Blood Pressure, Heart Rate, and CNS Stimulant Medication Use in Children with and without ADHD: Analysis of NHANES Data

Abstract

It is estimated that 2–3% of children in the US have hypertension (HTN) and 8% of children ages 4–17 carry the diagnosis of attention-deficit hyperactivity disorder (ADHD). The prevalence of HTN and cardiovascular (CV) risk factors in children with ADHD on CNS stimulant treatment (stimulants) compared to no treatment and compared to their healthy counterparts is not well described. Using National Health and Nutrition Survey data, we examined demographic, blood pressure (BP) and CV risk factors of 4,907 children aged 12–18 years with and without the diagnosis of ADHD, and further examined the CV risk in a subgroup of ADHD patients on stimulants. Three hundred eighty-three (10.7%) children were reported to have ADHD, of whom 111 (3.4%) were on stimulants. Children with ADHD on stimulants were significantly younger, male, and white compared to those with ADHD not on medication and those without ADHD. Body mass index (BMI), eGFR, cholesterol, the prevalence of albuminuria, and poverty were not significantly different between the three groups. One hundred sixty (2.7%) had BP in the hypertensive and 637 (12.4%) in the pre-hypertensive range. The prevalence of elevated BP (HTN and/or pre-HTN range) was not different between children with ADHD on stimulants compared to ADHD without medication and those without ADHD. Heart rate (HR) was significantly higher in the ADHD group on stimulants vs. the groups ADHD on no stimulants and without ADHD. When the relationship between stimulants and the risk of abnormal BP was examined, there was a significant interaction between having BP in the HTN range and sex. After adjusting for BMI, race, and age, females with ADHD on stimulants tended to be older and had significantly more BP in the hypertensive range. On the other hand, males were more likely to be of a white race and older, but not hypertensive. Children with ADHD on stimulants have significantly higher HR than children with ADHD on no stimulants and children without ADHD. On the other hand, the prevalence of abnormal BP classification is comparable between the three groups.

Interventions for Attention-Deficit Hyperactivity Disorder: A Year in Review

“…Despite the ubiquitous use of stimulant drugs to treat ADHD, there is concern for associated adverse events. Several recent studies [9,10] have suggested an increased risk of experiencing a later cardiovascular event when taking stimulants in childhood and children with ADHD on stimulants have significantly higher heart rates than children with ADHD not taking stimulants or children without ADHD [9]. There is also evidence that long-term stimulant use may impact the growth trajectories of children.…”

New Formulations of Stimulants: An Update for Clinicians

“…As noted before, both isomers nonselectively release monoamines into the synaptic cleft. While d-AMP has a fourfold greater impact on dopamine than l-AMP, this needs to be put in context as a relative assessment because both isomers can increase striatal dopamine by greater than 5000% of the baseline value (Heal et al 2013). In a similar vein, l-AMP has a comparable or greater impact on norepinephrine when compared to d-AMP, but both isomers have a very potent effect (Heal et al 2013;Markowitz and Patrick 2017).…”

“…While d-AMP has a fourfold greater impact on dopamine than l-AMP, this needs to be put in context as a relative assessment because both isomers can increase striatal dopamine by greater than 5000% of the baseline value (Heal et al 2013). In a similar vein, l-AMP has a comparable or greater impact on norepinephrine when compared to d-AMP, but both isomers have a very potent effect (Heal et al 2013;Markowitz and Patrick 2017). This must be interpreted in the context of nonracemic mixtures of AMP isomers in which d-AMP predominates (e.g., mixed AMP salt formulations) (Markowitz and Patrick 2017).…”

“…Mild changes in pulse and blood pressure also can occur and warrant monitoring during initiation of treatment and periods of dose adjustment (Graham et al 2011;Pediatrics 2011;Feldman et al 2018). While routine ECG screening is not indicated, patients with either a family or personal history of cardiovascular risk should undergo ECG testing or cardiology consultation before starting stimulants (Bélanger et al 2009;Cooper et al 2011;Hailpern et al 2014). Comorbid tics are not a contraindication to use, but tics should be monitored (Cohen et al 2015).…”

The Association between Low Blood Pressure and Attention-Deficit Hyperactivity Disorder (ADHD) Observed in Children/Adolescents Does Not Persist into Young Adulthood. A Population-Based Ten-Year Follow-Up Study

“…When children with ADHD are treated with stimulants, they often show an increase of their usually low BP concurrently with symptom improvement [ 51 , 52 , 53 , 54 ]. This clinical observation and additional findings from diurnal heart rate, cortisol level and sleep stages suggest a dysregulation of the autonomic nervous system in children with ADHD and leads to the subcortical (low) arousal hypothesis.…”