AHA Statement on Stimulant Medications in Children Affects Clinical Practice in Texas

Community pediatricians’ clinical practice has been affected after the American Heart Association (AHA) issued a scientific statement suggesting that universal electrocardiographic (ECG) screening should be done for children who are prescribed stimulant medications to treat attention-deficit/hyperactivity disorder (ADHD), according to the findings of a new study. The results of the single-center retrospective evaluation were recently published in the Archives of Pediatrics & Adolescent Medicine [2011;165(2):166-170]. In recent years, there has been some concern and controversy about whether it is safe to use stimulant medications to treat children with ADHD. According to the study’s authors, there have been 28 sudden deaths in children treated with methylphenidate hydrochloride or amphetamines between January 1992 and February 2005. Because of this concern, in 2008 the AHA issued a scientific statement suggesting universal ECG screening for patients who are prescribed stimulant medication for ADHD. In this retrospective analysis, researchers assessed the impact of this statement on Texas community pediatricians who use the Texas Children’s Hospital by comparing the ECG ordering practices of pediatricians for the year before and the year after the statement was released. Researchers reviewed the ECG orders at the hospital from community pediatricians for stimulant medication screening to assess the number of screenings, the rate of abnormal ECG findings among those screened, and the estimated cost of the screenings. Children who had a known preexisting cardiac disease or an arrhythmia were excluded from the analysis. Researchers also sent a single-question electronic survey to community pediatricians in the Houston area who refer ECGs to the hospital to determine whether physicians believe they have changed their clinical practice in response to the statement. The main outcome measures of the study were abnormal ECG findings, further work-up, and change in clinical practice. Researchers found that in the year following the AHA statement there was a significant increase in the number of ECGs pediatricians ordered each month. The mean (SD) number of ECGs per month went from 6.9 (3.2) the year before the statement was released to 31.2 (9.5) ECGs per month in the year after the statement was issued. Of the 372 ECGs that were ordered after the 2008 AHA statement, researchers reported that 24 ECGs, or 6.4%, had abnormal findings. At the last follow-up, none of the patients with abnormal findings were found to have definitive cardiac disease and no one was restricted from taking stimulant medication. However, researchers found that the ECG and following work-up delayed ADHD therapy in 25% of the cases with abnormal findings. As part of the study cost evaluation, the study’s authors also reported that the average (SD) reimbursed cost for an abnormal ECG work-up—excluding the cost of the initial ECG screening—was $1870 ($907). While the data showed a clear increase in the mean ECG per month after the AHA statement was released, the majority (65.3%) of community pediatricians from the Houston area who responded to the electronic survey believed their clinical practice had not changed. However, 34.6% of pediatricians said the statement had changed their clinical practice and 23% said they now universally perform ECG screening on all children before prescribing stimulant medication. Researchers found that those clinicians who changed their clinical practice were more likely to be closer to training (P=.008). In conclusion, the authors said that more research is needed to assess the overall impact of the AHA statement; however, in this study, there was a significant increase in mean ECGs per month following the 2008 statement. Researchers acknowledged several study limitations, including that it was a single-center regional study; there were a relatively small number of abnormal ECG findings, which limited the statistical power and predictive value of the results; some patients with abnormal findings were still waiting to undergo follow-up; and the pediatrician survey was self-selective.—Jill Sederstrom