Grade C recommendation: Lacking direct evidence

The American Heart Association (AHA) suggests a screening ECG before starting stimulant medications in children with attention-deficit hyperactivity disorder (ADHD). A rare association of sudden cardiac death with stimulant drugs is presumed to occur in predisposed patients. Stimulant-drug monographs generally state that the drug should not be used in children with serious cardiac problems. Screening considerations to identify heart disease include patient and family history, physical exam, and baseline ECG (repeated after age 12 years if a baseline ECG was conducted prior to age 12 years). The patient history should include questions about history of fainting or dizziness, seizures, rheumatic fever, chest pain or shortness of breath with exercise, unexplained change in exercise tolerance, palpitations, increased heart rate, extra or skipped heartbeats, high BP, heart murmur (other than innocent or functional murmur) or history of other heart problems, intercurrent viral illness with chest pains or palpitations, and current medications and health supplements. Physical exam should include evaluation for abnormal heart murmur, hypertension, arrhythmia, tachycardia, and physical findings suggestive of Marfan’s syndrome. It is reasonable to check history, physical examination, and ECG for children already taking stimulants (Circulation. 2008;117:2407-2423).