Review
Cardiovascular Risk of Stimulant Treatment in Pediatric Attention-Deficit/Hyperactivity Disorder: Update and Clinical Recommendations

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Objective

This review provides an update on the cardiovascular impact of therapeutic stimulant-class medication for children and adolescents with attention-deficit/hyperactivity disorder (ADHD).

Method

Relevant clinical literature was ascertained using PubMed searches limited to human studies and the English language as of May 2011. Current practice guidelines and consensus statements also were reviewed.

Results

Stimulant-class medications for healthy children and adolescents with ADHD are associated with mean elevations in blood pressure (ā‰¤5 mmHg) and heart rate (ā‰¤10 beats/min) without changes in electrocardiographic parameters. A subset (5ā€“15%) of children and adolescents treated may have a greater increase in heart rate or blood pressure at a given assessment or may report a cardiovascular-type complaint during stimulant treatment. It is extremely rare for a child or adolescent receiving stimulant medication to have a serious cardiovascular event during treatment, with the risk appearing similar to groups of children not receiving stimulant medication.

Conclusions

Clinicians should adhere to current recommendations regarding the prescription of stimulant medications for youth with ADHD. Scientific inquiry is indicated to identify patients at heightened risk and to continue surveillance for the longer-term cardiovascular impact of these agents.

Section snippets

Method

Relevant clinical literature on the CV effects of stimulant medications for ADHD was sought using two PubMed searches. In the first search, search terms included stimulant, methylphenidate and amphetamine, each combined with ADHD, and cardiovascular, cardiac, blood pressure, electrophysiology, ECG, severe adverse outcomes, and sudden death. Searches were limited to human studies and the English language through May 2011. In the second search, to ensure the capture of CV outcomes in the context

Short-Term Impact on Heart Rate and Blood Pressure

Controlled studies conducted during the 1970s and 1980s described the acute CV response 1 to 2 hours after administration of immediate-release (IR) stimulants, largely methylphenidate (MPH). These studies primarily involved small samples of school-age Caucasian children with ADHD symptomatology.9, 10 Compared with the ā€œminorā€ impact on BP, HR was viewed as highly sensitive to MPH,23 with significant increases compared with placebo, and greater elevations in medication-naive children than in

Discussion

This review outlines what is known about the CV impact of therapeutic stimulant medication for pediatric ADHD, and what remains uncertain. Consistent with the sympathomimetic nature of these agents, mean elevations in BP (ā‰¤5 mmHg) and HR (ā‰¤10 beats/min) have been seen in samples of children and adolescents with ADHD. Greater increases in BP or HR can be expected in a sizeable minority (5-15%), although the limited literature has suggested that multiple elevated BP readings occur in fewer

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    Disclosure: Dr. Hammerness has participated in continuing medical education (CME) activities, professional talks, and/or writing supported by Ortho-McNeil Janssen and Shire. He has served on the advisory board for Shire. He has participated in research studies funded by Cephalon, Eli Lilly and Co., GlaxoSmithKline, Johnson and Johnson, McNeil, Merck, New River, Novartis, Ortho-McNeil Janssen, Pfizer, Shire, Takeda, and Elminda. He has received honoraria from commercial entities supporting the Massachusetts General Hospital Psychiatry Academy. Dr. Perrin has served as a consultant for Pfizer. Dr. Wilens has received grant support from Abbott, McNeil, Eli Lilly and Co., Nextwave, the National Institutes of Health (NIH)/National Institute of Drug Abuse, Merck, and Shire. He has served on the speakers' bureau for Abbott, AstraZeneca, McNeil, Eli Lilly and Co., Nextwave, NIH, Novartis, Merck, and Shire. He receives royalties from Guilford Press. Ms. Shelley-Abrahamson reports no biomedical financial interests or potential conflicts of interest.

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