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September 2008

Valproate for Agitation in Dementia
In two studies, valproate (Depakote and others) did not seem to decrease agitation and aggression in patients with dementia.

Topiramate in the Treatment of Borderline Personality Disorder
Preliminary research suggests topiramate may be useful in the treatment of borderline personality disorder.

In Brief
Generic Risperidone Now Available; Ginkgo biloba Not Effective for Dementia; Autism Linked to Defects in “Learning” Genes

Quetiapine Augmentation in GAD: A Negative Trial
In a recent study, augmenting paroxetine (Paxil and others) treatment of generalized anxiety disorder with quetiapine (Seroquel) was ineffective.

BTP Announces ASCP Partnership
BTP proudly announces our partnership with the American Society of Clinical Psychopharmacology (ASCP) and extends a warm welcome to all ASCP members.

ECGs for Kids with ADHD?
An electrocardiogram may be advisable for some children before they begin pharmacologic treatment for attention-deficit/hyperactivity disorder.

ECGs for Kids with ADHD?

September 2008

The American Heart Association (AHA) recently recommended that children being evaluated for treatment of attention-deficit/hyperactivity disorder (ADHD) should have an electrocardiogram (ECG) and, if it was abnormal, a consultation with a pediatric cardiologist.1,2 The AHA also recommends a family history of cardiac disease and a physical examination for signs of cardiac abnormalities. A controversy has resulted.

Experts in ADHD fear that the ECG recommendation is excessive and unnecessary, the expense would be considerable, and the shortage of pediatric cardiologists could make it impossible for children to get necessary treatment. The Journal of the American Medical Association quotes Dr Michael Ackerman of the Mayo Clinic as saying that the data underpinning this recommendation are insufficient and the recommendation premature.2 A clarifying statement from the AHA suggests that ECGs should be obtained if the physician "feels it is warranted."

ADHD may be more prevalent in children with heart disease than in the general pediatric population, and children with serious heart problems or defects have died while taking ADHD medications. The US Food and Drug Administration (FDA) advises evaluating patients for cardiovascular problems before treatment with ADHD medications. Of approximately 2.5 million children that the Centers for Disease Control and Prevention estimate took ADHD medications in 2003, Ackerman estimates a sudden death rate of about 3 per year. A retrospective study of 55,000 ADHD patients aged 3 to 20 years found patients who took stimulants had small increases in blood pressure and palpitations but no increase in cardiac deaths or hospitalizations.3

If a child's pretreatment ECG is abnormal, the AHA calls for consultation with a pediatric cardiologist before starting ADHD medications. They further advise blood pressure checks within 1 to 3 months and follow-ups every 3 to 6 months. Ackerman counters that the cost of the routine ECG screenings and follow-ups for possible abnormalities will be $250 million, which could be prohibitive. Further, ECGs in children can be hard to interpret without considerable expertise.

Steven Pliszka, MD, who was lead author of a 2007 ADHD practice guideline by the American Academy of Child and Adolescent Psychiatry, does not think routine ECG screening is necessary.4 He recommends a thorough medical history and examination, which include inquiry about family and personal cardiac history and risk factors.

Labeling for the D-amphetamine/amphetamine combination drug Adderall includes a black-box warning concerning sudden death with misuse. Methylphenidate (Ritalin and others) does not carry such a warning, but all stimulants carry warnings to avoid their use in pediatric patients with cardiac problems.

There does appear to be a small risk of serious cardiac adverse effects, including possible sudden death, associated with ADHD medications, particularly stimulants. Taking a history of cardiac problems and risk factors in patients and family members is good practice. Where there is elevated risk, psychiatrists should discuss with patients' pediatricians the advisability of an ECG and cardiology consultation.

1Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL; American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee; American Heart Association Council on Cardiovascular Nursing: Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs: A scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation 2008;117:2407-2423.

2Hampton T: Group's advice on cardiac testing for children with ADHD draws criticism. JAMA 2008;299:2735.

3Yan J: Stimulants show little risk of major cardiac events. Psychiatr News 2008;43:23.

4Yan J: Psychiatrists take issue with AHA's recommendations. Psychiatr News 2008;43:27-34.