From the Guidelines
Treating ADHD with stimulant therapy in someone with a history of cerebrovascular accident (CVA) and pulmonary embolism (PE) is generally considered high risk and should be approached with extreme caution. Stimulant medications can increase blood pressure and heart rate to a mild and clinically insignificant degree, on average, with increases of 1–2 beats per minute for heart rate and 1–4 mm Hg for systolic and diastolic blood pressure 1. However, a subset of individuals (5%–15%) may experience more substantial increases in heart rate and blood pressure, emphasizing the need for close monitoring of vital signs in patients receiving stimulant treatment 1.
Given the patient's history of CVA and PE, non-stimulant alternatives should be considered first-line therapy to minimize the risk of cardiovascular events and thromboembolism. Options include atomoxetine (Strattera), guanfacine (Intuniv), or clonidine, which generally have less impact on cardiovascular parameters 1. If stimulant therapy is deemed necessary after careful risk-benefit analysis, it should only be initiated under close medical supervision with a cardiologist's clearance, starting at the lowest possible dose with gradual titration while monitoring vital signs and cardiovascular symptoms.
Key considerations for stimulant therapy in this context include:
- Monitoring heart rate and blood pressure regularly
- Performing electrocardiograms to assess cardiovascular risk
- Assessing for symptoms suggesting cardiovascular complications
- Titrating the dose gradually to minimize the risk of adverse effects
- Considering alternative therapies, such as non-stimulant medications, if stimulant therapy is not tolerated or is ineffective. The increased risk associated with stimulant therapy in patients with a history of CVA and PE stems from the potential for hemodynamic changes and vasoconstriction, which could theoretically increase the risk of recurrent stroke or thrombotic events in predisposed individuals 1.
From the FDA Drug Label
5.2 Risks to Patients with Serious Cardiac Disease
Sudden death has been reported in patients with structural cardiac abnormalities or other serious cardiac disease who were treated with CNS stimulants at the recommended ADHD dosage Avoid methylphenidate hydrochloride use in patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrythmia, coronary artery disease, or other serious cardiac disease.
5.3 Increased Blood Pressure and Heart Rate
CNS stimulants cause an increase in blood pressure (mean increase approximately 2 to 4 mmHg) and heart rate (mean increase approximately 3 to 6 bpm). Some patients may have larger increases. Monitor all methylphenidate hydrochloride-treated patients for hypertension and tachycardia.
5.6 Peripheral Vasculopathy, Including Raynaud’s Phenomenon
CNS stimulants, including methylphenidate hydrochloride oral solution, used to treat ADHD are associated with peripheral vasculopathy, including Raynaud’s phenomenon.
Treating ADHD with stimulant therapy, such as methylphenidate, in someone with a history of CVA (Cerebrovascular Accident) and PE (Pulmonary Embolism) is considered high risk due to the potential for increased blood pressure and heart rate, as well as peripheral vasculopathy.
- Cardiovascular risks: The patient's history of CVA and PE may increase the risk of further cardiovascular complications when using stimulant therapy.
- Monitoring requirements: Close monitoring of blood pressure and heart rate is necessary when using methylphenidate in patients with a history of cardiovascular disease. The use of methylphenidate hydrochloride in patients with serious cardiac disease is generally avoided, and caution is advised when considering its use in patients with a history of CVA and PE 2.
From the Research
Treatment of ADHD with Stimulant Therapy
- Stimulants, such as methylphenidate and amphetamines, are the recommended first-line option for the pharmacological treatment of individuals with attention deficit hyperactivity disorder (ADHD) 3.
- However, some patients with ADHD will not respond optimally to stimulants, and alternative pharmacological strategies may be considered 3, 4.
Risks of Stimulant Therapy in Patients with a History of CVA and PE
- There is limited information available on the risks of stimulant therapy in patients with a history of cerebral vasculature accidents (CVA) and pulmonary embolism (PE).
- However, it is known that stimulants can increase blood pressure and heart rate, which may be a concern in patients with a history of CVA and PE 5.
Alternative Treatment Options
- Non-stimulant medications, such as atomoxetine, may be considered for patients who do not respond or poorly tolerate stimulants 4, 6.
- Bupropion, a dopamine and norepinephrine reuptake inhibitor, has also been shown to be effective in improving ADHD symptoms in some patients 7.
- Combination therapy with stimulants and non-stimulants, such as atomoxetine, may also be effective in treating ADHD in some patients 6.