Does every kid on stimulants need an EKG?

Oh boy, oh,  BOY!!! When my wife showed me this issue on the internet last night I gave a big sigh and an eye roll.  I knew the phone calls would start early and heavy.  For those of you who have not heard, the American Heart Association issued a recommendation that all children who are going to be placed on stimulants should receive “careful heart screenings that include electrocardiograms (EKG’s) to rule out heart abnormalities”.  These recommendations were based on the data that was used in the FDA’s review of stimulants last year.  That data (reported to the FDA) included 19 cases of sudden unexplained death and 26 additional cases where children suffered strokes, cardiac arrests or other cardiovascular events while on the medicine between 1999 and 2004.  In the statistical analysis of the data, however, there was no evidence that pointed to the stimulants as the causative factor in these tragic events.  The sad truth is that kids sometimes have cardiac events and the rate of those events is not statistically higher in kids that took stimulants.  Also of note here is that other professional organizations (such as the American Academy of Child and Adolescent Psychiatry) do not share these recommendations.  Following the FDA review, the warnings for use of stimulants were amended to include the risk of cardiovascular events.  Most of us who prescribe these meds have included a warning about the low risk of sudden unexplained death when we talk to parents about the medicine. 

So what do I think about the AHA warnings???

I think they add a new layer of confusion to the process and needlessly increase the costs of health care when we are all trying to be reasonably frugal.  Medical tests need to be tailored to the clinical situation and there is no evidence that giving an EKG to every child that is going to be placed on stimulants is going to save lives.  My position on this remains unchanged by these recommendations because they are not based on new data and the data that has already been presented and reviewed was inconclusive at best. BUT, now, thank you very much, I have to practice a more defensive brand of psychiatry and order an EKG on every child that I see.  That means when you bring your child to me and they are failing school because they can’t pay attention, you are going to have to wait an additional week or two . . . or three . . . to make the appointment to get the EKG, get the EKG done (probably during school hours), get the EKG read, and get the report back to me so that I can prescribe the medicine.  All that in addition to the one to two month wait to see me (unless you are lucky and squeeze in earlier).  Does it make sense? NO.  If I ran the world, here would be my recommendations:

1.  EKG and full cardiac work up is mandatoryfor any child who has a history of a heart murmur, chest pain, passing out, or if there is a family history of cardiac events at a young age.

2.  EKG and full cardiac work up should be done if the parents want it.

Pretty straight forward . . .

The unfortunate truth is that no matter what we do, we cannot keep our kids completely safe.  Not giving a kid medicine is not necessarily keeping them safe.  Untreated ADHD (and stimulants are the gold standard for medication treatment) is associated with academic decline, lower self esteem, depression and increased risk of substance abuse.  Avoiding use of medication that clearly helps most kids just because of the statistically insignificant risk of a cardiac event would make no sense.  More kids die every year driving with their family on summer vacation and no one is advocating staying home.  The risk of cardiac events should not keep you away from using these medications to help your kids.  But the bottom line is . . . if the work up would make you feel better, get it done. 

–Dan Hartman, MD

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