By Alan Mozes
Monday, April 21, 2008 12:00 AM
MONDAY, April 21 (HealthDay News) -- The American Heart Association on Monday issued recommendations that call for cardiovascular screening before prescribing stimulant treatment for all children diagnosed with attention-deficit hyperactivity disorder (ADHD).
The guidelines are meant to address mounting fears that these medications can raise the risk for cardiac complications among those with underlying heart disease.
"This is new, and it is a shift in our policy," said Dr. Victoria L. Vetter, head of the association's statement writing committee, and a professor of pediatrics at the University of Pennsylvania School of Medicine in Philadelphia.
"But we're not recommending that every child in the country have these heart screenings, rather that they be used as a reasonable tool for this small, particular group of children about to take ADHD medications, so we can ensure the treatment proceeds as safely as possible," she added.
The recommendations were published online Monday inCirculation, a journal of the American Heart Association (AHA).
They include: the taking of a detailed patient and family medical history, particularly regarding heart disease; a full physical exam, including blood pressure and heart beat monitoring; an electrocardiogram (ECG); and a pediatric cardiologist consultation prior to treatment if evidence of heart disease is uncovered.
After treatment begins, the AHA said that children should continue to have blood pressure check-ups once every one to three months, as well as routine health check-ups every six to twelve months.
The AHA noted that ADHD is the most common neurobehavioral disorder among American kids, with estimates indicating that between 4 percent and 12 percent of American school-aged children have the condition.
Currently, more than 2.5 million children in the United States are being prescribed ADHD medications, the organization noted.
According to the U.S. National Institutes of Health (NIH), the most effective ADHD medications typically belong to the "stimulant" class of drugs, which includes amphetamines, methylphenidates and dextroamphetamines.
Some of the names under which these drugs are marketed include Adderall, Concerta, Dexedrine, Focalin, Ritalin, Ritalin SR or LA, and Metadate ER or CD. The new recommendations refer to all of these stimulants, as well as to a newer drug known as Strattera, which was recently approved by the U.S. Food and Drug Administration as a non-stimulant treatment for ADHD.
Though ADHD stimulants increase a child's heart rate and blood pressure, the NIH noted that no evidence has indicated that such medications are addictive, and side effects do not typically pose any danger for most healthy children.
However, children with underlying heart disease who take stimulants for ADHD appear to face an increased risk for sudden cardiac arrest, the AHA noted. This risk association is particularly troublesome for young ADHD patients, because heart disease often goes undiagnosed in children and may be present without noticeable symptoms.
The AHA also pointed to a number of studies that suggest that between 33 percent and 42 percent of pediatric heart patients also have ADHD.
FDA data collected for the period 1999 through 2004 revealed that 19 children following an ADHD prescription regimen had died suddenly, while 26 experienced heart complications such as stroke, heart attack, and/or heart palpitations.
Vetter noted that, in 2005, the Canadian equivalent of the FDA -- Health Canada -- decided to place a ban on Adderall, an amphetamine-based ADHD medication designed for kids over the age of 3. The Canadian decision was actually based on a review of FDA records concerning 12 reported deaths among American children taking ADHD drugs.
Vetter pointed out that the Canadian decision was based on an assessment of collected data based on family self-reports (sometimes in the absence of autopsy records), rather than a complete scientific analysis.
"But the reality is that we were faced with some kids who had ADHD who suddenly died," she said. "And a lot of them were exercising at the time, which is when most of the kids who have electrical malfunctions of the heart would have a sudden cardiac death. So we have to assume they experienced a cardiac death."
In February 2007, the FDA ordered makers of ADHD medications to develop guidelines that alert patients to the heart risks associated with their treatments.
"But it's not that these are dangerous medicines," stressed Vetter. "But by adding the ECG, and by being aware of possible heart disease, and monitoring the kids once you prescribe the medications, one can go ahead and treat the ADHD. And these kids can be very happy."
Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Schneider Children's Hospital in New Hyde Park, N.Y., agreed that the point of expanded screenings is to identify a child's underlying heart complication, not to look for problems with the stimulants themselves.
"Serious cardiac complications from stimulant medications are very rare," Adesman said. "But because there are concerns on the part of parents and some physicians, routine ECG screenings will provide greater reassurance for the vast majority of patients for whom ADHD medications are being considered."
For more on ADHD treatments, visit the National Institute of Mental Health.
SOURCES: Victoria L. Vetter, M.D., head, American Heart Association statement writing committee, and professor, pediatrics, University of Pennsylvania School of Medicine, Philadelphia; Andrew Adesman, M.D., chief, developmental and behavioral pediatrics, Schneider Children's Hospital, New Hyde Park, N.Y.; April 21, 2008,Circulationonline