When the American Heart Association recommended in April that all 2.5 million children taking stimulant drugs for ADHD should have an electrocardiogram to screen for hidden heart problems (because a small number of these children die from abnormal heart rhythms), it came as an unpleasant surprise for parents. Turns out it was an unpleasant surprise for the American Academy of Pediatrics, too, which got the news just a few hours before the recommendation went public. So, a few weeks later, the pediatricians released their own recommendation: No ECGs.
What should parents make of this expert smackdown? "The evidence is clearly not there to support the notion of routine ECGs for children being put on ADHD medications," insists James Perrin, chief of general pediatrics at Massachusetts General Hospital and author of the new AAP report to be published in the August Pediatrics. "We are very clear in saying, 'No, we do not believe your child should have an ECG.' " The pediatricians posted their no-ECGs manifesto on their website on May 28, but word is only now filtering out.
In response, the cardiologists softened their stance. "We say it is reasonable to add an ECG, but it is not mandatory," says Timothy Gardner, medical director of Christiana Care Center for Heart & Vascular Health in Wilmington, Del., and president of the AHA. He notes that children with cardiovascular abnormalities are more likely to have ADHD. "If you're a pediatric cardiologist, and you're seeing patients with ADHD, it would seem very reasonable to include an electrocardiogram to look for unsuspected abnormalities."
Although the Food and Drug Administration required manufacturers of ADHD drugs to add cardiovascular problems to the list of side effects in 2007, there is no evidence that the drugs cause heart conditions or sudden cardiac death. Rather, the cardiologists are concerned that the slight increase in blood pressure caused by stimulant drugs could make an undiagnosed heart condition worse. An analysis presented to the FDA when it was considering the label changes showed 19 sudden deaths in children taking ADHD medications between 1998 and 2003. Each year, sudden cardiac death kills an estimated 1,000 to 7,000 children.
The cardiologists' concern was sparked by fears that doctors weren't doing everything possible to prevent the sudden deaths. Still, ECGs are a less-than-perfect screening tool for sudden cardiac death, which often has no symptoms. In addition, evidence on whether taking Ritalin and other stimulant drugs increases the risk of sudden cardiac death is contradictory. "We recognize that there are no clinical trials to inform us on this topic, and that there is variance in opinion on this topic", the Heart Association's paper continues. "There are no widely accepted recommendations or standards of care for cardiac monitoring on stimulant medications."
But the pediatricians are not convinced that widespread screening will do a good enough job of detecting hidden heart problems. ECGs cost $100, and often deliver false positives, meaning that a child could be in for a follow-up echocardiogram and other tests that can cost upwards of $1,000. That's why the pediatricians don't recommend routine ECGs for all children or for student athletes. Instead, they say that each child, whether she has ADHD or not, should have a careful cardiovascular exam as part of routine care. That means the doctor takes a family history of cardiovascular disease and does an exam that includes listening to the heart with a stethoscope. Only if the history and exam raise questions should a child be referred to a pediatric cardiologist, Perrin says. The cardiologist can decide of an ECG is necessary.
So, parents are left to decide who to believe—the cardiologists or the pediatricians. It may all come down to a parent's personal worry level, and whether insurance will pay the cost of the test. Welcome to the complex, contradictory world of modern medicine. "It is a little bit awkward sometimes, when it looks like the experts are in dispute," Gardner says.
That's for sure.