Elk Grove Village, IL - The American Academy of Pediatrics (AAP) has issued a new policy statement emphasizing that routine ECGs for children receiving medications for attention-deficit/hyperactivity disorder (ADHD) are not warranted [1]. The statement comes after advice by the American Heart Association (AHA) earlier this year [2] that physicians consider ordering an ECG to aid them in deciding whether or not underlying heart disease is present before prescribing ADHD drugs.

A spokesperson for the AHA told heartwire that in June it "clarified" its original advice, issued in April, in a joint advisory from the AHA and the AAP [3], saying that an ECG should be at the physician's discretion and it is not mandatory to obtain one. The AHA also updated its original statement [4]. "Our recommendations have not changed since we issued them this spring. Rather, we issued a clarification as a result of confusion and concern among the public and healthcare professionals. Routine use of ECGs to assess these children has not ever been part of our recommendations," the spokesperson said.

The current statement from the AAP, published in the August 2008 issue of Pediatrics, formalizes its position on the issue, an AAP spokesperson told heartwire. However, the two organizations still seem somewhat at variance on the strength of the advice they are issuing, with the AHA still more strongly recommending the use of an ECG than the AAP.

The AHA makes the following recommendations for children starting ADHD medications:

• A thorough patient and family history should be obtained for assessment of these children. This is a class I recommendation (using the ACC/AHA classes of recommendations and levels of evidence).
• Acquiring an ECG is a class IIa recommendation. This means it is reasonable for a physician to consider obtaining an ECG as part of the evaluation. It is not mandatory but rather is left to the physician's discretion. Treatment of a patient with ADHD should not be withheld because an ECG is not done. The child's physician is the best person to assess whether there is a need for an ECG.
• It is reasonable to use ADHD medications with caution in patients with known congenital heart disease and/or arrhythmias if these patients are stable and under the care of a pediatric cardiologist.

The latest AAP statement says that the AHA's recommendation to obtain an ECG before starting medications to treat ADHD "contradicts the carefully considered and evidence-based recommendations of the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics." It notes that these organizations have concluded that sudden cardiac death in people taking medications for ADHD is a very rare event, occurring at rates no higher than those in the general population of children and adolescents. It also notes that it has not been shown that screening ECGs before starting stimulants have an appropriate balance of benefit, risk, and cost-effectiveness for general use in identifying risk factors for sudden death. "Until these questions can be answered, a recommendation to obtain routine ECGs for children receiving ADHD medications is not warranted," the statement concludes.

The AAP statement adds that the authors of the AHA statement acknowledge the lack of evidence showing a benefit of routine ECG screening for these children but still assigned their recommendation for screening a IIa classification (weight of evidence/opinion is in favor of usefulness/efficacy) and a category C level of evidence (only consensus opinion of experts, case studies, or standard of care). The AAP disagrees with both of these classifications. "Using AHA criteria, the AAP would, at most, classify this recommendation as IIb ('the level of evidence is less well established by evidence/opinion. . . . Additional studies with broad objectives needed'). In addition, using the AAP classification of recommendations, the AAP would assign the recommendation a category D level of evidence (on the basis of expert opinion without even observational studies)," the statement says, adding that the AAP avoids making guideline recommendations with a category D level of evidence.

It further claims that expert opinion suggests that the 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," the statement concludes.

The AAP makes the following recommendations:

• Careful assessment of all children, including those starting stimulants, using a targeted cardiac history (eg, patient history of previously 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, which includes a careful cardiac examination (evidence quality: C; strength: recommendation). If patient history, family history, or physical exam is suggestive of cardiac disease, further evaluation is advised, with input from a pediatric cardiologist.
• 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 (evidence quality: D; strength: option).
• More research is needed on risk factors for sudden cardiac death among all children and adolescents, including those with ADHD who are treated with stimulant medications. Better methods of detecting hidden cardiac disease in children should be another focus of such research efforts.

But cardiologist Dr Steven Nissen (Cleveland Clinic, OH) says the AAP statement is misguided. He commented to heartwire: "It suggests that as many as 8% of children should be treated with amphetamines or related stimulant drugs. These drugs increase blood pressure and have not been studied in long-term trials. The statement asserts that sudden death is not more common in children receiving these drugs. However, the FDA has issued a warning for all of the ADHD drugs that states that they can cause sudden death at usual doses. It is irresponsible for a professional medical society to recommend to its members that they ignore an FDA-mandated warning. This is the second time in a few weeks where the AAP has issued poorly thought-out guidelines that promote inappropriate drug use in children. The previous statement promoted statin use in children as young as eight years of age."