NEW ORLEANS – An electrocardiogram isn’t necessary for student athletes or children taking stimulant medications for attention disorders unless the child has cardiac risk factors or a family history of early-onset heart disease.
ECGs are not always easy to obtain, and they cost parents money, time, and anxiety, Dr. Christopher Snyder said at the annual meeting of the American Academy of Pediatrics. To be really useful, he said, they should be read by a pediatric cardiologist – a specialist in remarkably short supply.
"Just don’t do it. You don’t need to do it!" said Dr. Snyder, a pediatric cardiologist at the Rainbow Babies and Children’s Hospital in Cleveland.
The American Heart Association (AHA) recommends against routine ECGs in student athletes. The only children who really need the test before playing sports are those with a family or personal history of specific cardiac findings, including:
• Unexplained fainting.
• Excessive fatigue with exercise.
• Abnormal blood pressure.
• Heart murmur.
• A relative who developed or died from heart disease at younger than 50 years.
• Signs of Marfan syndrome.
High school and college athletes should receive a biennial 12-item exam focused on personal and family findings, with a preparticipation history taken between the screenings, the guideline states.
Things aren’t quite so clear-cut with regard to ECGs for children beginning a stimulant medication. "There is no evidence that this is needed, but we do it because we think we should," Dr. Snyder said. Medications for attention-deficit/hyperactivity disorder (ADHD) "have never been shown to cause heart problems, although there might be a slight increase in blood pressure of about 1 mm Hg and a slight increase in heart rate – about 1 beat per minute. Sudden cardiac death has been reported and linked to ADHD medications, but it’s never been proven to have any causal association."
The AHA’s 2008 ADHD medication cardiac screening recommendation contributed to the confusion about the necessity of an ECG for these children, Dr. Snyder said. "It’s not mandatory, and it’s left to the physician’s discretion," but the guideline suggests that an ECG will strengthen the accuracy of any cardiac risk screening.
The minimal screen before starting a stimulant medication should include looking for cardiac structural abnormalities, heart murmurs, hypertension, palpitations, arrhythmia, syncope, signs of Marfan syndrome, and family history, the guideline noted. But, it added, "Some of the cardiac conditions associated with sudden cardiac death might not be detected on a routine physical examination. Therefore it can be useful to add an ECG, which may increase the likelihood of identifying significant conditions ... that are known to be associated with sudden cardiac death."
Despite suggesting ECGs, the AHA guideline gave them a class IIa recommendation and a C evidence level. It also recommended that the test be read by a pediatric cardiologist, and that it might need to be repeated after the onset of puberty, if symptoms develop, or if cardiac problems develop in a family member.
Shortly after the AHA recommendation came out, the American Academy of Pediatrics (AAP) published its own guideline, which called the cardiology paper "controversial" and made clear its disagreement with the guideline.
"The AAP and its constituent groups disagree with the AHA statement as to both the classification and the level of evidence. ... Moreover, the substantial expert opinion and reasoning outlined in the AHA statement suggests that harm outweighs the benefit of recommending routine ECGs for healthy children who are starting stimulant medication for ADHD. Accordingly, the AAP would recommend against such routine ECG screening."
There’s no good evidence that sudden death occurs any more frequently among children taking the medications, AAP asserted. Therefore, a targeted cardiac personal and family history, combined with a thorough physical, is adequate not only to identify any cardiac risk factors, but to pinpoint any other health concerns that might warrant attention.
"Electrocardiography or echocardiography in this population would not otherwise be routine or recommended," according to the AAP statement.
Dr. Snyder did not disclose any relevant financial conflicts.