The new recommendation calling for electrocardiogram screening for children with attention-deficit/hyperactivity disorder before initiating pharmacologic treatment is not based on data, according to an expert in child and adolescent psychiatry.
Dr. David Fassler said that at this point, there is no evidence that such screening would enhance safety or reduce the risk of rare but potentially serious heart-related problems.
“The best advice is for parents to talk to their child's doctor,” Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington, said when asked about the recommendations. “They can then decide together what, if any, additional evaluation may be warranted.”
Under the recommendations, issued in April by the American Heart Association, if patient history, family history, clinical examination, and/or ECG results suggest a higher risk, a referral to a pediatric cardiologist is warranted.
For patients currently taking methylphenidate, amphetamine, or another treatment for ADHD, a comprehensive assessment of cardiac risk is reasonable if deemed necessary, according to the AHA scientific statement published in Circulation, available at circ.ahajournals.org
The AHA recommendations, offered by Dr. Victoria L. Vetter of the Children's Hospital of Philadelphia and her colleagues, say it is important to pay particular attention to symptoms such as palpitations, near syncope, or syncope that might indicate a cardiac condition.
Consider all other medications taken by a pediatric patient, including over-the-counter agents, according to the recommendations, titled “Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs.”
Cardiac risk assessment of all children before prescribing ADHD medications, ongoing monitoring, and specific guidelines for children with known structural heart disease or other heart conditions are outlined in the statement.
In 1999, the AHA addressed concerns about potential adverse cardiac effects of psychotropic medications in children, but made no specific recommendations about stimulants. However, “since that time, a constellation of circumstances has come together, necessitating a second look at this complicated issue,” the authors of the current statement wrote.
The authors note that ADHD might be more prevalent among children with heart disease than the estimated 4%–16% of the general population. One study, for example, indicated that 45% of children with heart disease had abnormal attention scores and 39% had abnormal hyperactivity scores (Pediatrics 2000;105:1082–9).
The recommendation for selective ECG screening is new. The writing group suggested the testing will increase the likelihood of identifying significant cardiac conditions such as hypertrophic cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome that might place the child at risk.
“We recognize that the ECG cannot identify all children with these conditions but will increase the probability,” wrote Dr. Vetter and the six other experts on the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular Nursing.
“The use of selective ECG screening in this population is thought to be medically indicated and of reasonable cost.” Dr. Vetter, the majority of writing group members, and the four physician reviewers had no relevant financial disclosures.
A physician familiar with interpretation of pediatric ECG should assess results, according to the recommendations. A repeat ECG might be useful after initiation of ADHD medication if there is a change in relevant family history or, if the first ECG was performed before the age of 12, after the child turns 12 years old.
Initial assessment of a child with ADHD should include personal history of fainting or dizziness, particularly with exercise; seizures; rheumatic fever; chest pain or shortness of breath with exercise; an unexplained, noticeable change in exercise tolerance; palpitations, increased heart rate, or extra/skipped heartbeats; history of hypertension; and other factors.
Relevant family history includes sudden or unexplained death of someone young, sudden cardiac death or myocardial infarction before age 35 years, sudden death during exercise, and cardiac arrhythmias.
During physical examination, assess the child for an abnormal heart murmur and other cardiovascular abnormalities, including hypertension. It also is important to assess the child for irregular or rapid heart rhythm, as well as findings suggestive of Marfan syndrome.
Refer any patient with significant findings to a pediatric cardiologist for further evaluation, because a routine physician examination might miss some conditions associated with sudden cardiac death, the authors recommended. Pediatricians should perform ongoing assessment of patients identified at risk at each subsequent visit, according to the guidelines. A physical examination including blood pressure and pulse assessment is suggested. “There are no clinical studies or data indicating that children with most types of congenital heart disease are at significant risk for sudden cardiac death while on these [ADHD] medications,” the authors wrote. Nevertheless, the authors addressed cardiovascular monitoring of children with known structural heart disease or other heart conditions.