Cardiovascular monitoring of children and adolescents with heart disease receiving stimulant drugs: A scientific statement from the American Heart Association Council on cardiovascular disease in the Young Congenital Cardiac Defects Committee and the Council On Cardiovascular Nursing

Over the past decade, concerns have been raised regarding the safety of a variety of psychotropic medications in children and adolescents, the appropriate selection of patients for therapy, and the indications for cardiovascular monitoring. In 1999, concerns over potential cardiovascular effects of psychotropic drugs, especially tricyclic antidepressants1,2 but including stimulants, prompted the American Heart Association (AHA) scientific statement “Cardiovascular Monitoring of Children and Adolescents Receiving Psychotropic Drugs. ”3 At that time, no specific cardiovascular monitoring was recommended for the use of stimulant medications. Since that time, a constellation of circumstances have come together, necessitating a second look at this complicated issue. These circumstances include an increased awareness of the presence of attention deficit/hyperactivity disorder (ADHD) in the general population and in children with preexisting cardiac conditions; public concerns about the side effects and toxicities of medications, especially psychotropic medications in children; and regulatory factors and warnings issued by the US Food and Drug Administration (FDA) and by the pharmaceutical industry in response to the FDA. At a time when there is much discussion of the side effects of drugs and of the use of psychotropic drugs in children in the media and lay literature, it is particularly important for the medical profession to play a significant role in critically evaluating the use of stimulant medication in children, including those who may have undiagnosed heart disease and those who are known to have heart disease. The writing group for “Cardiovascular Monitoring of Children and Adolescents with Heart Disease Receiving Stimulant Drugs” reviewed the literature relevant to this topic since the last publication of the AHA scientific statement that included these drugs in 1999 to assist the group in their recommendations. Literature searches were conducted in PubMed/MEDLINE databases to identify pertinent articles. The major search terms included stimulant drugs, methylphenidates, amphetamines, sudden cardiac death (SCD), death, arrhythmias, ventricular tachycardia, ADHD, attention deficit disorder, cardiovascular side effects, treatment of ADHD in children, ADHD and stimulant medications, SCD in children and adolescents, methylphenidates and cardiac death, and amphetamines and cardiac death. Searches were limited to the English language from 1980 through August 2007. In addition, related article searches were conducted in MEDLINE to find further relevant articles. The information available on the FDA Web site (www.fda.gov) regarding Advisory Committee meetings was used. Finally, committee members recommended applicable articles outside the scope of the formal searches. Using the evidence-based methodologies developed by the American College of Cardiology/AHA Task Force on Practice Guidelines, the writing group has given classifications of recommendations and levels of evidence when applicable. The classifications of recommendations and levels of evidence are shown in Table 1. A recommendation with level of evidence B or C does not imply that the recommendation is weak. Many important