What are the recommended psychotropic medications for treating Attention Deficit Hyperactivity Disorder (ADHD) in patients status post Coronary Artery Bypass Graft (CABG)?

ADHD Treatment in Post-CABG Patients

Atomoxetine is the preferred psychotropic for ADHD treatment in post-CABG patients, but only after complete surgical recovery (3-6 months) and cardiovascular stabilization, with cardiology consultation required before initiation. 1

Immediate Post-Operative Period (0-3 months)

• Avoid initiating any ADHD medications during the immediate post-operative period and focus exclusively on optimizing guideline-directed medical therapy including beta blockers, statins, ACE inhibitors/ARBs, and antiplatelet agents 1
• Beta blockers must be reinstituted as soon as possible after CABG in all patients without contraindications (Class I recommendation) 2, 3
• Aspirin should be initiated within 6 hours postoperatively 3
• Statins must never be discontinued perioperatively (Class III: HARM to stop) 3
• ACE inhibitors or ARBs should be reinstituted once the patient is stable 3

Delayed Initiation (3-6 months post-CABG)

First-Line: Atomoxetine (Non-Stimulant)

Atomoxetine is the safest option for post-CABG patients because it causes small increases in heart rate and blood pressure that are generally minor, time-limited, and of minor clinical significance, unlike stimulants. 4

• Consider atomoxetine only after complete surgical recovery and cardiovascular stabilization (3-6 months post-CABG) 1
• Ensure the patient is on optimized beta blocker therapy before initiation, as beta blockers provide some protection against atomoxetine's cardiovascular effects 1
• Obtain cardiology consultation before initiation in this high-risk population 1
• Atomoxetine does not cause statistically or clinically significant increases in QTc interval 4
• The risk for serious cardiovascular adverse events and sudden cardiac death with atomoxetine is extremely low 4

Absolute Contraindications to Atomoxetine

• Recent perioperative complications including myocardial infarction or heart failure 1
• Left ventricular ejection fraction <30% 1
• Patients who cannot tolerate beta blockers 1

Stimulants: Generally Avoided

Stimulant medications (methylphenidate and amphetamine derivatives) should generally not be used or used only with extreme caution in adults with pre-existing cardiovascular conditions. 5

• Stimulants increase heart rate by 3-10 beats/min, systolic blood pressure by 3-8 mm Hg, and diastolic blood pressure by 2-14 mm Hg 6
• Stimulants may delay ventricular repolarization 6
• Pre-existing cardiovascular conditions reduce the likelihood of stimulant therapy initiation in younger adult ADHD patients 5
• If stimulants are considered, great caution is advised in patients with a personal or family history or other known risk factors for cardiovascular disease 4

Monitoring Requirements

• Continuous ECG monitoring must be performed for at least 48 hours after CABG to detect arrhythmias 3
• Maintain mean arterial pressure greater than 60 mm Hg, particularly in patients with preexisting renal dysfunction 3
• Monitor heart rate and blood pressure closely if atomoxetine is initiated 4, 6

Key Clinical Pitfall

The most common error is initiating ADHD medications too early in the post-operative period before cardiovascular stabilization is complete. Wait at least 3-6 months post-CABG and ensure all guideline-directed cardiac medications are optimized first 1. The benefits of treating ADHD must be weighed against the cardiovascular risks in this high-risk population, and cardiology consultation is mandatory 1.