Heart risk in ADHD drugs?

Pennsylvania - New Jersey - New York - Nationwide

Heart Association calls for child cardiac testing.

April 22, 2008

Millions of children taking drugs for attention deficit hyperactivity disorder should be checked for heart problems, the American Heart Association said yesterday, a recommendation that also might identify more youngsters with cardiac disorders.

Ritalin, Adderall, Concerta, and other stimulants commonly prescribed to treat ADHD can increase blood pressure and heart rate. While not a problem for the vast majority of patients, they can lead to life-threatening conditions and even sudden cardiac death in those with heart conditions.

"We want all children to have safe access to these medications," said Victoria L. Vetter, a pediatric cardiologist at Children's Hospital of Philadelphia and lead author of the recommendations published today in Circulation, the heart association journal.

For the drugs to be truly safe, Vetter said in an interview, children with heart problems must be identified.

The committee of experts nevertheless emphasized that children on ADHD drugs should not stop. The recommendations are meant to prompt doctors to more carefully screen the heart health of young patients, Vetter said - "not freak out parents."

More than 2.5 million children take medication to treat ADHD, which is often characterized by hyperactivity, difficulty paying attention, and a tendency to act impulsively. Stimulants help them to focus and control their behavior.

Last year, a warning about possible risk to people with heart problems was added to the labels of most of these drugs after the Food and Drug Administration got reports that 19 children had died suddenly and an additional 26 suffered strokes, cardiac arrests, or other cardiovascular events while on the medication between 1999 and 2004.

The new recommendations go further. Before being started on stimulants for ADHD, the heart association said, all children should receive careful heart screenings that include electrocardiograms (EKGs) to rule out heart abnormalities.

Children who are already taking the drugs but did not receive an EKG should get one. An EKG is a test that detects and records the electrical activity of the heart. It shows how fast the patient's heart is beating and whether the rhythm is steady or irregular.

A spokeswoman for Novartis Pharmaceuticals Corp., which makes Ritalin, said the company had not seen the latest heart association statement and could not comment, but she pointed out that the label did suggest patients be evaluated for heart problems.

Medications are not the only potential cause for higher heart rates. Athletics can have a similar effect, and the heart association has in the past discussed whether students should be given EKGs before participating in sports. But it has not made such a recommendation.

There is no agreement in the medical community about the need for an EKG when prescribing stimulants for ADHD, either. The heart association's new guidelines are at odds with those of the American Academy of Pediatric and Adolescent Psychiatry.

"Ultimately my concern isn't so much whether or not EKGs are done; my concern is that we develop a consensus between professional organizations so that we can guide our patients," said Richard Kingsley, chief of child psychiatry at Alfred I. duPont Hospital for Children in Wilmington.

"The data, upon my review, would suggest that there really was not an additional risk for children taking psycho-stimulants," he added.

Steven Pliszka, a child psychiatrist at the University of Texas in San Antonio, said he was baffled by the EKG recommendation.

There is no evidence that sudden death is a bigger problem for children taking stimulants than for children who aren't taking the drugs, Pliszka said.

He said he was worried the recommendation for an EKG might deter people from seeking treatment due to the added expense and hassle. Moreover, psychiatrists aren't likely to have an EKG machine, and pediatricians might not either, making patients go elsewhere to get the test.

Vetter acknowledged that creating a system to enable such routine testing might take some time to work through but said the potential lifesaving benefits outweighed the relatively modest cost.

For the last three years, patients with ADHD at Children's Hospital of Philadelphia have been screened with EKGs, Vetter said. "We have been doing this, it is being paid for by insurers, and it is not burdensome."

Those tests, she said, have identified "a number of kids with heart disease."

"The purpose of the statement is to improve the safe care and enhance our ability to treat children with ADHD, not impede it," Vetter said.