Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder
- Stuart Berger, MD
Stuart Berger, MD
- Executive Director, Pediatric Heart Center at Lurie Children's Hospital
- Vice Chair, Clinical Affairs Pediatrics at Lurie Children's Hospital
- Professor of Pediatrics, Northwestern University
Reports of sudden unexpected deaths (SUD) among patients taking stimulant drugs for attention deficit hyperactivity disorder (ADHD) have led to concerns regarding the safety of psychotropic medications. In particular, the question of whether or not stimulant drugs increase the risk of adverse cardiovascular events has led to a debate on the appropriate evaluation to identify patients with undiagnosed at-risk congenital heart disease and/or arrhythmias prior to starting a patient on medications for the treatment of ADHD.
The risk of sudden cardiac death in patients receiving stimulant medications for ADHD and the cardiac evaluation of these patients will be reviewed here. The pharmacotherapy for ADHD is discussed in greater detail separately. (See "Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents".)
RISK OF SUDDEN UNEXPECTED DEATHS
ADHD is a common childhood disorder affecting up to 8 to 10 percent of all school-aged children. Stimulant drugs including methylphenidate (Ritalin, Methylin, Concerta, Focalin, Metadate), dextroamphetamine (Dexedrine), and mixed amphetamine salts (eg, Adderall) are effective in improving behavior in these patients. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis", section on 'Epidemiology' and "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Stimulants versus other medications'.)
Reports of unexpected deaths of children receiving stimulant therapy have led to concerns that these medications increase the risk of cardiovascular (CV) adverse events, including sudden unexpected deaths (SUD) [1-3]. However, large cohort studies have not shown an increased risk of serious CV adverse events in children treated with stimulant therapy compared with the general pediatric population, as discussed in the following section.
Children without cardiac disease — Based on the available evidence, it appears that children without cardiac disease who receive stimulant therapy are not at increased risk for CV events compared with the general pediatric population. As a result, we follow the recommendations of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) that stimulant pharmacotherapy can be initiated in a child with ADHD if there is no evidence of cardiac disease based upon a comprehensive CV-focused history and physical examination. (See 'Recommended approach' below.)
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- RISK OF SUDDEN UNEXPECTED DEATHS
- Children without cardiac disease
- Children with cardiac disease
- FDA position
- KNOWN CARDIAC EFFECTS
- Stimulant medications
- CARDIAC EVALUATION
- Recommended approach
- - History
- - Physical examination
- - Monitoring
- SUMMARY AND RECOMMENDATIONS