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Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder

Cardiac evaluation of patients receiving pharmacotherapy for attention deficit hyperactivity disorder
Author:
Stuart Berger, MD
Section Editor:
John K Triedman, MD
Deputy Editor:
Carrie Armsby, MD, MPH
Literature review current through: Nov 2022. | This topic last updated: Oct 20, 2022.

INTRODUCTION — Reports of sudden unexpected deaths (SUDs) among patients taking stimulant drugs for attention deficit hyperactivity disorder (ADHD) have led to concerns regarding the safety of psychotropic medications. In particular, the question of whether or not stimulant drugs increase the risk of adverse cardiovascular (CV) events has led to a debate on the appropriate evaluation to identify patients with undiagnosed at-risk congenital heart disease (CHD) and/or arrhythmias prior to starting a patient on medications for the treatment of ADHD.

The risk of sudden cardiac death in patients receiving stimulant medications for ADHD and the cardiac evaluation of these patients will be reviewed here. The pharmacotherapy for ADHD is discussed in greater detail separately. (See "Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents".)

RISK OF SUDDEN UNEXPECTED DEATHS — ADHD is a common childhood disorder, affecting up to 10 percent of all school-aged children. Stimulant drugs including methylphenidate (Ritalin, Methylin, Concerta, Focalin, Metadate), dextroamphetamine (Dexedrine), and dextroamphetamine-amphetamine (eg, Adderall) are effective in improving behavior in these patients. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis", section on 'Epidemiology' and "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Stimulants versus other medications'.)

Reports of unexpected deaths of children receiving stimulant therapy have led to concerns that these medications increase the risk of cardiovascular (CV) adverse events, including sudden unexpected deaths (SUDs) [1,2]. However, large cohort studies have not shown an increased risk of serious CV adverse events in children treated with stimulant therapy compared with the general pediatric population, as discussed in the following section.

Children without cardiac disease — Based on the available evidence, it appears that children without cardiac disease who receive stimulant therapy are not at increased risk for CV events compared with the general pediatric population.

In the largest cohort study based on data from four large health plans that was sponsored by the US Food and Drug Administration (FDA) and the Agency for Healthcare Research and Quality, there was no difference in the risk for serious CV events (sudden cardiac death, acute myocardial infarction, or stroke) between children and young adults (age range 2 to 24 years) receiving stimulant ADHD pharmacotherapy and nonusers (adjusted hazard ratio [HR] 0.75, 95% CI 0.31-1.85) [3]. The incidence of serious CV events in this cohort was 3.1 per 100,000 person-years.

In another cohort study from the United States that used two large preexisting administrative databases, there was no difference in the rate of SUD in all children between 3 and 17 years of age who received stimulant therapy (users) from control patients matched by database source, gender, age, and state (HR 1.6, 95% CI 0.19-13.60) [4]. In addition, there was no difference in all-cause mortality between the two groups (HR 0.76, 95% CI 0.52-1.12). Although 241,417 users were identified, the HR could not be determined for predetermined events of interest, because of the low or absent CV events. In the user group, there were no reported strokes or myocardial infarction and the crude incidence rate for SUD was 0.6 per 100,000 patient-years.

In another population-based cohort study of over one million children from the United States, health care claims data for 28 state Medicaid programs from 1999 to 2006 showed that treatment with stimulant therapy was not associated with increased short-term risk of severe cardiac events in children between 3 and 18 years of age [5]. In this study, the overall rate of serious CV events (sudden cardiac death, acute myocardial infarction, or stroke) was 2.8 per 100,000 patient-years; the rate was not statistically different for children who were nonusers, current users, and former users of stimulant therapy (3.5, 1.7, and 1.5 per 100,000 patient-years, respectively).

In contrast, a retrospective study that used national mortality data reported an association between stimulant medication and SUD [6]. In this study, which compared the rate of stimulant use in children who died as passengers in a motor vehicle accident with those who died suddenly, the rate of stimulant medication use was higher in the SUD group compared with those in the motor vehicle accident group (1.8 versus 0.4 percent). However, the FDA concluded that this study was not able to verify a relationship between the use of stimulant therapy and SUD, because of methodologic limitations [7]. These limitations included potential bias (the recall of stimulant use was up to 20 years after a child's death), the possibility that medical evaluation was more thorough in children with SUD than in those who died as a result of a motor vehicle accident, the low frequency of stimulant use in both groups (the national estimated rate is 4.3 percent), and a 40 percent parental refusal rate of participation. Because of these concerns, the FDA has stated that the results of this study should not serve as a basis to discontinue stimulant therapy in children with ADHD.

Children with cardiac disease — ADHD is common in children with congenital heart disease (CHD) [8-12]. Limited data are available on the risks of SUD in children with CHD and concomitant ADHD who are treated with stimulant medications [13]. In one small trial of 12 children with velocardiofacial syndrome (eight with CHD), patients had no evidence of hypertension, tachycardia, or electrocardiogram (ECG) changes when they received methylphenidate for their ADHD [14]. In addition, there are no data to suggest that specific forms of CHD carry an increased risk of SUD in association with ADHD drugs.

The risk of cardiac events may be higher in children with other forms of pediatric cardiac disease, including long QT syndrome (LQTS). In a case-control study of 48 children with LQTS treated with ADHD medications (chiefly stimulants) and followed for approximately eight years, the rate of syncope was greater than that of age-, gender-, and QTc duration-matched patients with LQTS not taking ADHD medications (30 versus 14 percent) [15]. Other major cardiac events, such as cardiac arrest and LQTS death, were rare and did not differ between groups. (See "Congenital long QT syndrome: Epidemiology and clinical manifestations".)

Adults — Among adult patients who are either current or new users of stimulant medications, there appears to be no increased risk of serious CV events.

This was illustrated in a large retrospective cohort study of adults (age range 25 to 64 years) based on data from four large health plans that was done in parallel with the study performed in children discussed above [3,16]. Multivariant analysis demonstrated a lower risk of serious CV events (defined as myocardial infarction, stroke, and sudden cardiac death) in individuals who were current users of stimulant therapy versus nonusers (relative risk [RR] 0.83, 95% CI 0.72-0.96). In new users of ADHD medications compared with controls, the risk of serious CV events was even lower (RR 0.77, 95% CI 0.63-0.94). However, there may be a modest amount of healthy-user bias that favored the current users of stimulant therapy. To adjust for this potential bias, a multivariant analysis that compared current users with individuals who had used stimulant therapy more than one year ago (defined as remote use) found no difference in the risk of serious CV events (RR 1.03, 95% CI 0.86-1.24). The crude incidence of serious CV events in the overall cohort was 1.34 per 1000 person-years.

These results showing no increased risk of serious CV events are consistent with previously discussed studies in pediatric patients [3,4,16].

US Food and Drug Administration position — In an updated safety review, the FDA summarized the findings of the largest cohort study in children that did not show an association between ADHD pharmacotherapy and adverse CV events [3,17]. Based on these results, the FDA continues to recommend that clinicians prescribe these medications according to the professional prescribing label and that patients continue to use prescribed therapy for the treatment of ADHD. Patients should be monitored for changes in heart rate and blood pressure. Stimulant therapy generally should not be prescribed in patients with serious heart problems or in whom an increase in blood pressure or heart rate would be problematic. In these individuals, if ADHD therapy is deemed necessary, it should be managed in consultation with a cardiologist. (See 'Known cardiac effects' below and 'Monitoring' below.)

KNOWN CARDIAC EFFECTS

Stimulant medications — Studies evaluating cardiovascular (CV) effects of stimulant medications found the following modest CV changes in patients treated with a dosing regimen that is effective in improving behavior [18-24]:

Pulse increases of 3 to 10 beats per minute

Systolic blood pressure increases of 3 to 8 mmHg

Diastolic blood pressure increases of 2 to 14 mmHg

These changes were illustrated in a prospective study of 114 adolescents (mean age 14.1 years) who were treated with extended-release methylphenidate [25]. CV parameters were assessed at six weeks (when the mean dose of methylphenidate was 63 mg), three months, and six months for 57 patients with a mean daily dose of 67 mg. The following findings were noted:

At six weeks compared with baseline, there was a small increase in mean heart rate (82 versus 86 beats per minute). This change persisted throughout six months of follow-up without any further change in heart rate.

Mean systolic blood pressure increased slowly throughout the entire six months (113, 115, 115, and 117 mmHg at baseline, six weeks, three months, and six months, respectively).

There were no clinically significant changes in the diastolic blood pressure and electrocardiogram (ECG), and no serious CV event occurred.

Although 10 patients had subjective CV complaints, six of these had a comorbid anxiety disorder, which was thought to be a main contributor to these symptoms. Symptoms of another patient were related to the use of albuterol during an asthma attack. All other complaints were one-time isolated reports that were judged to be mild or moderate in severity. No complaint was associated with a change in vital signs or ECG abnormalities.

Patients receiving stimulant therapy visited the emergency department or clinician office more frequently than those who were not treated with medications because of cardiac symptoms (10.9 versus 9.1 events per 1000 patient-years, adjusted hazard ratio [HR] 1.2, 95% CI 1.04-1.38) [26]. The cardiac symptoms included syncope, tachycardia, or palpitations. However, the group that received stimulant therapy was more likely to receive other psychotropic medications (antidepressants and antipsychotic agents), be male, and be non-Hispanic. The incidence of fatal and serious cardiac abnormalities was low, not different between the two groups, and similar to the rates seen in the general pediatric population.

One small study suggested that there may be evidence of arterial stiffness, but further investigation is needed to confirm and determine any clinically significant effect [23].

Atomoxetine — Atomoxetine is a selective norepinephrine reuptake inhibitor, which is used as an alternative to stimulant therapy in the treatment of ADHD. (See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Stimulants versus other medications'.)

In a comprehensive review of a clinical trial database that included >8000 patients treated with atomoxetine, most pediatric patients experienced modest increases in heart rate and blood pressure and 8 to 12 percent experienced more pronounced changes (≥20 beats per minute, ≥15 to 20 mmHg) [27]. Thus, the prescribing information for atomoxetine includes a warning that the drug "generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to its noradrenergic effects" [28].

If questions arise, consultation with a cardiologist experienced in managing children with CV disease is warranted.

CARDIAC EVALUATION — We agree with the 2008 recommendations of the American Academy of Pediatrics and the American Heart Association that the evaluation of children with ADHD prior to initiation of medication should include a comprehensive, cardiovascular (CV)-focused patient history, family history, and physical examination, as discussed in the following sections [29]. If the history and examination are not suggestive of cardiac disease, the available evidence suggests that ADHD pharmacotherapy can be safely initiated without additional evaluation (eg, electrocardiogram [ECG]) [29,30]. (See 'Additional evaluation' below.)

This approach is endorsed by several other professional organizations, including the American Academy of Child and Adolescent Psychiatry, the American College of Cardiology, Children and Adults with Attention-Deficit/Hyperactivity Disorder, the National Institute for Children's Health Quality, and the Society for Developmental and Behavioral Pediatrics.

The aim of the cardiac evaluation is to identify underlying cardiac disease that may predispose the child to serious CV events, including sudden cardiac death. However, it is important to note that the available evidence does not suggest a causal association between CV risk and stimulant use. Furthermore, there are no specific cardiac conditions for which there is definitive evidence that the use of ADHD medications should be contraindicated. What is clear, however, is that limiting or delaying a child's access to effective treatment for ADHD could have serious implications (such as increased risk of adolescent substance use disorder, academic failure, and accidents) in patients who are not effectively treated. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

We suggest that clinicians who prescribe medications for ADHD discuss the benefits and potential adverse effects of treatment with patients and parents, emphasizing the uncertainty about a causal association between CV risks (including sudden unexpected death [SUD]), as previously discussed [31,32]. (See 'Risk of sudden unexpected deaths' above.)

History — The history is focused on detecting signs of cardiac disease in the patient or family, including sudden cardiac death in family members. Important aspects of the history include the following [33] (see "Suspected heart disease in infants and children: Criteria for referral", section on 'Symptoms'):

Patient history of cardiac disease, rheumatic fever, fainting or dizziness (especially with exercise), seizures, chest pain or shortness of breath with exercise, unexplained change in exercise tolerance, palpitations, high blood pressure, and heart murmur.

Prescribed and over-the-counter medications and nonprescribed health supplements, particularly those with CV effects.

Family history of SUD or an event requiring resuscitation in children or young adults, cardiac arrhythmias (eg, Wolff-Parkinson-White syndrome), long QT syndrome (LQTS), catecholaminergic paroxysmal ventricular tachycardia, Brugada syndrome, arrhythmogenic right ventricular dysplasia, hypertrophic cardiomyopathy, dilated cardiomyopathy, and Marfan syndrome. (See "Causes of wide QRS complex tachycardia in children" and "Clinical features and diagnosis of supraventricular tachycardia (SVT) in children" and "Genetics of dilated cardiomyopathy" and "Hypertrophic cardiomyopathy: Gene mutations and clinical genetic testing" and "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders".)

Physical examination — Important aspects of the physical examination include the following [33] (see "Suspected heart disease in infants and children: Criteria for referral", section on 'Physical examination findings'):

Measurement of blood pressure and heart rate

Cardiac auscultation to detect the presence of a heart murmur, or irregular or rapid heart rhythm (see "Approach to the infant or child with a cardiac murmur")

Physical findings associated with Marfan syndrome (see "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders")

Additional evaluation — If the history and examination are not suggestive of cardiac disease, pharmacotherapy can be initiated or continued without additional evaluation [30]. An ECG is not required before initiating stimulant therapy for patients with ADHD. However, if the child is known to have cardiac disease, or if the history or physical examination is suggestive of cardiac disease, further evaluation, including ECG and/or consultation with a pediatric cardiologist, is warranted. Decisions regarding initiation of pharmacotherapy in children with underlying cardiac disease should be made in collaboration with the child's cardiologist. Based upon the available evidence, there are no specific cardiac diagnoses that are considered to be absolute contraindications to medical ADHD therapy.

Routine ECG screening in all patients treated with ADHD stimulant therapy is not recommended, as the incidence of sudden cardiac death appears to be either lower (albeit possibly underreported) or similar to that in the general pediatric population. In addition, false positives are very common in ECG screening. There are no specific ECG findings associated with an increased likelihood of a serious cardiac adverse event due to ADHD therapy [34,35].

These points were illustrated in a retrospective study of 1470 children with ADHD receiving pharmacotherapy that were screened with an ECG from April to September 2008 [34]. In this cohort, ECG studies were interpreted as abnormal in 119 patients (8.1 percent). Further work-up including transthoracic echocardiogram, stress test, and Holter monitor identified cardiac disease in five subjects (0.3 percent of the entire cohort). The diagnoses included ventricular pre-excitation syndrome (n = 2), bicuspid aortic valve (n = 2), and a moderate-size secundum atrial septal defect (n = 1). The estimated cost to identify each case of cardiac disease was USD $17,162. In three of these cases, there is no contraindication of ADHD therapy, and, in the other two (asymptomatic ventricular pre-excitation syndrome), it is unclear whether ADHD therapy would be withheld. These results suggest that ECG is not a cost-effective screen to detect cardiac disease in children with ADHD.

A modeled economic evaluation studied various strategies of identifying children receiving ADHD therapy at risk for sudden cardiac death and concluded that there may be a borderline cost-effectiveness of screening with an ECG [36]. An accompanying editorial, as well as the authors, however, point out that some of the assumptions used to develop the model are not well established or may vary greatly [36,37].

Monitoring — During treatment with ADHD stimulant therapy, the patient should be assessed for any changes in CV symptoms (eg, fainting or dizziness, seizures, chest pain or shortness of breath with exercise, unexplained change in exercise tolerance, or palpitations). Evaluation should include measurement of heart rate and blood pressure to ascertain whether there have been any significant changes in these signs, especially if the blood pressure reaches either prehypertension or hypertension levels. (See "Definition and diagnosis of hypertension in children and adolescents".)

In patients with concerning symptoms or findings, consultation with a pediatric cardiologist should be considered.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Attention deficit hyperactivity disorder".)

SUMMARY AND RECOMMENDATIONS

Attention deficit hyperactivity disorder (ADHD) is a common childhood disorder, affecting up to 8 to 10 percent of all school-aged children. Stimulant drugs are effective in improving behavior in these patients. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis", section on 'Epidemiology' and "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Stimulants versus other medications'.)

Although there had been concerns of serious adverse cardiac effects, stimulant therapy does not appear to increase the risk of sudden unexpected cardiac death or other serious cardiac complications (eg, myocardial infarction or stroke) in patients without underlying cardiac disease. (See 'Risk of sudden unexpected deaths' above.)

Stimulant medications are known to have modest cardiovascular (CV) effects including small elevations in heart rate (3 to 10 beats per minute), systolic blood pressure (3 to 8 mmHg), and diastolic blood pressure (2 to 14 mmHg). (See 'Known cardiac effects' above.)

Based upon the available evidence, we agree with the approach outlined by the American Academy of Pediatrics and the American Heart Association for a careful pretreatment evaluation including a comprehensive CV-focused patient history, family history, and physical examination. If the history and examination are not suggestive of cardiac disease, pharmacotherapy can be initiated or continued without additional evaluation. (See 'Cardiac evaluation' above.)

An electrocardiogram (ECG) is not required before initiating stimulant therapy for patients with ADHD. However, if the patient is known to have cardiac disease, or if the history or physical examination is suggestive of cardiac disease, further evaluation including ECG and/or consultation with a pediatric or adult cardiologist is needed. (See 'Additional evaluation' above.)

The potential risks of stimulants should be discussed with the family when deciding upon the management strategy for any patient with ADHD. (See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications", section on 'Stimulants versus other medications'.)

Children who are prescribed ADHD stimulant therapy should be routinely evaluated for any changes in heart rate or blood pressure, as well as CV symptoms during treatment. (See 'Monitoring' above.)

  1. Nissen SE. ADHD drugs and cardiovascular risk. N Engl J Med 2006; 354:1445.
  2. Gorman RL. FDA Panel recommends black box warning on ADHD stimulant medications. AAP News 2006; 27:16.
  3. Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med 2011; 365:1896.
  4. Schelleman H, Bilker WB, Strom BL, et al. Cardiovascular events and death in children exposed and unexposed to ADHD agents. Pediatrics 2011; 127:1102.
  5. Winterstein AG, Gerhard T, Kubilis P, et al. Cardiovascular safety of central nervous system stimulants in children and adolescents: population based cohort study. BMJ 2012; 345:e4627.
  6. Gould MS, Walsh BT, Munfakh JL, et al. Sudden death and use of stimulant medications in youths. Am J Psychiatry 2009; 166:992.
  7. Communication about an Ongoing Safety Review of Stimulant Medications used in Children with Attention-Deficit/Hyperactivity Disorder (ADHD). http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm165858.htm (Accessed on November 07, 2011).
  8. Mahle WT, Clancy RR, Moss EM, et al. Neurodevelopmental outcome and lifestyle assessment in school-aged and adolescent children with hypoplastic left heart syndrome. Pediatrics 2000; 105:1082.
  9. Bass JL, Corwin M, Gozal D, et al. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence. Pediatrics 2004; 114:805.
  10. Shprintzen RJ. Velocardiofacial syndrome. Otolaryngol Clin North Am 2000; 33:1217.
  11. Gothelf D, Gruber R, Presburger G, et al. Methylphenidate treatment for attention-deficit/hyperactivity disorder in children and adolescents with velocardiofacial syndrome: an open-label study. J Clin Psychiatry 2003; 64:1163.
  12. Holland JE, Cassidy AR, Stopp C, et al. Psychiatric Disorders and Function in Adolescents with Tetralogy of Fallot. J Pediatr 2017; 187:165.
  13. Batra AS, Alexander ME, Silka MJ. Attention-deficit/hyperactivity disorder, stimulant therapy, and the patient with congenital heart disease: evidence and reason. Pediatr Cardiol 2012; 33:394.
  14. Wilens TE, Biederman J, Lerner M, Concerta Study Group. Effects of once-daily osmotic-release methylphenidate on blood pressure and heart rate in children with attention-deficit/hyperactivity disorder: results from a one-year follow-up study. J Clin Psychopharmacol 2004; 24:36.
  15. Zhang C, Kutyifa V, Moss AJ, et al. Long-QT Syndrome and Therapy for Attention Deficit/Hyperactivity Disorder. J Cardiovasc Electrophysiol 2015; 26:1039.
  16. Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. JAMA 2011; 306:2673.
  17. FDA Drug Safety Communication: Safety Review Update of Medications used to treat Attention-Deficit/Hyperactivity Disorder (ADHD) in children and young adults. http://www.fda.gov/Drugs/DrugSafety/ucm277770.htm (Accessed on November 07, 2011).
  18. Findling RL, Biederman J, Wilens TE, et al. Short- and long-term cardiovascular effects of mixed amphetamine salts extended release in children. J Pediatr 2005; 147:348.
  19. Rapport MD, Moffitt C. Attention deficit/hyperactivity disorder and methylphenidate. A review of height/weight, cardiovascular, and somatic complaint side effects. Clin Psychol Rev 2002; 22:1107.
  20. Findling RL, Short EJ, Manos MJ. Short-term cardiovascular effects of methylphenidate and adderall. J Am Acad Child Adolesc Psychiatry 2001; 40:525.
  21. Samuels JA, Franco K, Wan F, Sorof JM. Effect of stimulants on 24-h ambulatory blood pressure in children with ADHD: a double-blind, randomized, cross-over trial. Pediatr Nephrol 2006; 21:92.
  22. Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity disorder: update and clinical recommendations. J Am Acad Child Adolesc Psychiatry 2011; 50:978.
  23. Kelly AS, Rudser KD, Dengel DR, et al. Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with attention deficit hyperactivity disorder treated with stimulants. J Pediatr 2014; 165:755.
  24. Hennissen L, Bakker MJ, Banaschewski T, et al. Cardiovascular Effects of Stimulant and Non-Stimulant Medication for Children and Adolescents with ADHD: A Systematic Review and Meta-Analysis of Trials of Methylphenidate, Amphetamines and Atomoxetine. CNS Drugs 2017; 31:199.
  25. Hammerness P, Wilens T, Mick E, et al. Cardiovascular effects of longer-term, high-dose OROS methylphenidate in adolescents with attention deficit hyperactivity disorder. J Pediatr 2009; 155:84.
  26. Winterstein AG, Gerhard T, Shuster J, et al. Cardiac safety of central nervous system stimulants in children and adolescents with attention-deficit/hyperactivity disorder. Pediatrics 2007; 120:e1494.
  27. Reed VA, Buitelaar JK, Anand E, et al. The Safety of Atomoxetine for the Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Comprehensive Review of Over a Decade of Research. CNS Drugs 2016; 30:603.
  28. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021411s048lbl.pdf (Accessed on July 19, 2017).
  29. American Academy of Pediatrics/American Heart Association clarification of statement on cardiovascular evaluation and monitoring of children and adolescents with heart disease receiving medications for ADHD. Available at: americanheart.mediaroom.com/index.php?s=43&item=422 (Accessed on June 09, 2008).
  30. Perrin JM, Friedman RA, Knilans TK, et al. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics 2008; 122:451.
  31. Stein MT. FDA preliminary report: safety of stimulant medications. Journal Watch Pediatr Adolesc Med 2006; 5:36.
  32. Wilens TE, Prince JB, Spencer TJ, Biederman J. Stimulants and sudden death: what is a physician to do? Pediatrics 2006; 118:1215.
  33. Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: 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. Circulation 2008; 117:2407.
  34. Mahle WT, Hebson C, Strieper MJ. Electrocardiographic screening in children with attention-deficit hyperactivity disorder. Am J Cardiol 2009; 104:1296.
  35. Thomas PE, Carlo WF, Decker JA, et al. Impact of the American Heart Association scientific statement on screening electrocardiograms and stimulant medications. Arch Pediatr Adolesc Med 2011; 165:166.
  36. Denchev P, Kaltman JR, Schoenbaum M, Vitiello B. Modeled economic evaluation of alternative strategies to reduce sudden cardiac death among children treated for attention deficit/hyperactivity disorder. Circulation 2010; 121:1329.
  37. Triedman JK, Alexander ME. Needle in a haystack: modeling the incidence of sudden cardiac arrest in healthy children. Circulation 2010; 121:1283.
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