Is an electrocardiogram (EKG) necessary before starting Adderall (amphetamine and dextroamphetamine)?

EKG Before Starting Adderall

An EKG is not routinely required before starting Adderall in asymptomatic patients without cardiac risk factors, but a careful cardiovascular history and physical examination are mandatory to identify those who need further cardiac evaluation including an EKG. 1

FDA-Mandated Cardiovascular Assessment

The FDA drug label for amphetamine products explicitly states that "children, adolescents, or adults who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram)." 1

Who Requires an EKG Before Starting Adderall

Obtain a baseline EKG if any of the following are present:

• Known structural cardiac abnormalities (congenital heart disease, cardiomyopathy) 1
• Serious heart rhythm abnormalities or family history of sudden death or ventricular arrhythmia 1
• Pre-existing cardiovascular disease including hypertension, heart failure, recent myocardial infarction, or coronary artery disease 1
• Symptoms suggestive of cardiac disease such as exertional chest pain or unexplained syncope 1
• Personal or family history of cardiovascular risk factors 2

Evidence on Routine Screening

Research demonstrates that routine screening EKGs in ADHD patients rarely change management. A community-based study of 691 screening EKGs found that only 0.14% resulted in a change in management decisions, with 6.1% requiring further consultation but most revealing no significant pathology. 3

Despite this low yield, the cardiovascular risks are real. Stimulants cause modest increases in blood pressure (2-4 mmHg) and heart rate (3-6 bpm), and rare cases of myocardial infarction have been reported even in adolescents without cardiovascular risk factors. 1, 4

Clinical Approach

For patients WITHOUT cardiac risk factors:

• Detailed cardiovascular history focusing on syncope, chest pain, palpitations, exercise intolerance, and family history of sudden death 1
• Physical examination including blood pressure and cardiac auscultation 1
• No routine EKG needed if history and exam are unremarkable 3

For patients WITH any cardiac risk factors or abnormal findings:

• Obtain baseline EKG before initiating therapy 1
• Consider cardiology consultation for interpretation and further evaluation 5
• The specific ADHD medication choice may need to be tailored based on the cardiac condition 5

Important Caveats

The American Heart Association guidelines on psychotropic medications recommend ECG monitoring for drugs like phenothiazines that prolong QT intervals 6, 7, but amphetamines do not typically cause clinically significant QT prolongation. Large-scale evidence shows the risk of serious cardiovascular events with ADHD medications is extremely low at therapeutic doses. 2

Common pitfall: Failing to obtain adequate cardiovascular history before prescribing. The history is more important than routine screening EKGs in identifying at-risk patients. 1

Monitoring during treatment: Patients who develop chest pain, syncope, or other cardiac symptoms while on Adderall require prompt cardiac evaluation including EKG, regardless of whether a baseline EKG was obtained. 1