Choosing Wisely:

Don’t order a screening ECG prior to initiation of attention-deficit/hyperactivity disorder therapy in asymptomatic, otherwise healthy pediatric patients with no personal or family history of cardiac disease.

Rationale and Comments: Many pediatricians obtain ECGs in healthy patients with no personal or family history* of cardiac disease prior to initiating stimulant therapy for attention-deficit/hyperactivity disorder out of fear of triggering an adverse cardiovascular event or worsening a previously undiagnosed cardiovascular disease. However, the probability that such screening will lead to the diagnosis of cardiac disease is low. Furthermore, when ECG abnormalities are identified, they rarely warrant a change in planned attention-deficit/hyperactivity disorder therapy. As a result, obtaining the ECG increases health care costs and can increase stress for both the patient and family. If there is concern based on the history and physical examination, then a pediatric cardiology referral is a reasonable consideration. (*Family history should assess specifically for the following types of cardiovascular diseases: connective tissue disorders; cardiomyopathies; arrhythmias, including need for pacemaker or defibrillator implantation; storage diseases; sudden unexplained death; premature cardiovascular disease prior to the age of 50 years.)
Sponsoring Organizations:
  • American Academy of Pediatrics – Section on Cardiology and Cardiac Surgery
  • Sources:
  • American Academy of Pediatrics guidelines
  • Disciplines:
  • Cardiovascular
  • Pediatric
  • References: • Cooper WO, et al. ADHD drugs and serious cardiovascular events in children and young adults. N Engl J Med. 2011;365(20):1896-1904.
    • Mahle WT, et al. Electrocardiographic screening in children with attention-deficit hyperactivity disorder. Am J Cardiol. 2009;104(9):1296-1299.
    • Perrin JM, et al.; American Academy of Pediatrics, Black Box Working Group, Section on Cardiology and Cardiac Surgery. Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics. 2008;122(2):451-453.
    • Shahani SA, et al. Attention deficit hyperactivity disorder screening electrocardiograms: a community-based perspective. Pediatr Cardiol. 2014;35(3):485-489.
    • American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022.

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