Health Canada released a statement advising against stimulants in ADHD patients with cardiac disease in May 2006, after isolated reports of sudden death The impact of this advisory on 1) physicians’ cardiovascular assessment of all children with ADHD before starting stimulant medications, and 2) on the treatment of children with potential or real cardiac disease was assessed by questionnaires mailed to noncardiologists and pediatric cardiologists in Canada from the Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia. Of a total of 2326 questionnaires distributed, 717 (31%) were returned. The proportion performing a full screen increased for both noncardiologists (0.2% to 15.1%) and cardiologists (54.8% to 68.6%) after the advisory. The change in the use of a modified screen was 7.4% to 34.5% for noncardiologists and no increase for cardiologists (7.8% to 5.9%). The proportion of noncardiologists willing to prescribe stimulant medications in children with potential or actual cardiac issues showed a considerable decrease. These changes in practice following the advisoiy have occurred despite the lack of studies to address the actual cardiac risks of stimulant medications. Consensus recommendations are needed to determine whether screening before starting treatment is necessary and which children may be treated cautiously. [1]

COMMENT. A full cardiac screen consists of all of the following: ask about a history of congenital heart disease, family history of sudden death, and family history of early coronary infarct, record the pulse and blood pressure, check for murmur, and obtain ECG. A modified screen differs only in that the ECG is performed selectively for children with abnormal exam.

In the US, the American Academy of Pediatrics, contrary to an American Heart Association statement advising pre-treatment ECG, considers routine ECG before starting stimulant therapy for ADHD to be unnecessary. Cardiac history and examination are recommended, and ECG and cardiac consultation, only if clinically indicated (Ped Neur Briefs Sept 2008;9:66). [2]