimulants once the family, the pediatrician and a consulting pediatric cardiologist agree that it's justifiable and safe," Adesman said.

He added: "There are only a few very specific, relatively uncommon cardiac problems where one would be hesitant to use a stimulant."

The survey also found nearly half (46 percent) of pediatricians said they also discussed stimulant-related heart risks with parents. In most situations, making sure families are fully informed of any risks is good practice, Fornari said. But given how little evidence there is that ADHD medications pose heart risks to children, in this situation those conversations may be causing unnecessary worry and deterring some families from trying stimulants.

Almost 3 million children in the United States take prescription medications for ADHD each year. Children with the neurobehavioral disorder have excessive levels of activity, inattention and impulsiveness.

More information:

The U.S. National Institute of Mental Health has more on ADHD.

Posted: January 2012


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