Clear the Fog On Attention-Deficit/Hyperactivity Disorder
by John H. Samson, M.D., F.A.A.P.
July 7, 2008
There has been a flurry of recommendations from the American Heart Association and the Food and Drug Administration which have clouded the air with a fog of uncertainty. Does a patient need an electrocardiogram or an ECHO cardiogram before starting on medication for ADHD syndromes? Does a child that has been on medication for this condition need one or both of these studies?
The official publication of the American Academy of Pediatrics, the AAP News, printed an article by Lori O’Keefe in the June 2008 edition. Here is a reprint of a section of that article which bullet points the AAP-AHA clarification that was promulgated May 15, 2008.
- The scientific statement included a review of data that show children with heart conditions have a higher incidence of ADHD.
- Because certain heart conditions in children may be difficult (even, in some cases, impossible) to detect, the AAP and AHA feel that it is prudent to carefully assess children for heart conditions who need to receive treatment with drugs for ADHD.
- Obtaining a patient and family health history and doing a physical exam focused on cardiovascular disease risk factors(Class I recommendations in the statement) are recommended by the AAP and AHA for assessing patients before treatment with drugs for ADHD.
- Acquiring an ECG is a Class II recommendation. This means that it is reasonable for a physician to consider obtaining an ECG as part of the evaluation of children being considered for stimulant drug therapy, but this should be at the physician’s judgment, and it is not mandatory to obtain one.
- Treatment of a patient with ADHD should not be withheld because an ECG is not done. The child’s physician is the best person to make the assessment about whether there is a need for an ECG.
- Medications that treat ADHD have not been shown to cause heart conditions nor have they been demonstrated to cause sudden cardiac death. However, some of these medications can increase or decrease heart rate and blood pressure. While these side effects are not usually considered dangerous, they should be monitored in children with heart conditions as the physician feels necessary.
Let me highlight some of the statements in the report:
- Before stimulants are prescribed a careful patient and family history with an examination focusing on cardiovascular disease risk factors is needed.
- Based upon #1 a physician may elect to:
A) get an ECG
B) get am ECHO cardiogram
C) have the patient see a cardiologist before starting the medication. As the author clearly states, an ECG is not mandatory.
My own opinion is that if any risk of heart disease or cardiac reaction to the drug exists, the patient needs more that a single ECG. - Medications used to treat ADHD have NOT been shown to CAUSE heart disease.
- These medications have been demonstrated to cause sudden cardiac death.
- Because the medications can alter blood pressure and heart rate, children and adults should be monitored to be sure that the value remains within normal limits. That is one of the reasons we follow our patients with regular evaluations every four months while they are on the mediation.
I want to thank the American Academy of Pediatrics and the author Lori O’Keefe for clearing the fog. We can now chart a straight course to good therapy for the children who have the highly impacted condition of Attention-Deficit/Hyperactivity Disorder.
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