Magazine article Clinical Psychiatry News

Screen ADHD Patients First, Heart Group Says

Magazine article Clinical Psychiatry News

Screen ADHD Patients First, Heart Group Says

Article excerpt

The new recommendation calling for electrocardiogram screening for children with attention-deficit/hyperactivity disorder before initiating pharmacologic treatment is not based on data, according to an expert in child and adolescent psychiatry.

Dr. David Fassler said that at this point, there is no evidence that such screening would enhance safety or reduce the risk of rare but potentially serious heart-related problems.

"The best advice is for parents to talk to their child's doctor," Dr. Fassler, clinical professor of psychiatry at the University of Vermont, Burlington, said when asked about the recommendations. "They can then decide together what, if any, additional evaluation may be warranted."

Under the recommendations, issued in April by the American Heart Association, if patient history, family history, clinical examination, and/or ECG results suggest a higher risk, a referral to a pediatric cardiologist is warranted.

For patients currently taking methylphenidate, amphetamine, or another treatment for ADHD, a comprehensive assessment of cardiac risk is reasonable if deemed necessary, according to the AHA scientific statement published in Circulation, available at circ.ahajournals.org (Circulation 2008 April 21 [doi: 10.1161/circulation.aha.107.189473]).

The AHA recommendations, offered by Dr. Victoria L. Vetter of the Children's Hospital of Philadelphia and her colleagues, say it is important to pay particular attention to symptoms such as palpitations, near syncope, or syncope that might indicate a cardiac condition.

Consider all other medications taken by a pediatric patient, including over-the-counter agents, according to the recommendations, titled "Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs."

Cardiac risk assessment of all children before prescribing ADHD medications, ongoing monitoring, and specific gudelines for children with known structural heart disease or other heart conditions are outlined in the statement.

In 1999, the AHA addressed concerns about potential adverse cardiac effects of psychotropic medications in children, but made no specific recommendations about stimulants. However, "since that time, a constellation of circumstances has come together, necessitating a second look at this complicated issue," the authors of the current statement wrote.

The authors note that ADHD might be more prevalent among children with heart disease than the estimated 4%-16% of the general population. One study, for example, indicated that 45% of children with heart disease had abnormal attention scores and 39% had abnormal hyperactivity scores (Pediatrics 2000;105:1082-9).

The recommendation for selective ECG screening is new. The writing group suggested the testing will increase the likelihood of identifying significant cardiac conditions such as hypertrophic cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome that might place the child at risk.

"We recognize that the ECG cannot identify all children with these conditions but will increase the probability," wrote Dr. Vetter and the six other experts on the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young and the Council on Cardiovascular Nursing. …

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