Cardiovascular Risks, Evaluation, & Monitoring

ADHD Part 2

Cardiovascular risks, evaluation, & monitoring

Sudden cardiac death in persons taking medications for ADHD is a very rare event, occurring at rates no higher then the general population1. Sudden cardiac death occurs at an incidence of 0.8-6.2/100,0002.

2011 AAP Policy Statement: Cardiovascular monitoring

See Attached CV Monitoring ADHD1 for more details & explanations.

Policy is endorsed by American Academy of Child & Adolescent Psychiatry, the Society for Development & Behavioral Pediatrics, and National Initiative for Children’s Health Quality, the National Association of Pediatric Nurse Practioners, & Children & Adults with Attention Deficit/Hyperactivity Disorder.

1. Careful assessment of all children, including those starting simulants, by using a targeted cardiac history & physical examination, including a careful cardiac examination (GRADE C) a. Patient hx of previously detected cardiac disease b. Palpitations c. Syncope d. Seizures e. Family hx of sudden death in children or young adults f. Hypertrophic cardiomyopathy 2. AAP encourages primary care & subspecialty physicians to continue currently recommended treatment for ADHD, including stimulant medications without obtaining routine ECG’s or routine subspecialty cardiology evaluations for most children before starting these medications (GRADE D)

1 This policy was in response to the American Heart Association Statement recommending that is reasonable to obtain ECG testing as part of the evaluation of children being considered for stimulant drug therapy.

AHA Recommendations (see attached for more details & explaninations2): 1. After a diagnosis of ADHD has been made, but before a stimulant or other medication is initiated, a thorough evaluation should be performed as indicated below with special attention to symptoms that can indicate a cardiac condition such as palpitations, near syncope, or syncope. a. All medications used (prescribed & OTC) should be determined b. Complete family hx- especially for conditions known to be associated with sudden cardiac death: HCM, Long QT syndrome, WPW, and Marfan syndrome. 2. Detection of the above sx or family history should warrant an evaluation by a pediatric cardiologist before initiation of therapy.

2 3. A thorough physical examination for HTN, cardiac murmurs, and physical findings of Marfans, and signs of irregular rhythms should be conducted 4. Some cardiac conditions associated with sudden cardiac death may not be detected on routine examination. Therefore it can be useful to add an ECG, which may increase the likelihood of identifying significant cardiac conditions. 5. Pediatric cardiology consult- should be obtained before stimulant medication is started if there is any significant findings on physical exam, ECG, or history (patient or family). Recommendations for history/physical per AHA2: 1. Patient hx should elicit the following: a. Hx of faiting or dizziness (especially with exercise) b. Seizures c. Rheumatic fever d. Chest pain or SOB with exercise e. Unexplained, noticeable change in exercise tolerance f. Palpitations, increased HR, or extra/skipped heart beats g. Hx of high blood pressure h. Hx of heart murmur other than innocent or functional or hx of heart problems i. Intercurrent viral illness with chest pain or palpitations j. Current medications & health supplements 2. Family Hx should elicit the following: a. Sudden or unexplained death in someone young b. Sudden cardiac death or “heart attack” in members <35 y/o c. Sudden death during exercise d. Cardiac arrhythmias e. Hypertrophic cardiomyopathy or other cardiomyopathy (dilated & RV) f. Long QT syndrome, short QT syndrome, or Brugada syndrome g. WPW or similar abnormal rhythm conditions h. Event requiring resuscitation in young members (<35) including syncope i. Marfan syndrome 3. CV Physical Exam: a. Abnormal heart murmur b. Other cardiovascular abnormalities- HTN, irregular or rapid heart rhythm c. Physical findings of Marfan syndrome 4. ECG recommendations- reasonable to obtain a. Should be read by pediatric cardiologist or cardiologist or physician with expertise in reading pediatric electrocardiograms b. Once medication is started, if ECG obtained before 12 y/o, may warrant consideration of repeat ECG

3 c. Development of new symptoms or change in family hx, may warrant consideration of repeat ECG

Recommendations for Monitoring per AHA2:  Continuing assessment of patients at each visit by physical examination & by questions regarding potential cardiac symptoms as well as family hx.  Blood pressure & pulse should be evaluated during follow-up within 1-3 months & at follow-up every 6-12 months. Monitor more frequently during titration & weaning of α- agonists  Any cardiac symptoms should result in appropriate referral & testing to determine whether any other serious cardiac side effects are present  Patient monitoring for specific drugs

References:

1. Perrin JM, Friedman RA, Knilans TK et al. AAP policy Statement: Cardiovascular Monitoring and Stimulant Drugs for Attention- Deficit/Hyperactivity Disorder. Pediatrics 2008; 122 (2): 451-453. 2. Vetter VL, Elia J, Erickson C, et al. 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 Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation 2008; 117 (118): 2307-2423.