Does a 7-year-old boy with Attention Deficit Hyperactivity Disorder (ADHD), combined type, and a medical history significant for asthma require an Electrocardiogram (ECG) prior to prescribing a stimulant?

ECG Screening Before Stimulant Therapy for ADHD

No, an ECG is not required prior to prescribing a stimulant for this 7-year-old boy with ADHD and asthma, according to current recommendations.

Cardiac Risk Assessment Guidelines

The American Academy of Pediatrics (AAP) provides clear guidance on this issue:

• Routine ECG screening is not recommended before starting stimulant medication in children without cardiac risk factors 1.
• Stimulant medications have not been shown to increase the risk of sudden death beyond that observed in children who are not receiving stimulants 2, 1.
• The risk of serious cardiovascular events with stimulant use is extremely low in otherwise healthy children 2.

Appropriate Pre-Treatment Assessment

Instead of an ECG, the following assessment is recommended:

1. Thorough cardiac history, including:

   • Personal history of specific cardiac symptoms (chest pain, syncope, palpitations, shortness of breath with exercise)
   • Family history of sudden death, cardiovascular symptoms, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, or long QT syndrome 2, 1

2. Baseline vital signs:

   • Blood pressure
   • Heart rate
   • Height and weight 2

When ECG IS Indicated

An ECG would be warranted if any of these risk factors are present:

• Personal history of cardiac symptoms
• Family history of sudden cardiac death or serious arrhythmias
• Abnormal findings on cardiac examination
• Pre-existing structural cardiac abnormalities
• Cardiomyopathy
• Serious heart rhythm abnormalities 1, 3

Cardiovascular Effects of Stimulants

Stimulant medications typically cause:

• Mild increases in heart rate (1-2 beats per minute)
• Mild increases in blood pressure (1-4 mmHg) 2
• More substantial increases in HR and BP in a subset (5-15%) of patients 2

Monitoring Recommendations

During treatment with stimulants:

• Monitor vital signs at baseline and follow-up visits
• Track growth (height and weight) due to potential growth velocity effects
• Be alert for any emerging cardiac symptoms 2, 1

Caution

The 2008 American Heart Association statement that recommended ECG screening before stimulant treatment 2 led to a significant increase in ECG referrals 4, but this recommendation was not supported by subsequent evidence and guidelines. A study found that the yield of performing ECGs with an indication of stimulant medication screening is very low 4.

The current consensus from the American Academy of Pediatrics is that ECG screening is not necessary for children without cardiac risk factors prior to starting stimulant medication 2, 1.