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HUGE NEWS! New Guidelines Urge Heart Tests Before Kids Take ADHD Drugs!
Note from Ilena Rosenthal, Health Lover ... finally, a start in the
New Guidelines Urge
Heart Tests Before Kids
Take ADHD Drugs
By RON WINSLOW
April 22, 2008
Children diagnosed with attention deficit and hyperactivity disorder
should have a thorough heart work-up, including an electrocardiogram,
before taking stimulants such as Ritalin to treat the condition,
according to a new recommendation by the American Heart Association.
The advice marks the first time a medical-guidelines body in the U.S.
has urged wide use of an electrocardiogram, which charts electrical
activity in the heart, to screen a presumed healthy population for
But there is debate among experts about the value of using the test to
screen such a large pool of patients to detect a rare condition. The
hope is that such a test -- in combination with a comprehensive
checkup -- will help to avoid the rare cases of sudden cardiac arrest
that have been linked to the widely used medicines.
AN ADHD CARDIAC CHECKLIST
A child diagnosed with ADHD should get a thorough heart checkup,
• Patient and family history, with special attention to palpitations,
fainting or recent difficulties during exercise.
• A physical, including blood pressure and a check for abnormal
• An electrocardiogram to measure electrical function of the heart.
• If necessary, a consultation with a pediatric cardiologist to
discuss important findings.
Source: American Heart Association
"The goal is to improve the care of children, including allowing them
to have their ADHD treated and have it done safely," says Victoria
Vetter, director of electrophysiology at Children's Hospital of
Philadelphia and lead author of the heart association's statement.
Since 1999, fewer than 30 sudden deaths among children have been
linked to the drugs, which are currently taken by more than 2.5
million youngsters in the U.S. Issues of cost, available expertise in
reading children's ECGs and concern about false-positive tests are
prompting some experts to question the rationale for urging an ECG in
"This is a $250 million recommendation," says Mike Ackerman, a
pediatric cardiologist at the Mayo Clinic in Rochester, Minn., who
estimates the total cost of an ECG at about $100. "We're really trying
to find a needle in a haystack, and we have no data yet to know that
the screening program they're recommending would capture" those few
at-risk individuals. Dr. Ackerman was a member of another American
Heart Association panel that last year stopped short of recommending
routine ECG screening for heart abnormalities in young competitive
ADHD is a disorder affecting about 4% to 8% of American children ages
4 to 17 (some estimates range as high as 16%), and is marked by
inattention and disorganized or impulsive behavior. Critics believe it
is overdiagnosed, but left untreated, those who suffer the malady are
at heightened risk of such problems as failure in school, car
accidents and substance abuse.
Drugs prescribed for ADHD include Novartis AG's Ritalin, Shire PLC's
Adderall and Eli Lilly & Co.'s Strattera, and they have proved
effective in controlling symptoms. The heart association's
recommendation applies to all such drugs. Generally, stimulants used
to treat ADHD long have been linked to slight increases in blood
pressure and heart rate. More seriously, children with underlying
congenital heart disease appear to be susceptible to rare episodes of
heartbeat irregularities that can cause sudden cardiac arrest. There
isn't any evidence linking the drugs to sudden death among children
without an underlying congenital heart condition, researchers say.
Three years ago, Canadian regulators suspended sales of Adderall based
on reports of 20 deaths linked to the medicine over the previous
decade. A year later, an advisory panel to the U.S. Food and Drug
Administration recommended stringent "black box" warnings on the
medicines' labels regarding serious cardiovascular risks.
These developments prompted the heart association to review the
evidence surrounding the medicines, which led to the statement
published Tuesday in the group's chief journal, Circulation.
In an exam following an ADHD diagnosis, the statement says, doctors
should take a detailed patient and family history looking for, among
other things, any episodes of fainting or dizziness, heart
palpitations or murmurs or unexplained change in ability to exercise.
Patients and family members should disclose any unexplained death or
heart attack among young relatives. During a physical, patients should
be checked for abnormal heartbeats, high blood pressure or any traits
suggestive of Marfan syndrome, a condition associated with structural
defects in the heart.
An electrocardiogram can detect such abnormalities as a thickening of
the heart and a person's risk of runaway heartbeats that can cause
Dr. Vetter says the ECG is a "recommendation," not a requirement that
should prevent children from getting timely access to needed
medicines. "If they're on the medication, they shouldn't stop it," she
says, but they should get the heart work-up. Patients should have
periodic heart checkups while they are taking the medicines.
Dr. Vetter believes the cost of ECGs is reasonable and that they would
enable doctors to identify and treat patients with heart conditions,
which then could enable the patients to more safely take medicines for
ADHD. "We don't want to impede treatment of these children," she says.
"We are trying to allow them to be safely treated."
She also says her own research suggests that about 2% of children have
serious heart defects they don't know about, and that an ECG would be
able to detect many of them.
Still, there is little evidence from clinical studies that suggests
the benefit of ECG screening significantly outweighs the costs and
other risks. "The field is wrestling with how to screen for sudden
death involving young people in a variety of settings and we're really
perplexed," says Dr. Ackerman. Reading a child's ECG is especially
tricky, he says, and a big risk of a broad screening program is
false-positive tests that send children and their families on "an
emotional roller coaster" of unneeded and anxiety-provoking tests. And
getting a misdiagnosis of a heart defect expunged from a medical
record is very difficult, he says.
While the sudden death of child is tragic, "if we're going to change a
lot of people's lives and spend a lot of money," says Timothy Knilans,
director of cardiac electrophysiology at Cincinnati Children's
Hospital, "we ought to have a good scientific basis rather than do it
on the basis of what might feel right in somebody's gut."
Dr. Vetter and her colleagues who published the American Heart
Association statement acknowledge that hard data are lacking. They
also call for establishing a registry of cases of sudden cardiac death
in children, adolescents and young adults, with one goal of learning
more about what role ADHD drugs may play in such incidents and what
strategies may be effective in preventing them.
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