What is the appropriate management for a patient on Adderall (amphetamine/dextroamphetamine) 20 mg three times daily who reports intermittent chest pain?

Immediate Discontinuation of Adderall and Cardiac Evaluation Required

This patient requires immediate discontinuation of Adderall and urgent cardiac evaluation with ECG and troponin, as amphetamines cause myocardial ischemia through coronary vasoconstriction, increased oxygen demand, and can produce infarction even without obstructive coronary disease. 1

Critical Safety Concern: Excessive Dosing

• This patient is taking 60 mg/day total (20 mg three times daily), which is at the maximum approved dose, but the three-times-daily dosing is highly unusual and creates sustained sympathomimetic stress throughout the day 2
• Amphetamines consistently increase systolic blood pressure by 1.93 mmHg and diastolic by 1.84 mmHg, with heart rate increases of 3.71 beats per minute—effects that are sustained with chronic use 3
• The intermittent chest pain is a red flag for amphetamine-induced myocardial ischemia and warrants immediate medication cessation 1

Immediate Diagnostic Workup

• Obtain 12-lead ECG immediately to assess for ST-segment changes, ischemia, or arrhythmias, as up to 70% of amphetamine users have ECG abnormalities 1
• Measure cardiac troponin T or I at presentation and repeat at 6-12 hours to rule out myocardial infarction 1
• Check vital signs focusing on blood pressure and heart rate, as amphetamines create a hyperadrenergic state through catecholamine accumulation 1
• Consider echocardiogram to assess for left ventricular dysfunction or cardiomyopathy, as prolonged amphetamine use can cause structural cardiac abnormalities 4

Pathophysiology of Amphetamine-Induced Chest Pain

• Amphetamines block neuronal reuptake of norepinephrine and dopamine, creating dramatic increases in heart rate and blood pressure 1
• This produces coronary vasoconstriction while simultaneously increasing myocardial oxygen demand—a dangerous supply-demand mismatch 1
• Myocardial ischemia and infarction can occur even in the absence of obstructive coronary artery disease through direct vasospasm 1
• Additional mechanisms include increased platelet aggregability, endothelial dysfunction, and direct myocardial toxicity 1

Risk Stratification Based on Presentation

If the patient has ongoing chest pain at presentation:

• Transfer immediately to acute care setting for evaluation of acute coronary syndrome 1
• Administer sublingual nitroglycerin as first-line antianginal therapy 5
• Consider calcium channel blocker (e.g., diltiazem 20 mg IV) if no response to nitrates 5
• Do NOT use beta-blockers, as they may worsen vasospasm through unopposed alpha-adrenergic stimulation 5

If chest pain is currently resolved but intermittent:

• Still requires urgent evaluation with ECG and troponin to rule out recent ischemic events 1
• Discontinue Adderall immediately and do not restart until cardiac evaluation is complete 1
• Perform stress imaging or coronary CT angiography if initial workup is negative but suspicion remains 1

Management Algorithm

1. Stop Adderall immediately 1
2. Obtain 12-lead ECG and troponin 1
3. If positive for ischemia: Treat as acute coronary syndrome with nitrates and calcium channel blockers (avoid beta-blockers), proceed to coronary angiography if high-risk features present 1, 5
4. If initial workup negative: Repeat troponin at 6-12 hours, perform stress imaging or CCTA for risk stratification 1
5. Do not restart amphetamines if any evidence of cardiac ischemia or structural disease is found 1, 4

Alternative ADHD Management

• If ADHD treatment is still needed after cardiac clearance, consider non-stimulant options such as atomoxetine, which has a much safer cardiovascular profile 6
• Atomoxetine overdose produces only mild effects (drowsiness, agitation, tachycardia) compared to amphetamines 6
• Guanfacine or clonidine are additional non-stimulant alternatives, though they have their own cardiovascular effects (primarily hypotension/bradycardia rather than ischemia) 6

Critical Pitfall to Avoid

The most dangerous error would be continuing Adderall while "monitoring" the chest pain. Amphetamine-induced myocardial ischemia can progress to infarction, and the frequency of acute coronary syndrome in stimulant users presenting with chest pain approaches 10%, though death remains rare with appropriate management 1. The risk-benefit ratio clearly favors immediate discontinuation given the availability of safer ADHD treatment alternatives 6.