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

EKG Before Starting Adderall

An EKG is not routinely required before starting Adderall in all patients, but is mandatory for those with cardiac risk factors, structural heart disease, or concerning cardiac history. 1

Risk-Stratified Approach to Pre-Treatment Cardiac Evaluation

Patients Who Require Pre-Treatment EKG

The FDA label explicitly states that children, adolescents, or adults being considered for stimulant treatment should have a careful history (including family history of sudden death or ventricular arrhythmia) and physical exam, with further cardiac evaluation including electrocardiogram if findings suggest cardiac disease 1. Specifically:

• Patients with known structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems should obtain a baseline EKG before initiating therapy 1
• Those with cardiac risk factors require baseline EKG and consideration for cardiology consultation, as recommended by the American Heart Association 2
• Patients with pre-existing hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia need pre-treatment EKG 1
• Family history of sudden death or ventricular arrhythmia warrants pre-treatment cardiac evaluation including EKG 1

Patients Who May Not Require Routine EKG

• Healthy children, adolescents, and adults without cardiac symptoms, risk factors, or concerning family history do not require routine baseline EKG 1
• Amphetamines do not typically cause clinically significant QT prolongation, unlike phenothiazines, making routine screening less critical in low-risk populations 2

Clinical Rationale

Why Selective Rather Than Universal Screening

The cardiovascular effects of Adderall are modest in healthy individuals:

• Short-term treatment causes minimal cardiovascular changes with no clinically significant alterations in blood pressure or pulse at doses ≤15 mg/day 3
• Long-term treatment (up to 24 months) produces small mean changes: DBP +1.3 mmHg, SBP +2.3 mmHg, and pulse +2.1 bpm, which are not clinically significant 4
• Stimulants cause modest increases in blood pressure (2-4 mmHg) and heart rate (3-6 bpm) on average, though individual patients may have larger increases 1

Why High-Risk Patients Need EKG

The serious cardiovascular risks are concentrated in vulnerable populations:

• Sudden death has been reported in children and adolescents with structural cardiac abnormalities taking CNS stimulants at usual doses 1
• Sudden deaths, stroke, and myocardial infarction have been reported in adults taking stimulants at usual ADHD doses 1
• Adults have greater likelihood of serious structural cardiac abnormalities compared to children 1
• Case reports document myocardial infarction even in adolescents without traditional cardiovascular risk factors when using prescribed doses 5

Common Pitfalls to Avoid

• Failing to obtain adequate cardiac history before prescribing is the most critical error—specifically ask about personal cardiac symptoms, family history of sudden death, and structural heart disease 1
• Assuming young age eliminates cardiac risk—structural abnormalities can be present in children and adolescents without prior diagnosis 1
• Not monitoring blood pressure and heart rate during treatment—all patients require ongoing monitoring for larger-than-expected increases regardless of baseline EKG status 1
• Ignoring new cardiac symptoms during treatment—patients developing exertional chest pain, unexplained syncope, or cardiac symptoms require prompt cardiac evaluation including EKG 1

Monitoring During Treatment

Regardless of whether baseline EKG was obtained:

• All patients should be monitored for blood pressure and heart rate changes during treatment 1, 6
• New-onset hypertension occurs in approximately 10% of patients on stimulant therapy 6
• Patients developing cardiac symptoms require immediate cardiac evaluation including EKG and possible echocardiogram 1