Cardiac Risk With Stimulants

Question 1

What are some of the risks adolescents with ADHD face?

Answer 1

Higher rates of: 
Poor social relationships 
MVC, speeding and traffic violations
Delinquency
Poor vocational outcomes
Experiment with sex, tobacco, ETOH and drugs

Question 2

What is the rate of ADHD in kids with CHD and arrhythmias as compared to the general population?

Answer 2

CHD: higher. It has a rate of 30% in kids who had surgery for CHD. General population = 3-7%
Arrhythmias: no studies

Question 3

What is the rate of sudden death in kids?

Answer 3

1.3-8.5 per 100 000 patient years

Question 4

Which kids with CHD have higher rates of sudden death?

Do stimulants change these rates?

Answer 4

Tetralogy of fallot
D-TGA, especially mustard or senning procedures

There is little evidence that taking medication further increases the risk of sudden death

Question 5

What is the risk of sudden death in kids with ADHD on meds, as compared to the general population?

Answer 5

The same

Question 6

What is the evidence of the association between sudden death and stimulant use?

What do we say to parents?

Answer 6

The evidence is not entirely clear

Case control study: showed OR of sudden unexplained death of 7.4 when compared to stimulant use and sudden unexplained death. But this had s wide confidence interval (1.4-74.9) demonstrating the rarity of sudden death while on stimulants. 10 deaths in stimulant group and two in control out of 564 matched pairs. (Control was stimulants and MVC)

It is important to to recognise that exceedingly rare but real risks cannot yet be excluded and should be balanced against the risks associated with failing to treat children with ADHD.

Question 7

So what should clinicians do to screen for the risk of sudden death?

Answer 7

Focused history and physical

• decreases exercise tolerance
• palpitations and syncope with exertion or fright
• detailed family history (death

Question 8

Dress functional murmur mean a kid can’t have stimulants?

Answer 8

No.

Question 9

Should kids get an ECG if going on stimulants?

Answer 9

In Canada we say no because of a lack of published data.

Question 10

For kids with CHD or Arrhythmias, who is responsible for initiation stimulants given the higher risk?

Answer 10

The ADHD specialist.

This should be done in conjunction with the cardiologist