- There is an ongoing medical debate about whether children with attention deficit hyperactivity disorder should have a cardiac evaluation to identify underlying heart problems before being treated with stimulant medications.
- A new analysis finds that ECG screening can identify children at risk for sudden cardiac death, but is of borderline cost-effectiveness.
DALLAS, March 8, 2010 — Evaluating children for underlying heart problems before prescribing stimulant medications can identify children at risk for sudden cardiac death, but electrocardiogram (ECG) screening is of borderline cost-effectiveness compared to current practice, according to research reported in Circulation: Journal of the American Heart Association.
Screening children with an electrocardiogram (ECG) — compared with the current practice of taking a history and doing a physical exam — would be beneficial because those found to have underlying heart problems would not just be restricted from taking stimulant medications but discouraged from participating in many competitive sports, according to researchers at the National Institute of Mental Health and the National Heart, Lung, and Blood Institute, both part of the National Institutes of Health.
Stimulant medications, such as methylphenidate (Ritalin and Concerta) and amphetamines (Adderall), are used to treat attention deficit hyperactivity disorder (ADHD). These medications raise pulse rate and may increase the risk of sudden cardiac death (SCD) in children with certain underlying heart conditions, although the extent is unknown.
“Although rare, sudden cardiac death is a tragedy in children and student athletes, and something we want to take all reasonable steps to prevent,” said Jonathan Kaltman, M.D., a coauthor of the study and medical officer in the heart development and structural diseases branch of the National Heart, Lung, and Blood Institute. “There are many situations in medicine today in which decisions about whom and how to screen for potential problems are engaging health care professionals, policy makers, and the general public. Screening for risks of sudden cardiac death which might be precipitated by certain activities or medications is influenced by many factors, including economic. We undertook this study to provide data to contribute to this important and complex decision.”
The investigators used a cost-effectiveness model to compare two other screening strategies with the current standard of care (Strategy 1) — obtaining a history and physical and referring children with potential problems to a cardiologist. The results were as follows:
- Strategy 2: Obtain an ECG only on children with a normal history and physical, and refer those with suspicious findings on either screen (history/physical or ECG) to a cardiologist. This would save an additional 13 children from SCD for every 400,000 screened compared to Strategy 1. The cost is estimated to be $1.6 million per additional life saved and an estimated $39,300 per quality-adjusted life year saved (an outcome measure that takes disability and longevity into account).
- Strategy 3: Obtain an ECG on all children (in addition to history and physical), referring only those with an abnormal ECG to a cardiologist. This would also save an additional 13 children from SCD for every 400,000 screened compared to Strategy 1. The cost is estimated to be $1.2 million per additional life saved and an est. $27,200 per quality-adjusted life year saved.
- In 2008, the American Heart Association issued a scientific statement recommending that physicians take a patient and family health history and perform a physical exam focused on cardiovascular disease risk factors before prescribing stimulant medication.
The association also said it would be reasonable, but not mandatory, for a physician to consider obtaining an ECG as part of this evaluation, leaving the decision to each physician.
“We’re not making a recommendation but providing one type of analysis so others can determine what makes sense in the real world,” Kaltman said.
In an editorial in Circulation, John K. Triedman, M.D., senior cardiology associate at Children’s Hospital in Boston, Mass., and Mark E. Alexander, M.D., a cardiology associate at the same hospital, said the report from Kaltman and his colleagues didn’t examine a complete range of stimulant drug effects.
Combining the question of stimulant medications with the question of sports participation “confuses rather than clarifies the issue of ADHD as a standalone indication for screening,” they wrote. “However, this is clearly an important first step to answering some very contentious issues, which are not easily addressed… and which will nonetheless have direct effect on pediatric public health policy.”
“Preventing sudden cardiac death in children is an important issue,” said Paul Matherne, M.D., chair of the American Heart Association’s Council on Cardiovascular Disease in the Young. “While this study has limitations and is not conclusive, it does offer new approaches and insights that add to our understanding of preventing sudden death. Importantly, it highlights the need for more research into both screening to identify children at risk for sudden death, and for developing new therapies to treat these conditions.”
Co-authors are Peter Denchev, Ph.D. (lead author); Michael Schoenbaum, Ph.D.; and Benedetto Vitiello, M.D. Author disclosures are on the manuscript.
Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.americanheart.org/corporatefunding.
NR10 – 1048 (Circ/Denchev-Kaltman)