Cardiac Screening Is Not Routine Before Prescribing Stimulants



Twenty-four percent of 525 pediatricians surveyed agreed that children with attention-deficit/hyperactivity disorder should undergo cardiac screening before taking stimulants, according to a study published online Jan. 16 in Pediatrics.

Although postmarketing reports during the past decade have shown cases of sudden cardiac death (SCD) in children with attention-deficit/hyperactivity disorder (ADHD) who were taking stimulants, findings from studies specifically addressing the topic have been inconsistent, said Dr. Laurel K. Leslie of Tufts Medical Center, Boston, and colleagues.

These studies have been undertaken in the wake of various recommendations for evaluation of cardiac status prior to starting stimulant treatment. In 2008, the American Heart Association "released a policy statement widely interpreted as recommending the routine use of electrocardiograms (ECGs) to evaluate children" prior to starting treatment with stimulant medication (Circulation 2008;117:2407-23).

As a clarification of that policy statement, the American Academy of Pediatrics (AAP) and the American Heart Association subsequently published a joint statement, which was endorsed by the American Academy of Child and Adolescent Psychiatry, that revised the American Heart Association’s original recommendation of the ECG. The joint statement stated that physicians should perform in-depth cardiac history and physicals (H&P) prior to starting stimulant treatment and get ECGs for children with positive findings. It noted that getting an ECG was a Class IIa recommendation so it is reasonable for a physician to consider an ECG, but not mandatory.

Then, the AAP stated in a 2008 policy statement that medications used to treat ADHD had not been shown to cause SCD, and there was not sufficient evidence to justify obtaining routine ECGs before starting treatment with stimulants. The AAP concluded that "until these questions are answered, a recommendation to obtain routine ECGs for children receiving ADHD medications is not warranted" (Pediatrics 2008;122:451-3).

In Dr. Leslie’s current study, 75% of the survey respondents agreed that physicians have a responsibility to inform families about the possible risk of SCD before children begin treatment with stimulants. However, only 30% agreed that the risk of a potential lawsuit was high enough to warrant cardiac screening (Pediatrics 2012;129:222-30).

In addition, 36% of the respondents agreed that informing families about a possible SCD risk might deter them from giving the stimulants to their children.

As part of the survey, each of the respondents reported the cardiac screening practices for his or her most recent patient with ADHD. Nearly all respondents (93%) completed a routine history and physical, and 71% collected an in-depth cardiac history, while 48% completed an in-depth cardiac history and physical.

Less than half (46%) of the physicians discussed cardiac risks with families of a recent patient with ADHD, although most (93%) of the respondents discussed weight loss or appetite suppression as a side effect of stimulants, 87% discussed sleep disturbance, and 75% discussed affective symptoms such as moodiness, irritability, and suicidality.

A total of 77 respondents (15%) reported ordering an ECG for their most recent patient; 42 of these did so because it was standard in their practices. Only 16 (21%) of the physicians who ordered ECGs reviewed the results themselves.

There was a general lack of comfort with cardiac screening procedures. A total of 71% of respondents said that their ability to interpret a pediatric ECG was a barrier to screening, and 18% said that their ability to perform an in-depth cardiac history and physical was a barrier. The respondents reported other barriers including lack of local specialists (18%), a long wait to see a specialist (37%), and patients’ inability to pay for care (52%).

In a multivariate analysis, certain associations emerged among attitudes, barriers, and physician practices, the researchers wrote. "Legal liability and physician responsibility to inform families of SCD risk were positively associated with an in-depth cardiac H&P, whereas barriers in ability to perform an in-depth cardiac H&P were negatively associated," they noted.

The findings suggest that balancing the potential benefits of stimulants for ADHD children with the obligation to inform families of a possible SCD risk remains a challenge for pediatricians, the researchers said.

"Shared decision-making extends informed consent by not only exchanging information about treatment options, risks, and benefits, but also by sharing viewpoints so that patients, families, and physicians become aware of each other’s perspectives with the goal of achieving a mutually agreed on treatment plan," Dr. Leslie and colleagues wrote.

The survey was mailed to 1,600 randomly selected AAP members who provide direct patient care to children aged 5-17 years with ADHD. Pediatricians who were retired, trainees, or not based in the United States were excluded. Most who responded were female, non-Hispanic/white, and practicing for an average of 18 years.


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