Does a 28-year-old with anxiety, normal body mass index (BMI), and recent cessation of marijuana and vaping, who is taking Adderall (amphetamine and dextroamphetamine) and has possible left ventricular hypertrophy (LVH) on electrocardiogram (EKG), require referral for further cardiovascular evaluation?

Referral for Possible Left Ventricular Hypertrophy on ECG in a Young Adult on Adderall

Yes, this 28-year-old patient on Adderall with possible left ventricular hypertrophy (LVH) on ECG should be referred for further cardiovascular evaluation, particularly echocardiography, due to the increased risk of cardiovascular complications associated with stimulant medications and the need to rule out structural heart disease.

Rationale for Referral

Stimulant Medication Concerns

• The FDA label for amphetamine (Adderall) explicitly warns about cardiovascular risks, stating that "stimulant products generally should not be used in children or adolescents with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems" 1
• Adults taking stimulants have a greater likelihood of having serious structural cardiac abnormalities and are at risk for sudden death, stroke, and myocardial infarction even at usual doses 1

ECG Findings of LVH

• While isolated voltage criteria for LVH on ECG may represent a normal variant, especially in young individuals, the American Heart Association recommends that in those with stage 2 hypertension or suggestion of target-organ damage, a screening echocardiogram is advisable 2
• The standard 12-lead ECG can show a variable combination of LVH, ST- and T-wave abnormalities that, when interpreted with imaging findings, can suggest underlying diagnoses 2

Recommended Evaluation Pathway

Step 1: Comprehensive Echocardiography

• Transthoracic echocardiography (TTE) is the cornerstone of initial evaluation for suspected LVH, assessing:
  • Maximum left ventricular wall thickness
  • Distribution pattern of hypertrophy
  • LV outflow tract obstruction
  • Mitral valve function
  • Left atrial size
  • LV systolic and diastolic function 3

Step 2: Additional Testing Based on Echocardiography Results

• If echocardiography confirms LVH:

  • 24-hour ambulatory ECG monitoring to detect ventricular tachycardia and identify patients who may be candidates for further intervention 2
  • 24-hour ambulatory blood pressure monitoring to exclude hypertension as a cause of LVH 3

• If echocardiography is inconclusive:

  • Consider cardiac magnetic resonance imaging (CMR) for more precise assessment of LV wall thickness and to detect areas of myocardial fibrosis 3

Special Considerations for This Patient

Risk Factors Present

1. Adderall use: Stimulants cause modest increases in blood pressure and heart rate, which may contribute to LVH development 1
2. Anxiety: Associated with elevated plasma adrenomedullin levels and increased LVH in patients with hypertension 4
3. Recent cessation of marijuana and vaping: May cause physiological changes that could temporarily affect cardiovascular function

Distinguishing Physiological from Pathological LVH

• The patient's low BMI (18) and young age could suggest athletic heart syndrome, but this must be distinguished from pathological LVH
• Echocardiography can help differentiate physiological hypertrophy from pathological LVH by assessing:
  • Left ventricular filling patterns
  • Isovolumic relaxation times
  • Chamber size 2

Important Caveats

• ECG criteria for LVH have low sensitivity (6-50%) compared to imaging (85-100%), especially in young individuals 3, 5
• A study of young healthy males found that ECG criteria had poor sensitivity for detecting true LVH as measured by CMR: Sokolow-Lyon criteria (38.7%), Cornell Amplitude (19.4%) 5
• Avoid attributing symptoms solely to anxiety without thorough cardiac evaluation 3
• Avoid using dobutamine for stress testing if HCM is suspected, as it can exacerbate obstruction 3

In summary, while ECG findings of LVH in young adults often represent normal variants, the combination of Adderall use, anxiety, and possible LVH on ECG warrants referral for echocardiography to rule out structural heart disease that could place the patient at increased risk for serious cardiovascular events.