Cardiac Issues with ADHD

Cardiology Pearls

Fall 2006 Volume 2, Issue 1

Attention deficit disorder and other “hyperactivity” diseases are very prevalent in our population. These behaviors seem to interfere with the children's abilities to concentrate and learn at school as well as sometimes their behavior can be disruptive to the other students in the classroom.

For many years now we have been using stimulant medications to treat this disorder. One of the first commonly used medications was, of course, Ritalin®, which has a long experience of use. Since that time, many other medications have been used, including Clonidine, Concerta, Strattera®, Adderall and D-amphetamine. As you are all aware, there has been a great deal of information in the media concerning the possible risks of these medications.

History of ADHD

ADHD was first described in the mid 1800's. In 1848 physicians were telling stories about “fidgety Phil” describing hyperactive behavior. In 1902 a British pediatrician George Frederick Still did a comprehensive observation of ADHD children. He described the children observed as aggressive, defiant, lawless, overactive, inattentive, dishonest, and accident prone. He felt that the problem was biological rather than a result of poor parenting. He theorized the behaviors either an inherited problem or the result of an injury at birth.

It's interesting that after the encephalitis epidemic in 1917 and 1918 there were many patients that were described as showing symptoms consistent with Still's behavioral problems. It was felt that it was related to brain damage even though they didn't suffer from encephalitis. Later when the physicians realized that many of these children were too intelligent to suffer brain damage, the disorder was labeled “minimal brain damage” and later called minimal brain dysfunction.

In 1937 doctors had discovered that amphetamines did help reduce the hyperactive impulsive behavior. Most of these medications were not used until the late 50's and 60's when stimulants were started to be used for impulsive behavior. In the early 1960's Stella Chase, et al described “hyperactive child syndrome”. Chase felt that this was a biological disease and it was caused by environmental problems. There is some question of whether they felt parenting, food additives or environmental toxins could cause some of these diseases, although more recently it is felt that these probably do not play a significant role.

In 1965 the American Psychiatric Association established the diagnostic category for “hyperkinetic reaction of childhood” and since that time thousands of children were followed with the diagnosis of hyperactivity, although this does not take into account those patients who have attention problems without hyperactivity, which is a real disorder.

A Canadian psychologist Virginia Douglas described four major characteristics of ADHD including 1) deficits in attention and effort, 2) impulsivity, 3) problems in regulating their activity levels, and 4) the need for immediate reinforcement.

In 1980 the American Psychiatric Association identified a collection of behavior patterns as “Attention Deficit Disorder” with or without hyperactivity and they named these disorders ADHD and ADD, respectively. In 1987 ADD remained attention deficit hyperactivity disorder to include symptoms with hyperactivity impulsivity as well as inattention.

An important finding in the 1990's was the fact that this also occurs in adults as well as children and has been treated in adults as well.

Ritalin® “Methylphenidate” was introduced in 1956 for treating ADHD. In the 60's, 70's and 80's, Ritalin® was by far the most commonly used medication used to treat ADHD. There were initially many conflicting concerns regarding possible risks of cardiac effects of Ritalin®. A recent FDA advisory noted that there were patients treated with Ritalin® who had sudden death; therefore, Ritalin® has not completely avoided risks. However, the risk for Ritalin® does appear to be less than that with some of the other medications such as Adderall.

Adderall has had some difficult press lately. The Canadian version of the FDA has actually withdrawn Adderall from their market because of the concerns of sudden death. The US FDA commented that of the 30,000,000 prescriptions written between 1999 and 2003 that the twelve deaths on patients with Adderall may not have been that significantly different from death in the normal population. Five of these twelve deaths had underlying structural heart defects. The other patients who had died included a family history of ventricular tachycardia, heat exhaustion and dehydration, near drowning, vigorous exercise, fatty liver and type I diabetes mellitus. This raised the question, “how much of the Adderall contributed to their sudden death event?” The US FDA still has specifically stated that only patients with underlying heart defects would be at a slightly increased risk for sudden death. However, they would not restrict the use of Adderall since so many patients would potentially benefit from Adderall.

Strattera® was introduced in the placecountry-regionU.S. for treating hyperactivity in 2002. Strattera® is the first non-stimulant medication approved by the FDA for treatment of ADHD. Strattera® is a nor epinephrine reuptake inhibitor. It doesn't seem to cause as much insomnia as the other stimulant medications do. It may cause less anxiety issues, and it does not have any abuse potential. Strattera® can cause allergic reactions as well as gastrointestinal disorders including decreased appetite, nausea, vomiting as well as occasional tiredness and dizziness and mood swings. In adults it can have some problems with constipation, dry mouth, nausea as well as some menstrual cramps and sexual side effects. There is some question whether Strattera® may have a slightly increased risk of suicidal thinking in patients who also have depression as part of the symptomatology. Therefore, it is recommended that if there is any question of suicidal thinking that Strattera® be avoided in those patients.

The cause of ADHD is still unknown although it certainly has evidence to suggest a neurological basis. There may be a chemical imbalance in brain neurotransmitters. There is no evidence to suggest poor parenting can elicit ADHD, although there has been some evidence to suggest some maternal smoking and/or alcohol during pregnancy may contribute to ADHD in a small percentage of the patients, as well as high lead levels in some young children may be associated with ADHD. There is no evidence that the disorder is triggered by sugar, food additives, allergies or immunizations. There have been some unusual cases where head trauma may be associated with ADHD.

The FDA has come out with an advisory on February 9th, 2006 concerning risk of attention deficit hyperactivity drugs. In their data they had 26 patients that died suddenly who were on these medications. It is interesting that the rate of sudden death is no different than the sudden death in a normal population. However, there are some concerns about the possible risks to patients with these medications. There have been no specific recommendations at this point in time other than counseling patients about potential risks.

At Carson & Appleton we do recommend that whenever a patient is started on a new medication for attention deficit hyperactivity or make a dose change they get an EKG performed. This would detect a lot of the more serious risks associated with ADHD medications.

On a separate idea, given the fact that there are some patients that have had some complications from ADHD even with a normal EKG, we at Carson & Appleton are starting a new study to look at ADHD medications in conjunction with a number of behavioral pediatricians in town. As part of the study, we will be evaluating about 50 patients prospectively doing echocardiograms before starting medications, at six months and twelve months after being on medication. Hopefully this will help give us a little more information, and we we'll be communicating this information back to the pediatricians in town once we have the data completed.

Unfortunately, there are still a lot of unknowns regarding stimulant medications. However the US FDA has stated the obvious, that “access to these therapies was important to those who could benefit,” and thus they “recommended that the products not be contraindicated in this country.” Hopefully this will become more clear over time.

	Carson & Appleton, M.D. \| home Sports Physical EKG's \| Cardiac Issues with ADHD \| Philips Ei33 echocardiogram system \| AMA prophylaxis changes \| Echocardiography accreditation \| EKG recommended for ADHD drugs \| Continuing Education: \| Pictures 2010 \| Pictures 2009 \| Pictures 2007 & 2008 \| Pictures 2005 & 2006 \| Picture 2005 & 2006 Specializing in Fetal, Pediatric & Adult Congenital Cardiology
	Cardiac Issues with ADHD Cardiology Pearls Fall 2006 Volume 2, Issue 1 Attention deficit disorder and other “hyperactivity” diseases are very prevalent in our population. These behaviors seem to interfere with the children's abilities to concentrate and learn at school as well as sometimes their behavior can be disruptive to the other students in the classroom. For many years now we have been using stimulant medications to treat this disorder. One of the first commonly used medications was, of course, Ritalin®, which has a long experience of use. Since that time, many other medications have been used, including Clonidine, Concerta, Strattera®, Adderall and D-amphetamine. As you are all aware, there has been a great deal of information in the media concerning the possible risks of these medications. History of ADHD ADHD was first described in the mid 1800's. In 1848 physicians were telling stories about “fidgety Phil” describing hyperactive behavior. In 1902 a British pediatrician George Frederick Still did a comprehensive observation of ADHD children. He described the children observed as aggressive, defiant, lawless, overactive, inattentive, dishonest, and accident prone. He felt that the problem was biological rather than a result of poor parenting. He theorized the behaviors either an inherited problem or the result of an injury at birth. It's interesting that after the encephalitis epidemic in 1917 and 1918 there were many patients that were described as showing symptoms consistent with Still's behavioral problems. It was felt that it was related to brain damage even though they didn't suffer from encephalitis. Later when the physicians realized that many of these children were too intelligent to suffer brain damage, the disorder was labeled “minimal brain damage” and later called minimal brain dysfunction. In 1937 doctors had discovered that amphetamines did help reduce the hyperactive impulsive behavior. Most of these medications were not used until the late 50's and 60's when stimulants were started to be used for impulsive behavior. In the early 1960's Stella Chase, et al described “hyperactive child syndrome”. Chase felt that this was a biological disease and it was caused by environmental problems. There is some question of whether they felt parenting, food additives or environmental toxins could cause some of these diseases, although more recently it is felt that these probably do not play a significant role. In 1965 the American Psychiatric Association established the diagnostic category for “hyperkinetic reaction of childhood” and since that time thousands of children were followed with the diagnosis of hyperactivity, although this does not take into account those patients who have attention problems without hyperactivity, which is a real disorder. A Canadian psychologist Virginia Douglas described four major characteristics of ADHD including 1) deficits in attention and effort, 2) impulsivity, 3) problems in regulating their activity levels, and 4) the need for immediate reinforcement. In 1980 the American Psychiatric Association identified a collection of behavior patterns as “Attention Deficit Disorder” with or without hyperactivity and they named these disorders ADHD and ADD, respectively. In 1987 ADD remained attention deficit hyperactivity disorder to include symptoms with hyperactivity impulsivity as well as inattention. An important finding in the 1990's was the fact that this also occurs in adults as well as children and has been treated in adults as well. Ritalin® “Methylphenidate” was introduced in 1956 for treating ADHD. In the 60's, 70's and 80's, Ritalin® was by far the most commonly used medication used to treat ADHD. There were initially many conflicting concerns regarding possible risks of cardiac effects of Ritalin®. A recent FDA advisory noted that there were patients treated with Ritalin® who had sudden death; therefore, Ritalin® has not completely avoided risks. However, the risk for Ritalin® does appear to be less than that with some of the other medications such as Adderall. Adderall has had some difficult press lately. The Canadian version of the FDA has actually withdrawn Adderall from their market because of the concerns of sudden death. The US FDA commented that of the 30,000,000 prescriptions written between 1999 and 2003 that the twelve deaths on patients with Adderall may not have been that significantly different from death in the normal population. Five of these twelve deaths had underlying structural heart defects. The other patients who had died included a family history of ventricular tachycardia, heat exhaustion and dehydration, near drowning, vigorous exercise, fatty liver and type I diabetes mellitus. This raised the question, “how much of the Adderall contributed to their sudden death event?” The US FDA still has specifically stated that only patients with underlying heart defects would be at a slightly increased risk for sudden death. However, they would not restrict the use of Adderall since so many patients would potentially benefit from Adderall. Strattera® was introduced in the placecountry-regionU.S. for treating hyperactivity in 2002. Strattera® is the first non-stimulant medication approved by the FDA for treatment of ADHD. Strattera® is a nor epinephrine reuptake inhibitor. It doesn't seem to cause as much insomnia as the other stimulant medications do. It may cause less anxiety issues, and it does not have any abuse potential. Strattera® can cause allergic reactions as well as gastrointestinal disorders including decreased appetite, nausea, vomiting as well as occasional tiredness and dizziness and mood swings. In adults it can have some problems with constipation, dry mouth, nausea as well as some menstrual cramps and sexual side effects. There is some question whether Strattera® may have a slightly increased risk of suicidal thinking in patients who also have depression as part of the symptomatology. Therefore, it is recommended that if there is any question of suicidal thinking that Strattera® be avoided in those patients. The cause of ADHD is still unknown although it certainly has evidence to suggest a neurological basis. There may be a chemical imbalance in brain neurotransmitters. There is no evidence to suggest poor parenting can elicit ADHD, although there has been some evidence to suggest some maternal smoking and/or alcohol during pregnancy may contribute to ADHD in a small percentage of the patients, as well as high lead levels in some young children may be associated with ADHD. There is no evidence that the disorder is triggered by sugar, food additives, allergies or immunizations. There have been some unusual cases where head trauma may be associated with ADHD. The FDA has come out with an advisory on February 9th, 2006 concerning risk of attention deficit hyperactivity drugs. In their data they had 26 patients that died suddenly who were on these medications. It is interesting that the rate of sudden death is no different than the sudden death in a normal population. However, there are some concerns about the possible risks to patients with these medications. There have been no specific recommendations at this point in time other than counseling patients about potential risks. At Carson & Appleton we do recommend that whenever a patient is started on a new medication for attention deficit hyperactivity or make a dose change they get an EKG performed. This would detect a lot of the more serious risks associated with ADHD medications. On a separate idea, given the fact that there are some patients that have had some complications from ADHD even with a normal EKG, we at Carson & Appleton are starting a new study to look at ADHD medications in conjunction with a number of behavioral pediatricians in town. As part of the study, we will be evaluating about 50 patients prospectively doing echocardiograms before starting medications, at six months and twelve months after being on medication. Hopefully this will help give us a little more information, and we we'll be communicating this information back to the pediatricians in town once we have the data completed. Unfortunately, there are still a lot of unknowns regarding stimulant medications. However the US FDA has stated the obvious, that “access to these therapies was important to those who could benefit,” and thus they “recommended that the products not be contraindicated in this country.” Hopefully this will become more clear over time.