ORLANDO – When prescribing stimulants for children, play it safe and screen for heart conditions, said Howard Schubiner, M.D., at a meeting sponsored by the American Academy of Pediatrics.
Although population-based studies fail to show a significant increased risk for sudden cardiac death associated with stimulant use, concerns remain, and physicians should quickly evaluate any cardiac symptoms that arise while children are taking stimulant medications, said Dr. Schubiner of Providence Hospital in Southfield, Mich.
The controlled-release amphetamine Adderall XR was removed from Canadian markets earlier this year because of concerns raised by sudden cardiac death in 12 children and 8 adults in the United States who were taking the medication. As of press time, the U.S. Food and Drug Administration had not taken any action to remove the product from U.S. markets, although the product now carries a black box warning about the increased risk for cardiac events. The FDA's decision stems from an analysis of data suggesting that the risk of sudden death does not differ significantly between children treated with stimulants and untreated children.
The 12 cases of death linked to Adderall occurred between 1999 and 2003, and the children (all males, mean age 12 years) had been taking daily doses of 10 mg–50 mg for durations of 1 day to 8 years.
Overall, the rate of sudden cardiac death in children in the United States is approximately 600 per year, excluding sudden infant death syndrome, Dr. Schubiner noted. Sudden, nontraumatic death accounts for 2%–20% of all deaths among children aged 1–20 years. Boys are three times more likely to die than girls. He cited a 1996 study in which 40 of 50 (80%) sudden deaths in children were due to underlying cardiac abnormalities (Am. J. Cardiol. 1996;77:992–5).
The most common cause of sudden cardiac death in children is hypertrophic cardiomyopathy, an autosomal dominant disorder seen in approximately 1 of every 500 people. Left ventricular hypertrophy occurs in approximately 75%–95% of these patients, but most do not have a discernible heart murmur.
Other cardiac problems that could increase the risk for sudden death in the presence of a stimulant include coronary artery syndrome, arrhythmogenic right ventricle dysplasia, long QT syndrome, and Brugada syndrome, the odds of which are several thousand to one, Dr. Schubiner said.
Adderall is most often used to treat attention-deficit hyperactivity disorder (ADHD), and is still warranted for use in children and adolescents with ADHD, as are other stimulants, Dr. Schubiner noted.
However, it is important and prudent to inquire into a personal history of any chest discomfort, shortness of breath (particularly with exercise), syncopal episodes, palpitations, dizziness, or fatigue.
It is also critical to ask about any family history of sudden cardiac deaths, myocardial infarctions prior to the age of 50 in men and 60 in women, cardiomyopathy, or congenital heart disorders.