Pediatric experts and AHA differ on cardiac evaluation prior to ADHD drugs

5 August 2008

MedWire News: The American Academy of Pediatrics (AAP) has issued a policy statement contradicting earlier American Heart Association (AHA) guidelines regarding the need to evaluate children's cardiac function before prescribing treatment for attention deficit/hyperactivity disorder (ADHD).

As reported by MedWire News, the AHA released updated guidelines in April this year recommending that it is "reasonable and useful" for children with ADHD to undergo an electrocardiogram (ECG) to check for any underlying heart condition prior to being given stimulant medications.

The AHA and AAP subsequently issued a joint statement in May modifying the original recommendation to state that it is reasonable to obtain an ECG prior to starting a child on stimulant therapy, but that this is done at the physician's discretion.

Now the AAP appears to be distancing itself from the AHA's position. In a statement published online in the journal Pediatrics, AHA experts headed up by James Perrin (Harvard Medical School, Boston, Massachusetts) contend that there is not enough evidence that routine use of ECG screening before initiating ADHD medication would prevent sudden cardiac death.

In particular, Perrin and co-authors state that they disagree with the class IIa ("weight of evidence is in favor of usefulness/efficacy") and level of evidence C ("only consensus opinion of experts, case studies, or standard of care") the AHA assigns to its recommendation, according to AHA/American College of Cardiology (ACC) criteria.

Using the AHA/ACC criteria, the AAP would "at most classify this recommendation as IIb ('level of evidence is less well established by evidence/opinion... Additional studies with broad objectives needed')," they write, and "assign the recommendation a category D level of evidence ('on the basis of expert opinion without observational studies')."

The statement continues that the AAP recommends clinicians carefully assess all children for cardiac abnormalities, including those in whom ADHD treatment is being considered, by using history and physical assessment.

"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," the authors write.

Pediatrics 2008; 122: 451-453