Are stimulants okay in patients with atrial fibrillation (A fib)?

From the Guidelines

Stimulants are not recommended for patients with atrial fibrillation (A-fib) as they can exacerbate the condition. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, the focus is on controlling heart rate and reducing symptoms, typically using beta-blockers, diltiazem, verapamil, or digoxin as first-choice drugs. Stimulants, on the other hand, can increase heart rate and blood pressure, potentially triggering or worsening A-fib episodes. Some key points to consider include:

• The potential of stimulants to activate the sympathetic nervous system, thereby increasing heart rate, contractility, and blood pressure, all of which can negatively impact A-fib management.
• The importance of working closely with healthcare providers, including cardiologists and psychiatrists, to find safe treatment approaches for conditions like ADHD in patients with A-fib.
• Considering non-stimulant alternatives, though being mindful of their potential cardiac effects.
• Informing all healthcare providers about the A-fib diagnosis and all current medications to ensure comprehensive care. Given the potential risks, it is crucial to avoid stimulants in patients with A-fib, focusing instead on evidence-based treatments for heart rate control as outlined in the guidelines 1.

From the FDA Drug Label

WARNINGS Serious Cardiovascular Events Sudden Death in Patients with Pre-existing Structural Cardiac Abnormalities or Other Serious Heart Problems Adults Sudden deaths, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual doses for ADHD Hypertension and Other Cardiovascular Conditions Stimulant medications cause a modest increase in average blood pressure (about 2 to 4 mmHg) and average heart rate (about 3 to 6 bpm), and individuals may have larger increases.

Stimulants and Atrial Fibrillation (A Fib) are not recommended. The FDA drug label warns of serious cardiovascular events, including sudden death, stroke, and myocardial infarction, in patients taking stimulant drugs, including those with pre-existing structural cardiac abnormalities or other serious heart problems. Atrial fibrillation is a type of serious heart rhythm abnormality that may place patients at increased vulnerability to the sympathomimetic effects of a stimulant drug. Therefore, caution is indicated in treating patients with atrial fibrillation or other cardiovascular conditions that may be compromised by increases in blood pressure or heart rate. 2

From the Research

Stimulants and Atrial Fibrillation

• The relationship between stimulants and atrial fibrillation (AF) is not directly addressed in the provided studies 3, 4, 5, 6, 7.
• However, studies have investigated the cardiovascular effects of stimulants, such as methylphenidate and amphetamines, which are commonly used to treat attention-deficit hyperactivity disorder (ADHD) 5, 6, 7.
• These studies have reported minor increases in heart rate and blood pressure, but the evidence is limited and the long-term effects on cardiovascular health are uncertain 5, 7.
• Atrial fibrillation is a common cardiac arrhythmia that can increase the risk of stroke and mortality, and its treatment typically involves drug therapy, catheter ablation, and other procedures 3, 4.
• The use of stimulants in patients with AF may require careful consideration and monitoring, as the potential interactions between stimulants and AF are not well understood 3, 4, 5, 6, 7.

Key Findings

• Methylphenidate and amphetamines may cause minor increases in heart rate and blood pressure, but the evidence is limited and the long-term effects are uncertain 5, 7.
• Atrial fibrillation is a common cardiac arrhythmia that requires careful management and treatment 3, 4.
• The use of stimulants in patients with AF may require careful consideration and monitoring, as the potential interactions are not well understood 3, 4, 5, 6, 7.

Cardiovascular Effects of Stimulants

• Methylphenidate and amphetamines have been reported to cause minor increases in heart rate and blood pressure, but the evidence is limited and the long-term effects are uncertain 5, 7.
• Atomoxetine may also increase blood pressure and heart rate, but the effects on cardiovascular health are not well understood 5, 7.
• The use of stimulants in patients with pre-existing cardiovascular conditions, such as AF, may require careful consideration and monitoring 3, 4, 5, 6, 7.