It's All About the Children

In April of this year, the American Heart Association (AHA) released the controversial recommendation (among others) that electrocardiograms (ECGs) were necessary for children and adolescents before they started attention deficit/hyperactivity disorder (ADHD) medications.  Following this recommendation, the phone calls and emails began flowing in.  Parents of children currently being treated for ADHD wanted to know whether their child needed an ECG.  And with these AHA recommendations, where was a prescriber of these medications to stand now that an enormous liability had been created?  Although I appreciated the discussion surrounding sudden cardiac death (SCD) with those taking stimulant medications, I was unaware of any scientific research to justify universal ECG screening. 

Now the thought process behind the AHA statement was that an ECG would help identify heart-related conditions such as Wolff-Parkinson-White (WPW) Syndrome, long QT syndrome, and hypertrophic cardiomyopathy, all potentially being negatively impacted by stimulant medications.  But again, at the present time, no data currently exists documenting an increased risk of SCD in those with an existing cardiac condition when compared to the general population.

Fortunately, the American Academy of Pediatrics (AAP) quickly responded to the AHA recommendations with a joint statement emphasizing that treating a child or adolescent with stimulant medications for ADHD should not be withheld if an ECG had not been performed.  And then shortly thereafter, on May 28^th the AAP further clarified any confusion by releasing a policy statement (http://www.aap.org/new/EKGstatement-052808.pdf) with the following recommendations (and please note these were taken verbatim from the policy statement):

1. The AAP continues to recommend a careful assessment of all children, including those starting stimulants, using a targeted cardiac history (e.g. patient history of previously and detected cardiac disease, palpitations, syncope, or seizures; a family history of sudden death in children or young adults; hypertrophic cardiomyopathy; long QT syndrome) and a physical examination, including a careful cardiac examination.
2. Given current evidence, the AAP encourages primary care and subspecialty physicians to continue currently recommended treatment for ADHD, including stimulant medications, without obtaining routine ECGs or routine subspecialty cardiology evaluations for most children before starting therapy with these medications
3. The AAP urges further research on risk factors for SCD among all children and adolescents, including those with ADHD treated with stimulant medications. Improved methods to detect children with hidden cardiac disease should be another focus of such research efforts.

So as it stands at the present time, routine ECGS are NOT necessary unless the patient's history, physical exam, or family history raises any concerns. 

Dr. Jeremy