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. 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 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).
Key Considerations:
- Coronary Vasospasms: are a type of serious cardiac condition that may be exacerbated by stimulant medications.
- ADHD Medications: such as Ritalin (methylphenidate) or Adderall (amphetamine and dextroamphetamine), can increase the risk of sudden death, stroke, and myocardial infarction in adults with pre-existing structural cardiac abnormalities or other serious heart problems.
- Increased Blood Pressure and Heart Rate: stimulant medications can cause a modest increase in average blood pressure and heart rate, which may be problematic for patients with coronary vasospasms.
- Contraindications: patients with known structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease, or other serious cardiac disease should generally not be treated with stimulant drugs.
Clinical Decision: Patients with coronary vasospasms should be carefully evaluated before prescribing ADHD medications, and alternative treatments should be considered due to the potential risks of sudden death, stroke, and myocardial infarction 1, 2.
From the Research
Prescribing ADHD medications to patients with coronary vasospasms requires extreme caution and is generally contraindicated due to significant cardiovascular risks. Stimulant medications like Ritalin (methylphenidate) and Adderall (amphetamine and dextroamphetamine) can increase heart rate, blood pressure, and myocardial oxygen demand, potentially triggering or worsening coronary vasospasms, as seen in a case report where a 21-year-old man with ADHD developed STEMI secondary to coronary vasospasm after taking methylphenidate 3. For patients with a history of coronary vasospasms, non-stimulant alternatives such as atomoxetine (Strattera), guanfacine (Intuniv), or bupropion should be considered as first-line treatments. If stimulants must be used, they should only be prescribed after thorough cardiovascular evaluation including ECG, stress testing, and consultation with a cardiologist, as recommended in a review of cardiovascular effects of stimulant and non-stimulant medication for children and adolescents with ADHD 4. Starting doses should be extremely low (e.g., 5mg of methylphenidate or 5mg of mixed amphetamine salts) with very gradual titration and regular cardiovascular monitoring. The mechanism behind this concern relates to stimulants' sympathomimetic effects, which increase catecholamine levels and can promote vasoconstriction. Patients should be educated about warning signs of cardiac issues such as chest pain, palpitations, shortness of breath, or syncope, with instructions to seek immediate medical attention if these occur, as vasospastic angina can lead to acute myocardial infarction and sudden cardiac death 5. Regular follow-up appointments should include blood pressure and heart rate monitoring, with consideration of periodic ECG assessment to evaluate for any cardiac changes. Key considerations for prescribing ADHD medications to patients with coronary vasospasms include:
- Avoiding stimulant medications whenever possible
- Using non-stimulant alternatives as first-line treatments
- Conducting thorough cardiovascular evaluation before prescribing stimulants
- Starting with low doses and gradually titrating
- Regularly monitoring cardiovascular health
- Educating patients on warning signs of cardiac issues.