NEW YORK – An electrocadiogram* probably isn’t necessary for most youngsters starting a medication for attention-deficit/hyperactivity disorder.
Some easy screening questions should be enough to identify any children who have cardiovascular risks that a stimulant could exacerbate, Dr. James J. McGough said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.
"I am going to suggest that we end this neurosis" about cardiovascular risks during ADHD treatment. "The questions to ask before starting a kid out on any psychotropic medication are the same you would ask any child who is getting a sports physical," said Dr. McGough, chief of staff of the Resnick Neuropsychiatric Hospital at the University of California, Los Angeles.
The biggest fear is sudden cardiovascular death – an event usually associated with sport. "I don’t think a month goes by that I don’t hear about a soccer player, cheerleader, or basketball player who has had a sudden death. It’s tragic, but it happens. The bottom line is that there is a three times greater risk of sudden death associated with sports than with being on a stimulant."
In light of this statistic, he said: "There would be more sense in doing an EKG on every high school athlete, but no one is calling for that."
The key questions that should be in every ADHD assessment focus on family and personal history:
• Have you ever fainted while exercising?
• Is there a family history of sudden cardiac death?
• Is there any cardiac abnormality or a heart murmur?
If the answer to any of these is "yes," the patient should see a pediatric cardiologist before starting a stimulant medication. Otherwise, Dr. McGough said, "The benefit of an EKG is really not worth the cost."
The American Heart Association raised concerns about cardiac death and ADHD medications in 2008, when it recommended that every child have an EKG read by a pediatric cardiologist before beginning stimulant medication. However, the group noted, although the test was preferred, it should not be mandatory (Circ. 2008;117:2407-23).
A 2009 postmortem case-control study seemed to bolster the recommendation (Am. J. Psychiatry 2009;166:992-1001).
The authors examined amphetamine exposure among 1,128 children aged 7-19 years, half of whom had a sudden unexplained death and half of whom died in motor vehicle accidents. Ten of those in the sudden death group had amphetamine exposure compared to two in the accident group – a significant difference. The authors concluded that amphetamines could increase the risk of sudden death.
Despite this study, the Food and Drug Administration decided not to require cardiac testing for every ADHD start, Dr. McGough said. More recent studies suggest that the risk is very small or absent.
"There are about a half dozen papers on this now," including one published recently and two large retrospective cohort studies published last year.
The current study examined the risk of cardiovascular events in a database of 171,126 youngsters aged 6-21 years. There were three new cardiac symptoms and less than one cardiac event per 1 million days of current stimulant use. Compared to the reference group, the adjusted odds ratio of cardiac events during current use was 1.18, and with past use, 0.93 (J. Am. Acad. Child Adolesc. Psychiatry 2012;51:147-56).
Last November, the New England Journal of Medicine published a cohort study of 1.2 million children and young adults, 373,667 of whom were currently using ADHD medications. There were 81 serious cardiovascular events, a rate of 3 per 100,000 person-years (N. Engl. J. Med. 2011;365:1896-904).
Another study appeared in Pediatrics. The cohort consisted of 241,417 ADHD medication users. No significant associations were found with sudden death, ventricular arrhythmia, or all-cause mortality. None of the strokes identified during exposed time to ADHD agents were validated (Pediatrics 2011;127:1102-10).
"I think it’s time we put an end to this brouhaha," Dr. McGough said.
Dr. McGough disclosed that he is on the advisory boards of NextWave Pharmaceuticals, Noven Pharmaceuticals, Shiongi, Shire Pharmaceuticals, and Supernus Pharmaceuticals. He also is a consultant for Alexa Pharmaceuticals and MedImmune.
* Correction 2/27/2012: The technology mentioned in this sentence previously was misidentified.