EKGs for ADHD

[OldPsychDoc]

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So the American Heart Assn has handed down the edict that all kids starting stimulants should get an EKG. They admit the risk is small, the article notes 19 sudden deaths and 26 "events" in kids on stimulants between 1999-2004, despite MILLIONS of kids taking stimulants. In another article on this, the comment was made that there are many more sudden cardiac deaths due to sports participation, but the pediatrics academy chose not to require EKGs to screen for this. The spokesperson for the AHA said ""It won't pick up every one. There will be some false positives. But it's a relatively inexpensive and simple test* that doesn't hurt the children in any way and it will let us identify some of these children and know that they have heart conditions."

(*I think she missed the lecture I had in med school about tests to screen for uncommon conditions. So say we do a $50 EKG on 10 million kids...and we still don't "pick up every one". Plus we will pull up thousands of incidentally abnormal EKGs that will require echoes and further follow-up testing--by cardiologists, saith the cynic in me...)

In the very next paragraph she says:
"We particularly don't want to scare people or to alarm them". 🙄

What do you all think--should this be the standard of care now? Are we just playing with a lawsuit if we don't send every ADHD kid we see to get an EKG? What's next?

 

[Faebinder]

I mean what do you expect from a heart association? It's almost like asking the mental health association if they think the mini mental exam should be done on everyone above 50.

This is garbage. It's almost like recommending a chest xray for everyone that walks in with a cough.

Tell you what.... we can ask the patient's parent if they are willing to pay $50 out of pocket for the EKG.... see their reaction.

 

[Anasazi23]

Again, more non-medicine commandments coming down from the mount from non-medical Moses.

This goes against every epidemiology class anyone's ever taken, and will cost the taxpayers hundreds of millions/year in another wasted medical procedure.

On the upside, psychiatrists can incorporate it into their outpatient billing if you wanted to make the best of it.

 

[Hurricane]

Just from reading that article, it sounds ridiculous, given their admitted lack of evidence of anything. They use the word "might" an awful lot.

But before concluding the AHA is made of *****s based on a yahoo article... perhaps the AHA produced a document somewhere that has actual data and scientific rationale in it?

 

[Chrismander]

Again, more non-medicine commandments coming down from the mount from non-medical Moses.

This goes against every epidemiology class anyone's ever taken, and will cost the taxpayers hundreds of millions/year in another wasted medical procedure.

On the upside, psychiatrists can incorporate it into their outpatient billing if you wanted to make the best of it.

Can we bill for EKGs we do in our office? Does insurance give a hard time because we're shrinks--i.e., do we end up having to preauthorize it and explain the necessity and clinical rationale while playing phone tag for 3 hours with some GED in a call center in Georgia? Is there a separate charge for interpreting it?

 

[Faebinder]

Can we bill for EKGs we do in our office? Does insurance give a hard time because we're shrinks--i.e., do we end up having to preauthorize it and explain the necessity and clinical rationale while playing phone tag for 3 hours with some GED in a call center in Georgia? Is there a separate charge for interpreting it?

You certainly can bill for it... and will get paid in some cases. But are you going to buy and maintain a machine for that? Waste of your patients money, your time, and the nurse time. How many 1st time ADHD patients do you expect to see?

 

[PeeWee137]

Tell you what.... we can ask the patient's parent if they are willing to pay $50 out of pocket for the EKG.... see their reaction.

i think ALOT of parents would pay the 50 bucks for an EKG, without a second thought. especially now that this is all over the news. and that is the problem. scare-mongering works, unfortunately.

 

[billypilgrim37]

To play Evil Psychiatrist for a moment, this could be a major boon for psychiatry as a medical specialty. It could also act to demystify some of the side effects for parents--I'm sure it would reassuring (even if falsely so) to know that the doctors "know what they're doing" before they put my kid on "that dangerous medication."

Besides, we already get EKGs before we put kids on QT-prolonging meds, right? We've got some attendings around here who LOVE giving kids thorazine with their Geodon.

I'm with Hurricane; let's wait till we see some data here. This might be entirely ridiculous, but maybe not. I don't know about your health systems, but EKGs aren't too expensive or that difficult to obtain around here. They're cheaper than a month supply of Concerta, at least.

And besides, how many kids present to a child psychiatrist having never been given a stimulant before by a pediatrician, who would have already had to screen with an EKG before starting the medications?

I'd appreciate it if crack dealers had to get EKGs before selling. That would only be fair.

 

[Faebinder]

To play Evil Psychiatrist for a moment, this could be a major boon for psychiatry as a medical specialty. It could also act to demystify some of the side effects for parents--I'm sure it would reassuring (even if falsely so) to know that the doctors "know what they're doing" before they put my kid on "that dangerous medication."

Besides, we already get EKGs before we put kids on QT-prolonging meds, right? We've got some attendings around here who LOVE giving kids thorazine with their Geodon.

I'm with Hurricane; let's wait till we see some data here. This might be entirely ridiculous, but maybe not. I don't know about your health systems, but EKGs aren't too expensive or that difficult to obtain around here. They're cheaper than a month supply of Concerta, at least.

And besides, how many kids present to a child psychiatrist having never been given a stimulant before by a pediatrician, who would have already had to screen with an EKG before starting the medications?

I'd appreciate it if crack dealers had to get EKGs before selling. That would only be fair.

😆

 

[PeeWee137]

FYI, the AACAP put out a statement :

[FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Arial,Helvetica,sans-serif]American Heart Association Advisory: All Children Receiving Ritalin Should Be Given ECG First...​

[FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Arial,Helvetica,sans-serif]Yesterday, the American Heart Association (AHA) released an advisory stating that, "all children with attention-deficit/hyperactivity disorder (ADHD) should get a careful cardiac evaluation and monitoring - including an electrocardiogram (ECG) - before starting treatment with stimulant drugs." ...
[FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Arial,Helvetica,sans-serif]The AACAP is seeking information from the AHA on the scientific basis of its statement. Our ADHD research specialists will then interpret the data and will make recommendations on clinical practice to our membership, via AACAP all member e-mail. We will work with our colleagues at CHADD and the AAP to update both clinicians and consumers.
The AHA advisory is not consistent with the FDA assessment or with the AACAP's Practice Parameter on the Assessment and Treatment of Children and Adolescents With Attention-Deficit Hyperactivity Disorder.. ..[FONT=Verdana,Geneva,Arial,Helvetica,sans-serif].
[FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Verdana,Geneva,Arial,Helvetica,sans-serif][FONT=Arial,Helvetica,sans-serif]The AACAP encourages parents to talk with their children's physicians and review all aspects of their children's medical histories and any family histories of heart problems and decide, with their physicians, what, if any additional evaluations should be made....

 

[kstotes]

Can we have a short discussion about the reality of this situation-- how many kids with fulminate ADHD are going to lie down for an EKG... and how many physicians are going to wait until said kids are still enough to avoid any movement artifact. Mind you these kids are not being treated at this point so they are at their zenith of annoyingness. Who knows maybe we can get "inability to sit still during EKG" added into diagnostic criteria for the DSM-V. Finally an objective diagnostic test in psychiatry!!!
I see it all going down something like this:

Doc: Ma'am according to this EKG your son has ADHD.

Mom: Oh my, how can you tell.

Doc: Well look here, see this, either your kid has Wolff-Parkinson-White or he wouldn't sit f-ing still for 10 seconds.

Mom: Oh dear, now he just got his immunizations last week, could that have caused this?

Doc: Get out of my office now... no seriously leave. No, no leave the child, it's better this way, trust me... I may still be able to save him.

Mom: But, but...

Doc: Ma'am, in my right hand I have a a syringe containing 10ml of shut-the-hell-up, in the other I have a 302 sheet... if you have aspirations to hold a job in the future I would leave now.

 

[BabyPsychDoc]

Can we have a short discussion about the reality of this situation-- how many kids with fulminate ADHD are going to lie down for an EKG... and how many physicians are going to wait until said kids are still enough to avoid any movement artifact. Mind you these kids are not being treated at this point so they are at their zenith of annoyingness. Who knows maybe we can get "inability to sit still during EKG" added into diagnostic criteria for the DSM-V. Finally an objective diagnostic test in psychiatry!!!
I see it all going down something like this:

Doc: Ma'am according to this EKG your son has ADHD.

Mom: Oh my, how can you tell.

Doc: Well look here, see this, either your kid has Wolff-Parkinson-White or he wouldn't sit f-ing still for 10 seconds.

Mom: Oh dear, now he just got his immunizations last week, could that have caused this?

Doc: Get out of my office now... no seriously leave. No, no leave the child, it's better this way, trust me... I may still be able to save him.

Mom: But, but...

Doc: Ma'am, in my right hand I have a a syringe containing 10ml of shut-the-hell-up, in the other I have a 302 sheet... if you have aspirations to hold a job in the future I would leave now.

This is brilliant, I love it!

 

[Anasazi23]

From the Wall St. Journal:
http://blogs.wsj.com/health/2008/05...t-cardiac-testing-for-adhd-drugs/?mod=WSJBlog

in a nutshell, there are 0.2-0.5 sudden deaths per 100,000 patient years.

Sudden death from the children <18 years old is higher, at 1.3-8.5 per 100,000 patient years.

Again, this flies in the face of all epidemiological science and cost-effectiveness.

 

[marie337]

I think it's interesting that the recommendations are to have the EKG read by an expert in pediatric EKGs. This, is of course, likely to provide more work for the cardiologists. Also, the AHA article even states that they don't know if the risk is actually any higher with stimulants or whether the new guidelines would even lower the risk. So, what are they basing everything on? I think it may be a conspiracy 🙄.