ECG Screening Before Prescribing ADHD Medications

Risk-Based Approach to Cardiac Screening

The American Academy of Pediatrics recommends obtaining a thorough cardiac history and physical examination before starting ADHD medications, and reserving ECG for those with identified cardiac risk factors 1
A personal cardiac history should be obtained, specifically asking about syncope or near-syncope, chest pain or palpitations, exercise intolerance or unexplained shortness of breath, and history of cardiac surgery or known heart disease 1
A family history should be obtained, specifically screening for sudden unexplained death before age 50, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, long QT syndrome, and other inherited arrhythmia syndromes 1

Stimulant medications cause mild, clinically insignificant increases in heart rate and blood pressure on average, and do not cause clinically significant QT prolongation 1, 2
The risk of sudden cardiac death with stimulant medications is extremely rare and not increased compared to non-medicated children 1
Non-stimulant medications have a similar cardiovascular risk profile to stimulants, with atomoxetine increasing heart rate and blood pressure, and guanfacine and clonidine decreasing heart rate and blood pressure 1

The American Academy of Pediatrics recommends monitoring vital signs regularly, including heart rate and blood pressure, at follow-up visits, and reassessing cardiac symptoms at each visit 1
5-15% of patients may experience clinically significant increases in heart rate or blood pressure requiring intervention 1
If new cardiac symptoms develop, an ECG should be obtained and a cardiology referral considered 1