ATTENTION DEFICIT HYPERACTIVITY DISORDER CARDIOVASCULAR ISSUES

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ATTENTION DEFICIT HYPERACTIVITY DISORDER
CARDIOVASCULAR ISSUES

• Trevor DeSouza M.D.
• Assistant Professor of Pediatrics UMDNJ NJ
  Medical School
• Attending Pediatric Neurologist,
• St. Claire's Hospital Denville, NJ
• Goryeb Childrens Hospital, MMH

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Children with ADHD Should Have EKG Before Taking
neurostimulants

• Stimulants can increase heart rate and blood
  pressure (insignificant for most children with
  ADHD)
• Significant for children with certain congenital
  heart disease and arrhythmias predisposition
  for sudden cardiac arrest
• Sudden cardiac deaths (SCD) account for 5 to 10
  of childhood deaths, and 20-50 of SCD occur in
  children with no symptoms.

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• ADHD is more common among children with
  congenital heart defects than in the general
  population occurring in as many as 40 of
  children who have had surgery to correct
  congenital defects.
• Some cardiac conditions might not be detected on
  routine PE, EKG is recommended and increases
  likelihood of identifying significant cardiac
  conditions that might place the child at risk.

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• Reports of 19 sudden deaths in children treated
  with ADHD drugs and 26 reports of other problems
  including strokes and abnormal heart rates
  between 1999 and 2003.
• Class 2a recommendation Useful, helpful, and
  reasonable, but has not been proven to be of
  benefit

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History

• Fainting and dizziness particularly with
  exercise, seizures, rheumatic fever, exercised
  induced chest pain or shortness of breath,
  palpitations, increased heart rate, extra or
  skipped beats, high blood pressure, significant
  heart murmur or heart problems, and intercurrent
  viral illness with chest pains and palpitations.
• Use of medications and health supplements

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Family History

• Sudden or unexplained death at early age, sudden
  cardiac death or heart attack in relatives
  younger than 35 years of age, sudden death during
  exercise, cardiac arrhythmias, hypertrophic
  cardiomyopathy, long QT syndrome, syncope or
  other event requiring resuscitation in those
  younger than 35 years, and Marfans syndrome.

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Physical Exam

• Blood pressure, pulse, evaluate for heart murmur,
  and physical features of Marfans syndrome

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EKG

• Baseline EKG to detect cardiovascular
  abnormalities (eg, HCM, LQTS, WPW anomaly)
• A second EKG may be useful if baseline EKG was
  done younger than 12 years or if new symptoms
  develop
• Pediatric cardiology evaluation

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• Category 1 Normal EKG findings (sinus
  bradycardia, sinus arrhythmia, and early
  repolarization) No pediatric cardiology consult.
  
• Category 2 Isolate atrial enlargement esp. RAE-
  atrial rhythms and 1? AV block pediatric
  cardiology consult, but do not rule out stimulant
  medication.
• Category 3 Abnormal findings LVH, WPW
  syndrome, and prolonged QTC pediatric cardiology
  consult before starting medication.

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Follow-Up

• Blood pressure check one to three months after
  starting medication and during routine follow-ups
  every six to 12 months thereafter