Safety of stimulants after cardiac ablation

[annoyedpsychiatrist]

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Someone with prior episodes of SVT, cardiac ablation twice, no episodes since. MRI/Echo relatively normal. Do you guys still get worried about giving stimulants to these people? Or not as concerned given it was effectively treated with ablation?

 

[annoyedpsychiatrist]

no replies lol

 

[comp1]

I mean no, there's no studies that I'm aware of for this specifically. Stimulants in someone with ANY cardiac history is a very risky thing. Pretty much every other treatment option should be eliminated first and the person should still be quite severely impaired by their symptoms. Even then, you're going to want to document the heck out of it and let the patient know that they likely have a higher risk of sudden cardiac death while on these medications, potentially significantly, but that there haven't been studies on it in specific.

 

[clausewitz2]

I mean no, there's no studies that I'm aware of for this specifically. Stimulants in someone with ANY cardiac history is a very risky thing. Pretty much every other treatment option should be eliminated first and the person should still be quite severely impaired by their symptoms. Even then, you're going to want to document the heck out of it and let the patient know that they likely have a higher risk of sudden cardiac death while on these medications, potentially significantly, but that there haven't been studies on it in specific.

There actually have been studies on sudden cardiac death and stimulants, they don't find very impressive results:

ADHD medications and risk of serious cardiovascular events in young and middle-aged adults - PubMed

Among young and middle-aged adults, current or new use of ADHD medications, compared with nonuse or remote use, was not associated with an increased risk of serious cardiovascular events. Apparent protective associations likely represent healthy-user bias.

pubmed.ncbi.nlm.nih.gov

We are talking about an increase of 3-5 points SBP and 5 BPM on average.

Remember, atomoxetine actually poses just as much of a risk of adverse CV events as any stimulant.

What you are describing OP is hardly a strict contraindication.

 

[Stagg737]

Short answer is I'm more concerned about it than someone with no cardiac history, but much less concerned than someone who is actively having arrhythmias or significant tachycardia or HTN.

Long answer has a lot more variables. Have they previously been on ADHD meds? Which ones? How effective were they? How severe are symptoms at baseline? How is their general medical health? Ie, is this cardiac problem a lone issue or does this person have a plethora of medical issues? I could certainly see a situation where I'd prescribe this person stimulants, but I also see a lot where I wouldn't.

 

[Attending1985]

There actually have been studies on sudden cardiac death and stimulants, they don't find very impressive results:

ADHD medications and risk of serious cardiovascular events in young and middle-aged adults - PubMed

Among young and middle-aged adults, current or new use of ADHD medications, compared with nonuse or remote use, was not associated with an increased risk of serious cardiovascular events. Apparent protective associations likely represent healthy-user bias.

pubmed.ncbi.nlm.nih.gov

We are talking about an increase of 3-5 points SBP and 5 BPM on average.

Remember, atomoxetine actually poses just as much of a risk of adverse CV events as any stimulant.

What you are describing OP is hardly a strict contraindication.

More than elevated BP I see people often on stimulants with a resting pulse above 100. It’s something I’ve noticed other providers don’t seem to care about. I do address and aim for reductions to get pulse below 100.

 

[comp1]

That study shows (loosely) that stimulants aren't correlated with cardiovascular events. I stand by limited research on cardiac ablation and stimulants in specific. It's risky. Try your absolute best to avoid it. If you can't, document the heck out of the discussion with the patient including that symptoms are extremely severe to justify the risk.

 

[clausewitz2]

That study shows (loosely) that stimulants aren't correlated with cardiovascular events. I stand by limited research on cardiac ablation and stimulants in specific. It's risky. Try your absolute best to avoid it. If you can't, document the heck out of the discussion with the patient including that symptoms are extremely severe to justify the risk.

You're right there not much on stimulants in people with svt a/p ablation specifically. What I can find does not read as if it is alarmed at the prospect

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1442-200X.2011.03326.x

What is the basis for calling it an extreme risk?

 

[ObsequiousAplomb]

More than elevated BP I see people often on stimulants with a resting pulse above 100. It’s something I’ve noticed other providers don’t seem to care about. I do address and aim for reductions to get pulse below 100.

Why? Is there any evidence that targeting the pulse to be below 100 in ADHD improves outcomes?

 

[mistafab]

Why? Is there any evidence that targeting the pulse to be below 100 in ADHD improves outcomes?

Pulse chronically above 100 increases risk of poor cardiovascular outcomes. When I am managing ADHD, this is just as important to me as very elevated blood pressure.

 

[calvnandhobbs68]

About the pulse thing, sure but you need to make sure you're getting a true resting pulse. Which usually means people doing their own blood pressure/HR measurements at home relatively frequently after resting for at least 5 minutes and without consuming anything else that'll bump their heart rate (including caffeine...huge complicating factor for a lot of adults).

So yes, if you're truly sitting around with a pulse >100 at rest for most of your day it's not great for your heart but I wouldn't measure that off of a few in office blood pressures.

 

[Attending1985]

Why? Is there any evidence that targeting the pulse to be below 100 in ADHD improves outcomes?

About the pulse thing, sure but you need to make sure you're getting a true resting pulse. Which usually means people doing their own blood pressure/HR measurements at home relatively frequently after resting for at least 5 minutes and without consuming anything else that'll bump their heart rate (including caffeine...huge complicating factor for a lot of adults).

So yes, if you're truly sitting around with a pulse >100 at rest for most of your day it's not great for your heart but I wouldn't measure that off of a few in office blood pressures.

If people are elevated in office I will have them check pulses at home. I’m always surprised by how many of my patients wear smart watches and have that data handy.

 

[calvnandhobbs68]

If people are elevated in office I will have them check pulses at home. I’m always surprised by how many of my patients wear smart watches and have that data handy.

I think smartwatches can be helpful for repeated intentional measurements of HR when you know what the conditions are but I can tell from personal experience my watch is terrible at recognizing automatically if I'm standing or sitting or resting or not....it'll also come up with some resting HR that's way off at times.

If you have someone sit for a few minutes calmly and then take their HR with the actual watch though, tends to be pretty accurate at non-extreme heart rates. It's even pretty accurate under extertion. Buttt "pretty" accurate means acutally that the average HR elevation as noted above (5 BPM) from stimulants is actually within the error range of an apple watch (MAE is like 6-7 BPM vs EKG).

Accuracy of Apple Watch Measurements for Heart Rate and Energy Expenditure in Patients With Cardiovascular Disease: Cross-Sectional Study - PMC

Wrist-worn tracking devices such as the Apple Watch are becoming more integrated in health care. However, validation studies of these consumer devices remain scarce. This study aimed to assess if mobile health technology can be used for monitoring ...

pmc.ncbi.nlm.nih.gov

It's probably more helpful if you have before and after smartwatch readings to see if there's a significant trend for elevated baseline HR after starting a stimulant.

 

[futureapppsy2]

About the pulse thing, sure but you need to make sure you're getting a true resting pulse. Which usually means people doing their own blood pressure/HR measurements at home relatively frequently after resting for at least 5 minutes and without consuming anything else that'll bump their heart rate (including caffeine...huge complicating factor for a lot of adults).

So yes, if you're truly sitting around with a pulse >100 at rest for most of your day it's not great for your heart but I wouldn't measure that off of a few in office blood pressures.

Not on stimulants, but I had this issue with my HR at my PCP a couple of years ago--I would pace around waiting to be called back for my appointment (often for 30 minutes or more) and they would walk me back to the exam room and immediately take my pulse--it would be in 100-110's range. EKG was normal, so my PCP thought it was IST and put me on a low dose of metoprolol, which absolutely messed me up. I noticed that my pulse was way below 100 at rest on my watch and asked them to just take my pulse again at the end of the appointments--it was indeed in the normal range

 

[ridethecliche]

I've treated kids with significant cardiac history with stimulants during training. Sometimes it was great because they had a monitor so you could see the results of a med in real time and work with cards to figure out what the threshold is.

Work with cards regardless lol