Stimulants, including methylphenidate and amphetamine salts, are considered the first-line treatment in most cases of attention-deficit/hyperactivity disorder (ADHD). The diagnosis of ADHD and the use of stimulants in both youth and adults have risen over recent decades. Approximately 6.1 million children and adolescents in the United States are currently on stimulants. Both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry recommend the use of FDA-approved medications for ADHD, including stimulants, as part of ADHD treatment. However, as with any medication, providers must weigh the benefits of stimulants against the risks, including the cardiovascular risks, associated with their use.
Stimulants work by increasing the levels of norepinephrine and dopamine in the frontal cortex. They also stimulate adrenergic receptors in the heart and blood vessels, leading to small increases in resting heart rate and blood pressure—on average, an increase of <10 beats per minute for heart rate and <5 mm Hg for both systolic and diastolic blood pressure. A minority (5-15%) of patients experience larger increases. The existing evidence on long-term cardiovascular risks of stimulants is mixed. Some studies have shown no increased risk, while others have cited an increased risk for arrhythmias, cerebrovascular disease, hypertension, ischemic heart disease, heart failure, pulmonary hypertension, and/or sudden cardiac death. Overall, existing studies are of limited quality and relatively short duration.
A 2024 case-control study by Zhang et al. examined the long-term (up to 14 years) cardiovascular effects of stimulants in 278, 027 individuals aged 6–64 years in Sweden. The results suggested that long-term use of ADHD medications was associated with an increased risk of hypertension and arterial disease. Each additional year of medication use was associated with an average of 4% increased risk of cardiovascular disease. The increase in risk was highest during the first three years of treatment and thereafter stabilized. Reassuringly, the study did not observe any statistically significant increases in the risk for arrhythmias, heart failure, ischemic heart disease, thromboembolic disease, or cerebrovascular disease.
When determining whether a stimulant is the right course of action for a particular patient with ADHD, providers must balance the potential benefits against these risks. Proper treatment of ADHD can improve educational, occupational, and social outcomes. Additionally, stimulants are associated with a decrease in unintentional physical injuries and deaths, substance use disorders, and criminal acts. These medications are highly effective, with response rates of 65-75% and an effect size of 1.0. Therefore, in a generally healthy child or adolescent without cardiac risk factors, stimulant medication should still be considered the first-line treatment for ADHD, and no routine cardiac evaluation is necessary. Consultation with cardiology may be warranted prior to stimulant initiation in cases of complex congenital heart disease or symptoms suggesting significant cardiovascular issues, such as severe palpitations, fainting, exercise intolerance (not accounted for by obesity), or a strong family history of sudden death.
To improve the cardiovascular safety of stimulant use, providers should have an extensive discussion with patients and parents about the risks, including cardiovascular risks, benefits, and alternatives of the medication. Screening each child for factors that increase cardiovascular risk, including personal and family cardiovascular history, is essential. Additionally, monitoring pulse and blood pressure at baseline and regularly throughout treatment is recommended. Psychopharmacology should be just one part of a comprehensive treatment plan, which may also include psychoeducation, behavioral therapy, lifestyle modifications including diet and exercise, linkage with community supports, and school resources. If stimulants are not an option, providers can explore alternative treatment options, such as nonstimulant medications (though selective norepinephrine receptor inhibitors and alpha 2 agonists also have cardiovascular risks to consider) or behavioral therapy without medications. Omega-3 fatty acids, video game treatment (e.g., Endeavor Rx), trigeminal nerve stimulation, or biofeedback also have some evidence for the treatment of ADHD.
References
Cortese S, Fava C. Long-term cardiovascular effects of medications for attention-deficit/hyperactivity disorder-Balancing benefits and risks of treatment. JAMA Psychiatry. 2024;81(2):123–24. https://doi.org/10.1001/jamapsychiatry.2023.4126
Dopheide JA, Stutzman DL. Five steps to improve cardiac safety of attention deficit hyperactivity disorder treatment. The Journal of Pediatric Pharmacology and Therapeutics. 2024;29.6:670-673.
Pliszka S. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2007;46(7):894-921.
Torres-Acosta N, O’Keefe J, O’Keefe C. et al. Cardiovascular effects of ADHD therapies: JACC review topic of the week. JACC. 2020;76(7): 858–866. https://doi.org/10.1016/j.jacc.2020.05.081
Wolraich, Mark L., et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2019;144(4).
Zhang L, Li L, Andell P, et al. Attention-deficit/hyperactivity disorder medications and long-term risk of cardiovascular diseases. JAMA Psychiatry. 2024;81(2):178–187. doi:10.1001/jamapsychiatry.2023.4294
AUTHOR:
Dr. Kristen Kim, MD
Child, Adolescent and Adult Psychiatrist
Vista Hill Foundation