Cardiac Screening Prior to Stimulant Treatment of ADHD: A Survey of US-Based Pediatricians

Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
PEDIATRICS (Impact Factor: 5.47). 02/2012; 129(2):222-30. DOI: 10.1542/peds.2011-1574
Source: PubMed


To determine pediatricians' attitudes, barriers, and practices regarding cardiac screening before initiating treatment with stimulants for attention-deficit/hyperactivity disorder.
A survey of 1600 randomly selected, practicing US pediatricians with American Academy of Pediatrics membership was conducted. Multivariate models were created for 3 screening practices: (1) performing an in-depth cardiac history and physical (H & P) examination, (2) discussing potential stimulant-related cardiac risks, and (3) ordering an electrocardiogram (ECG).
Of 817 respondents (51%), 525 (64%) met eligibility criteria. Regarding attitudes, pediatricians agreed that both the risk for sudden cardiac death (SCD) (24%) and legal liability (30%) were sufficiently high to warrant cardiac assessment; 75% agreed that physicians were responsible for informing families about SCD risk. When identifying cardiac disorders, few (18%) recognized performing an in-depth cardiac H & P as a barrier; in contrast, 71% recognized interpreting a pediatric ECG as a barrier. When asked about cardiac screening practices before initiating stimulant treatment for a recent patient, 93% completed a routine H & P, 48% completed an in-depth cardiac H & P, and 15% ordered an ECG. Almost half (46%) reported discussing stimulant-related cardiac risks. Multivariate modeling indicated that ≥1 of these screening practices were associated with physicians' attitudes about SCD risk, legal liability, their responsibility to inform about risk, their ability to perform an in-depth cardiac H & P, and family concerns about risk.
Variable pediatrician attitudes and cardiac screening practices reflect the limited evidence base and conflicting guidelines regarding cardiac screening. Barriers to identifying cardiac disorders influence practice.

Download full-text


Available from: Susan K Parsons, May 09, 2014
  • Source
    • "This concurs with another recent recommendation from North America (Hammerness et al., 2011). We note that according to a recent survey in the US, only 15% of paediatricians declared to ask systematically for an ECG before initiating psychostimulant treatment (Leslie et al., 2012). The EAGG points out that for ADHD patients without a known heart disease, the ADHD specialist is the appropriate individual to evaluate risk-benefit and make recommendations for pharmacological treatment. "
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well-tolerated, there are common, although less severe, as well as rare but severe adverse events AEs during treatment with ADHD drugs. The aim of this review is to provide evidence- and expert-based guidance concerning the management of (AEs) with medications for ADHD. METHODS: For ease of use by practitioners and clinicians, the article is organized in a simple question and answer format regarding the prevalence and management of the most common AEs. Answers were based on empirical evidence from studies (preferably meta-analyses or systematic reviews) retrieved in PubMed, Ovid, EMBASE and Web of Knowledge through 30 June 2012. When no empirical evidence was available, expert consensus of the members of the European ADHD Guidelines Group is provided. The evidence-level of the management recommendations was based on the SIGN grading system. RESULTS: The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviours and psychotic symptoms. CONCLUSION: Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment.
    Full-text · Article · Jan 2013 · Journal of Child Psychology and Psychiatry
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Objective: The purpose of this study was to determine psychiatrists' barriers, attitudes, and practices regarding cardiac screening prior to initiating stimulants in children with attention-deficit/hyperactivity disorder. Background: Professional and federal oversight organizations recently have debated the evidence regarding sudden cardiac death (SCD) risk with stimulants, and have published guidelines recommending cardiac screening. It is not known how psychiatrists have responded. Methods: This study was a cross-sectional survey of 1,600 randomly-selected U.S. members of the American Academy of Child and Adolescent Psychiatry. Analyses included descriptive statistics and logistic regression. Results: Response rate was 40%; 96% met eligibility criteria. Barriers to identifying cardiac disorders in general included ability to perform a routine physical examination (74%) and care coordination with primary care providers (35%). Only 27% agreed that SCD risk warranted cardiac assessment. Prior to starting a patient on stimulants, 95% of psychiatrists obtained a routine history. The majority either conducted (9%), or relied on primary care providers to conduct (67%) a physical examination; 26% did not obtain a physical examination. Nineteen percent of psychiatrists ordered an electrocardiogram (ECG), of those, non-mutually exclusive reasons for ordering an ECG included standard practice procedure (62%), clinical findings (27%), medicolegal considerations (25%), and guideline adherence (24%). On multivariate modeling, psychiatrists were less likely to conduct cardiac screening themselves if in private practice (referent: academic medical center), if >50% of their patients had private insurance, or if they believed their ability to perform a physical examination to be a barrier. When modeling cardiac screening performed by any healthcare professional (e.g., psychiatrist, primary care practitioner), screening was less likely if the psychiatrist was practicing in a community mental health center (referent: academic medical center), was male, or if >50% of that psychiatrist's patients had private insurance. Conclusion: Findings suggest the tacit interplay between primary care and psychiatry for the assessment and management of medical risks associated with psychotropic medications should be improved, and solutions prioritized.
    No preview · Article · Oct 2012 · Journal of child and adolescent psychopharmacology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: The objective of this study was to test whether physicians' attitudes regarding the impact of ADHD on health-related quality of life (HRQL) explain differences in practices for prescribing psychostimulants in children. Method: In a cross-sectional survey, U.S.-based pediatricians and psychiatrists ("physicians") used the Paper-Standard Gamble--a widely used preference-based assessment of HRQL--to rate four vignettes describing ADHD health states of varying severity. Associations between standard gamble scores and questions about prescribing practices were analyzed using ordinal logistic regression. Results: Surveys were mailed to 291 physicians; 127 (44%) returned complete forms. Lower standard gamble scores were associated with more emphasis on children's ADHD symptoms (p = .03) and less emphasis on parents' concerns about stimulant side effects (p = .03) when prescribing psychostimulants. Conclusion: Differences in physician perceptions of the severity of ADHD symptoms and in their emphasis on parental concerns about side effects may help explain variations in ADHD psychostimulant prescription patterns.
    No preview · Article · Nov 2012 · Journal of Attention Disorders
Show more