From the Guidelines
For individuals with congenital heart disease, I strongly recommend consulting with both a cardiologist and psychiatrist before starting any stimulant or non-stimulant medication, as safety depends on the specific heart defect and its severity. Generally, non-stimulants like atomoxetine (Strattera) at starting doses of 40mg daily (gradually increased if needed) may be safer than stimulants for attention disorders in these patients, as they have been shown to have fewer cardiovascular effects compared to stimulants 1. Guanfacine (Intuniv) at 1mg daily is another potentially safer option with less cardiovascular impact, and it has been approved as an adjunctive therapy to stimulant medications to decrease adverse effects such as sleep disturbances and cardiovascular effects 1. The concern with traditional stimulants (methylphenidate, amphetamines) is their potential to increase heart rate and blood pressure, which could be problematic for compromised cardiac function, although the risk of serious cardiovascular events is extremely low 1. Regular monitoring of vital signs, ECGs, and cardiac symptoms is essential regardless of medication choice, and the specific heart defect, surgical repairs, current cardiac function, and presence of arrhythmias will ultimately determine which medication offers the best safety profile for each individual patient. It is also important to consider the potential benefits of non-stimulants, such as their non-controlled status and "around-the-clock" effects, as well as their potential to improve functional impairment and quality of life 1. In addition, the 2018 AHA/ACC guideline for the management of adults with congenital heart disease emphasizes the importance of timely evaluation by ACHD and HF specialists to optimal care of patients with heart failure, which may be a concern for individuals with congenital heart disease taking stimulant or non-stimulant medications 1. Key considerations for medication choice include:
- The specific heart defect and its severity
- The presence of arrhythmias or other cardiac symptoms
- The potential for medication interactions or adverse effects
- The need for regular monitoring of vital signs and cardiac function
- The potential benefits of non-stimulants, such as improved functional impairment and quality of life.
From the Research
Recommendations for Stimulant and Non-Stimulant Medications
- For patients with congenital heart disease, stimulant medications can be considered for ADHD treatment when prescribed with appropriate monitoring and coordination with a cardiologist 2.
- Non-stimulant medications, such as atomoxetine, may be a useful option for patients with ADHD who are at risk of substance abuse or have co-morbid anxiety or tics 3.
- Atomoxetine has been shown to be effective and generally well-tolerated in children and adolescents with ADHD, with a negligible risk of abuse or misuse 3.
Cardiovascular Risks Associated with Stimulant Medications
- Currently available data suggest that there is no evidence for serious adverse cardiovascular complications in children with known cardiovascular diseases, including patients with congenital heart disease, who are treated with stimulant medications 4.
- Stimulant medication use in children with congenital heart disease was not associated with clinically significant changes in cardiovascular parameters compared with controls 2.
- However, it is recommended that patients with known cardiac disease or a history and physical examination suggestive of cardiac disease should have a consultation/evaluation with a pediatric cardiologist before starting stimulant medications 4.
Considerations for Patients with Congenital Heart Disease
- Children with congenital heart disease are at increased risk for attention-deficit/hyperactivity disorder (ADHD) 4, 5.
- The coordination of care between the primary care physician, the ADHD medication-prescribing physician, and the pediatric cardiologist may be important for patients with congenital heart disease and ADHD 4.
- Patients with congenital heart disease should be monitored closely for any changes in cardiovascular parameters or adverse events when taking stimulant medications 2.