Wednesday, April 23, 2008

Kids, Stimulants, and EKGs

Andrew Adesman, MDby Andrew Adesman, MD

The American Heart Association (AHA) this week released a statement calling for pre-treatment electrocardiograms (EKGs) and routine cardiac monitoring for children and adolescents prescribed stimulant medication for attention-deficit/hyperactivity disorder (AD/HD).

The intent of the AHA’s call for closer cardiac monitoring is to identify the very small number of children and adolescents who may have an undiagnosed heart problem. Overall, I think this makes an already safe process even safer. That said, I think there are some considerations and implications involved with such a recommendation.

First, I am concerned that while this screening test will undoubtedly identify the extremely small number of children who indeed are at some increased risk, it will lead to a delay in treatment for most children, incur an additional cost for some, and create a significant number of “false positives” that will lead to additional consultations.

To the extent that many people do not live close to a pediatric cardiologist, this will create an additional burden of time, anguish, and money. Although the decision should indeed fall to pediatric cardiologists, there may not be clear, evidence-based guidelines guiding them as they counsel families referred for a cardiac clearance for stimulant medication. (This of course assumes that a family can easily locate and get in to see a pediatric cardiologist.)

Since some of these rare cardiac conditions would be important to identify for their own sake, perhaps routine EKG screening should be done on all children. In other words, although the decision to treat with stimulant medication will increase the likelihood of imminent cardiac problems in some children evaluated for AD/HD, these health issues should be identified in all children if feasible. However, this is likely to be a resource issue.

Perhaps the most important point is that the EKG screening may, to some extent, give a false sense of security to families and clinicians. That is to say, in some rare cases the screenings could miss some cardiac problems that would be important to identify if stimulants are to be prescribed.

The AHA’s recommendations likely reflect a consensus by its leadership on what is considered reasonable and feasible. I am certain the points I have enumerated in this blog entry were considered in developing the recommendation.

So what should be done as we move forward with this recommendation? First, we must make sure we’re eliminating as many hurdles as possible for parents. Health insurance companies should play their role by accepting EKGs as “medically necessary” so that there are no payment denials for asymptomatic children. Pediatric cardiologists will need clear evidence-based guidelines that will help them as they advise families. And primary healthcare providers, who initiate the evaluation for AD/HD, will have to help shepherd parents through the various evaluations to avoid a significant delay in treatment for AD/HD. I take solace in knowing that CHADD and its sister organizations will do everything imaginable to help parents with these new recommendations.

Andrew Adesman, MD, is chief of developmental & behavioral pediatrics at Schneider Children’s Hospital, part of the North Shore-Long Island Jewish Health System in New Hyde Park, New York. A former member of CHADD’s board of directors and a current member of its professional advisory board, Dr. Adesman is recognized nationally for his clinical expertise in child development. He has authored many articles on AD/HD and co-authored the book Parenting Your Adopted Child.


Anonymous said...

Dr. Adesman,

Having read the article in Circulation, I am concerned that the scientific basis of this recommendaiton is lacking. The primary source they site for any scientific rational is the FDA package insert. We all know that this is subject to the collective opinion of the advisory panels, even in the abscence of data showing an increased risk. Also conspicuously abscent is the multicenter study from 2006 that showed that the risk of catastrophic cardiac events was not higher in ADHD treated kids and teens than in kids and teens on NO medication over a 2 yr. period(actually slightly lower risk - a study that would counter the basis of the AHA recommendation. There aren't enough ECG machines, and certainly not enough pediatric cardiologists to perform all of the ECG's recommended by this article. Finally, unnecessary anxiety has already been caused, and the risk of a wrongly based standard of care is high. I hope other bodies will speak out more directly so that this recommendation will be revisited.
C. A. Stilwell, Jr., MD, FAAP

Anonymous said...

Good morning -

I am the parent of an 8 year old boy (who I adopted at 8 months) that is diagnosed with ADHD/Aspergers. Matthew takes medication.

This article was extremely interesting to me. About two years ago his pediatrician read an article about getting children that are on medication to have their heart checked. She scheduled my son an appointment to have and EKG....they found out that he had a heart birth defect....if this test hadn't been done, the birth defect would not have been found. All is well, and the medication was in no part involved in the heart problem.

Just another note, thanks for the work you do. Although I am not a very active member, I do read each and every email.

Anonymous said...

I DO NOT AGREE with you.... I am ADHD. I had a bad experience taking stimulant drugs such as Adderal and Ritilin. I think these drugs can be LIFE-THREATENING and taking the extra EKG precaution is well Advised! Please send this
information on.It may save lives!

Anonymous said...

We had a heart episode with aidan 2 years ago and insisted on the ekg. It was normal However - I had to check a drug interraction concern for me yeastersday (I am on concerta) - went to their website and stumbled on a note they made warning folks of heart issues (rare) when using concerta and clonidine. So many kids use both at the same time - clonidine at night to get kids to sleep my son takes .2mg every night. So I called concerta's manuf to ask abt that - they said havg an ekg done when the child is on both meds is the key. Well that is key - we did not have the ekg done under those circumstances.
I will call our pediatrician - but it bothers me as I've never heard this warning - from Pfeffer from anyone. Don't want overreact but stopped the clonidine which is hard.
Is there anyone to put that question to at chadd?

Anonymous said...

EDITOR'S NOTE: The following comments are from Josephine Elia, M.D., who is a member of the faculty at Children's Hospital of Philadelphia (CHOP) and a member of the task force that authored the AHA statement. What follows is her response to Dr. Adesman's blog entry:

Dr. Elia's response...

1. We do not recommend delaying treatment until an EKG is obtained.
Since the EKG is medically indicated, insurers should cover cost.As with all testing, there will be “false positives”.

2. Access to a pediatric cardiologist will be difficult for some families. The role of the cardiologist is to assess and manage underlying cardiac pathology as they would do for any patient. Although we have data on safety of ADHD medications in children and adolescents without known cardiac disorders, we do not have data on the safety of ADHD meds in children with cardiac problems. Parents with children who are identified with cardiac conditions will need to consider the fact that the risks of treatment with ADHD medications are not yet known.

3. We concur that a routine EKG screening for all children would be ideal. In our center, The Children’s Hospital of Philadelphia, children with serious cardiac disorders have been found to have very high rates of ADHD. This has raised the question about the rate of cardiac problems in ADHD children. We do not know the answer to this question, and large epidemiological studies will be necessary to answer this, however our data suggest that the rate of cardiac conditions may be higher in the ADHD population than in the general population.

4. This is accurate, an EKG cannot identify all cardiac disorders, however it can identify many conditions such as arrhythmias or cardiac hypertrophy that are important.

5. The issues that are being raised are valid. These were discussed at length and the pros and cons considered. Since ADHD children may be at greater risk of cardiac disorders, a thorough cardiac history and an EKG is medically indicated.