Welcome to University of Iowa Health Care Today. Recently, the American Heart Association announced that some children who receive drug therapy for attention deficit hyperactivity disorder, or ADHD, should be screened for potential heart conditions. Dr. Dianne Atkins joins me now by phone to tell us more about this recommendation. Dr. Atkins is a professor and pediatric cardiologist at University of Iowa Children’s Hospital, located in UI Hospitals and Clinics. Dr. Atkins,

For children with ADHD, what medications are typically prescribed?

There’s a long list of drugs, but the first-line therapy is what we refer to as stimulant medications, and these are known by the names of Ritalin, Adderall, and Concerta, and there are some others. And then if those drugs are ineffective, there are a lot of other types of medications. As a cardiologist, I don’t tend to prescribe these myself, but sometimes some antidepressant medications are used. But the most typical one is a stimulant and that’s what this particular statement from the American Heart Association dealt with.

What is the benefit of the most commonly used medications for ADHD?

Well, Attention Deficit Hyperactivity Disorder is actually a fairly serious problem for a number of children. They have the inability to sit still, they can’t concentrate, they have a lack of impulse control, and these medications really help all of those types of symptoms. The medications tend to be very effective, and it really makes a difference in how well they perform in school and their social interactions. And as they become teenagers, their risk-taking behavior and impulse control—we know that teenagers who carry the diagnosis of ADHD are four times more likely to be involved in a serious motor vehicle accident—these medications can prevent some of that risk-taking behavior.

Why is the American Heart Association concerned about medication for ADHD in some children?

There are some scattered reports that have been reported to the U.S. Food and Drug Administration about sudden cardiac death or a child just dying very suddenly or unexpectedly while they are taking stimulant medications. But it’s not clear at all that the stimulant medications were the cause of the sudden cardiac death. The other thing that we’re concerned about is we know that children who have congenital heart disease, especially those who have required surgery in the first year or two of life, are more likely to have Attention Deficit Disorder, and there is some concern about the use of those medications in these children. And so the statement from the American Heart Association addresses both of those issues.

Prior to beginning the medication, what steps should be taken by their pediatrician?

The most important thing that the pediatrician needs to do is a thorough past medical history and family history of the patient; as well as a very thorough cardiac exam. The questions that need to be answered include: Does the child have a history of fainting, especially associated with exertion, or startle response, or emotional distress? Does the child have palpitations? Is there any history of chest pain in the child? And then, in terms of the family history, the same kinds of questions: Is there a history of sudden cardiac death, and by that we mean, again, dying very suddenly and unexpectedly—and that can include things like unexplained motor vehicle accidents, drownings, and other things than just sort of dying very unexpectedly. A history of seizures in the family? A history of coronary artery disease? So the typical kinds of problems that adults have requiring bypass, or angioplasty, or stent placement, that is not a risk factor for taking these stimulant drugs. And I think there’s a lot of confusion about that, because most of us have a history of some kind of heart disease in our family, but this is directed very specifically for the kinds of things that young people have.

When is it reasonable to consider also doing an electrocardiogram on a child before starting medication?

And I think, first of all, just to clarify; the American Heart Association is not saying that every child needs an electrocardiogram. It’s saying that it is reasonable to consider it if there is any evidence of sudden cardiac death or things that might promote that in the family. So if there is an answer of yes to any of the questions that I just talked about—fainting, irregular heartbeat, palpitations—then it might be reasonable to consider doing an electrocardiogram before starting the medication. But it’s not the situation where every child needs an ECG.

If a child has ADHD and also has a cardiovascular condition, should they not take medications to control their ADHD?

I think that needs to be individualized and the person who needs to make that decision is the child’s pediatric cardiologist. Again, the relationship between adverse cardiac events or death and stimulant therapy is still very poorly defined. There is a risk to having this disease and so that risk and benefit need to be weighed; along with the severity of the congential heart disease. So that’s a decision that needs to be individualized and really made by the pediatric cardiologist caring for the child.

Bottom line – what do you suggest that a parent with a child diagnosed with ADHD do before their child starts or changes their medication for the condition?

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Dianne Atkins, MD

UI Pediatric Cardiology