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Stimulants and Cardiovascular Issues: What You Need to Know

By Lisa Fields

Stimulants and Cardiovascular Issues

Stimulant medications used to manage ADHD symptoms have been shown to increase heart rate and blood-pressure levels. Because of that, researchers have been studying the effects of these drugs to see whether they may cause serious cardiovascular events in children or adults.

The good news: A growing body of research shows that ADHD stimulant medications do not increase the risk of heart attack, stroke or sudden cardiac death in children, teens or adults.

Safety announcements from the U.S. Food and Drug Administration (FDA) say that it’s reasonable for children and adults with ADHD who don’t have serious heart problems to take ADHD stimulant medications. Those include amphetamine mixed salts (Adderall), methylphenidate (Ritalin, Concerta), dexmethylphenidate (Focalin) and lisdexamfetamine dimesylate (Vyvanse).

However, the FDA safety announcements say children and adults with ADHD should not take these medications if increases in heart rate or blood-pressure levels would cause health problems in those individuals.

Whenever the risk of cardiovascular symptoms is a concern, patients should seek guidance from healthcare providers, such as pediatricians, internists or cardiologists. Research has not linked ADHD stimulants to cardiovascular events, but the possibility of an adverse event still exists.

“It is important to separate the group result from the individual result,” says Dr. Jan Buitelaar, a psychiatrist at Radboud University Medical Center in the Netherlands and vice president of the World Federation of ADHD. “Very minor changes in blood pressure and heart rate may present in some individuals as clinically significant larger changes.”

Stimulant usage and cardiovascular effects in children and teens

A 2017 meta-analysis study published in the journal CNS Drugs looked at the health effects of stimulant and non-stimulant ADHD medications on 5,837 children and teens who took the medication for up to eight years.

Researchers showed that those who took methylphenidate experienced relatively small statistically significant increases in their systolic blood pressure. (Systolic blood pressure is the top number in your blood pressure reading; it’s a measure of the force the heart puts on the walls of your arteries when it beats.)

The study also showed that those who took amphetamine and atomoxetine (a non-stimulant) experienced relatively small statistically significant increases in their systolic blood pressure, as well as their diastolic blood pressure and heart rate. (Diastolic pressure is the bottom number of your blood pressure reading; it’s a measure of the force the heart puts on the walls of your arteries between beats.)

Fourteen of the 18 studies that were included in the meta-analysis screened out children and teens with cardiovascular issues, so the conclusions may not be relevant to such children. If your child or teen with ADHD has a heart condition, experts say you should seek healthcare providers whose area of expertise is ADHD and cardiology.

“In case of cardiovascular disease, the clinician treating ADHD should seek advice from a pediatric cardiologist or pediatrician,” says Buitelaar, who was one of the meta-analysis’s authors. “This would require a workup including electrocardiogram and careful cardiovascular history. In most cases, careful cardiovascular monitoring will allow (doctors) to prescribe ADHD medications.”

Methylphenidate — Ritalin is the most common brand name — may be the most prescribed ADHD medication for children and teens. In the 2017 meta-analysis, it had the fewest cardiovascular effects of the medications studied. For this reason, doctors should consider prescribing methylphenidate before other ADHD medications to children and adolescents with cardiovascular conditions, according to Buitelaar.

In 2023, Buitelaar published another study about methylphenidate in the journal The Lancet, comparing its use in children and teens with ADHD to peers who didn’t take ADHD medication and those who didn’t have ADHD. Of the 1,410 study participants, patients who took methylphenidate had higher levels of diastolic blood pressure, systolic blood pressure and heart rate, but no one in the study experienced any serious adverse events.

None of the children or teens in the 2017 study who took methylphenidate, amphetamine or atomoxetine experienced serious heart conditions, such as heart attack, stroke or sudden cardiac death. However, 12.6% reported cardiovascular adverse effects, including high blood pressure, a rapid heart rate and a slower-than-normal heart rate. More research is needed to determine if ADHD medication may be linked with serious cardiovascular events.

“For these potentially very rare and very severe complications, such as heart attack, stroke and death, one needs much larger epidemiological samples — 1 million participants or more — to draw conclusions,” Buitelaar says.

Stimulant usage and cardiovascular effects in adults

The number of adults who have been prescribed stimulants for ADHD has grown in recent years, according to data from the U.S. Centers for Disease Control and Prevention. During the first year of the pandemic, ADHD stimulant prescription usage among adults rose even more.

Before and since that rise in stimulant use, researchers have explored any possible connections between stimulant use for ADHD and cardiovascular issues. In general, that research has found that stimulants showed some association with elevated blood pressure and heart rates in adults. But the research has not shown any detectable increase in serious cardiovascular events in clinical trials. And meta-analyses of such studies have not shown an association between stimulant medications and serious cardiovascular events.

Experts say doctors should still monitor blood-pressure levels and heart health of adults and children who take stimulants for ADHD.

“It is the purpose of the monitoring to pick up (clinically significant changes),” Buitelaar says.

More questions about using stimulants with older adults

The benefits versus cardiovascular risks to older adults using stimulants with ADHD is less clear.

A 2021 study published in the Journal of the American Board of Family Medicine analyzed prescription amphetamine usage among ADHD patients aged 65 and older, to look for the incidence of cardiovascular events. The researchers compared that data to the incidence of cardiovascular events among ADHD patients aged 65 and older who did not take amphetamine. The study included more than 13,000 older adults.

Researchers found that older adults with ADHD who took prescription amphetamine had higher blood-pressure levels and increased odds of cardiovascular events than adults who didn’t take amphetamine. There were 191 adverse cardiovascular events among amphetamine users, compared to 45 events among adults who didn’t take amphetamine. (Within the study, adverse events included heart attack, stroke, congestive heart failure, arrhythmia and atrial fibrillation.)

More research is needed to determine whether amphetamine usage is safe among ADHD patients aged 65 and older, according to the study authors.

Older adults who have taken amphetamine for ADHD should ask a cardiologist to assess whether or not they should continue taking the medication after age 65.

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