American Heart Association Guidelines on Medications for ADHD

In April, 2008, the American Heart Association released a scientific statement concerning the risk of sudden cardiac death in children taking medications for ADD/ADHD.  What follows is a brief summary of this statement.

What is known?

1. Sudden Cardiac Death causes an estimated 1000-7000 deaths of children and adolescents per year in the United States.

2.  Risk factors for Sudden Cardiac Death include cardiomyopathy which is an abnormal enlargement of the heart muscle.  Cardiomyopathies can be inherited or acquired, likely by viral infections which attach the heart muscle.  Other risk factors are Conduction abnormalities.  These affect how driving electrical impulses travel through the heart.  Congenital Heart Defects, even if they have been repaired, seem to be risk factors as well.

3.  Having ADD/ADHD does not increase an individual’s risk of sudden cardiac death.

Based on extensive review of scientific papers since 1980 and information from the FDA, the American Heart Association is recommending more cautious monitoring of children on certain medication, including those commonly used to treat ADD/ADHD.

Why these recommendations?

1. The medications commonly used are neuro-active.  They affect how chemical signals pass in the brain reducing impulsivity and increasing focus.  They also affect how chemical signals regulate blood pressure and heart rate.
2. The effects of these medications on the heart and blood pressure are generally small, but may be more significant in a patient with heart disease or with the risk factors for sudden cardiac death listed above.
3. In many children and adolescents, the risk factors for Sudden Cardiac Death are silent and may not be readily apparent even with a good medical history and physical.
4. An ECG (short for ElectroCardioGram also known as EKG) is a painless test which can give good information about the electrical impulses in the heart and can reveal signs of an enlarged heart associated with cardiomyopathy.  If an abnormality is found, your child will be referred to a cardiologist for a full work-up.

 Current Recommendations:

1. Full Physical by your physician including review of each patient’s medical history and the family medical history targeting risk factors for Sudden Cardiac Death.   The physical will include noted heart rate and blood pressure.
2. ECG before starting medication.  If the patient is already on medication, a baseline ECG should be done.  This will be repeated after the child turns 12 years.
3. Regular check-ups at 1 to 3 months after starting medication then every 6 to 12 months.  Immediate follow-up if any new cardiac symptoms develop.

Medications of concern:

• Amphetamine (Dextroamphetamine, Dextrostat, Adderall, Vyvanse)

• Methylphenidate (Ritalin, Concerta, Metadate, Methylin, Focalin, Daytrana)

• Atomoxetine (Straterra)

• Clonidine (Catapres)

• Guanfacine (Tenex)

• Desimpramine(Norpramin)/Imipramine (Tofranil)

• Bupropion (Welbutrin,Zyban)

• Modafanil (Provigyl)

(Note from Box Hill:  caffeine and decongestants are also agents which cause increased heart rate and blood pressure.  Please use caution and moderation with these substances).

Source:  Vetter,V.L., J.Elia, C. Erikson, S.Berger, N. Blum, K. Uzark and C.L. Webb. Cardiovascular Monitoring of Children and Adolescents with Heart Disease Receiving Stimulant Drugs.  A Scientific Statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. April 2008. Circulation, Journal of the American Heart Association. Available online: http://www.circ.ahajournals.org

This Summary prepared by K.L. Hopkins, M.D. 4/08