服药的多动症患儿无需常规EGG检查

新奥尔良——美国克利夫兰彩虹儿童医院的小儿心脏病专家Christopher Snyder博士在美国儿科学会(AAP)年会上称，除非具有心脏病风险因素或早发型心脏病家族史，否则因注意力缺陷多动障碍(ADHD)而服用兴奋性药物的学生运动员或儿童没有必要进行常规心电图(ECG)检查。

Snyder博士指出，ECG检查并非总是易于开展，并且费钱费时，导致父母忧虑。此外，要想真正达到检查目的，ECG检查结果还需要由小儿心脏病专家来解读，而小儿心脏病专家资源有限。“因此，最好不要做，也没有必要做！”
 


美国心脏协会(AHA)指南不支持对学生运动员进行ECG检查。只有具有下列具体心脏问题个人史或家族史的儿童在进行体育运动前才真正需要ECG检查：不明原因的昏厥、锻炼时过度疲劳、血压异常、心脏杂音、有1位亲属在50岁之前发生或死于心脏病以及马凡综合征迹象。该指南规定，高中和大学生运动员应该每2年接受1次针对个人和家族史的12项检查，并在2次检查之间接受1次运动前检查。

不过对于儿童开始服用兴奋性药物时是否进行ECG检查并非如此明确。没有证据表明这些儿童必须进行ECG检查，也没有证据显示ADHD药物可导致心脏问题，尽管这些药物有可能引起血压轻微升高约1 mmHg以及心率稍微加快(约1次/分钟)。虽有心源性猝死报告且与ADHD药物存在关联，但从未证实两者之间存在任何因果关系。

AHA 的2008年ADHD药物治疗心脏筛查推荐意见，导致了人们对这些儿童进行ECG检查的必要性出现困惑。虽然ECG检查并非强制性要求，而是由医生自行决定，但该指南认为ECG检查可提高任何心脏风险筛查的准确性。

该指南指出，开始服用兴奋性药物之前的最低程度的筛查应包括心脏结构异常、心脏杂音、高血压、心悸、心律不齐、晕厥、马凡综合症征兆以及家族史等检查。但指南还指出：“常规身体检查有可能不能发现某些与心源性猝死有关的心脏状况。因此，ECG检查有助于确认已知与心脏性猝死有关的重大状况。”

尽管建议进行ECG检查，但AHA指南将其列为IIa级推荐和C级证据。指南还建议检查结果应由儿科心脏病医生解读，并且如果出现症状或某一家庭成员发生心脏疾病，有必要在进入青春期后复检。

就在AHA上述指南发布不久，美国儿科学会(AAP)也发布了自己的指南，认为有关文献存在争议，并明确表示不同意AHA的推荐意见。AAP及其分会不同意AHA的推荐分级和证据分级。此外，AHA声明中大量专家意见和论证观点表明，建议对开始服用ADHD兴奋性药物的健康儿童进行常规ECG检查弊大于利。因此，AAP发对常规ECG筛查。

AAP声称，没有明确证据显示服用这些药物的儿童猝死几率较大。因此，针对性心脏病个人和家族史检查，并结合全面身体检查，无论对于确认任何心脏风险因素，还是对于查明任何其他健康方面的担忧都已经足矣。按照AAP的声明，“本不应该对这些人群进行常规心电图检查或推荐。”

Snyder博士没有披露任何相关利益冲突。

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By: MICHELE G. SULLIVAN, Cardiology News Digital Network

NEW ORLEANS – An electrocardiogram isn’t necessary for student athletes or children taking stimulant medications for attention disorders unless the child has cardiac risk factors or a family history of early-onset heart disease.

ECGs are not always easy to obtain, and they cost parents money, time, and anxiety, Dr. Christopher Snyder said at the annual meeting of the American Academy of Pediatrics. To be really useful, he said, they should be read by a pediatric cardiologist – a specialist in remarkably short supply.
 
"Just don’t do it. You don’t need to do it!" said Dr. Snyder, a pediatric cardiologist at the Rainbow Babies and Children’s Hospital in Cleveland.

The American Heart Association (AHA) recommends against routine ECGs in student athletes. The only children who really need the test before playing sports are those with a family or personal history of specific cardiac findings, including:

·Unexplained fainting.

·Excessive fatigue with exercise.

·Abnormal blood pressure.

·Heart murmur.

·A relative who developed or died from heart disease at younger than 50 years.

·Signs of Marfan syndrome.

High school and college athletes should receive a biennial 12-item exam focused on personal and family findings, with a preparticipation history taken between the screenings, the guideline states.

Things aren’t quite so clear-cut with regard to ECGs for children beginning a stimulant medication. "There is no evidence that this is needed, but we do it because we think we should," Dr. Snyder said. Medications for attention-deficit/hyperactivity disorder (ADHD) "have never been shown to cause heart problems, although there might be a slight increase in blood pressure of about 1 mm Hg and a slight increase in heart rate – about 1 beat per minute. Sudden cardiac death has been reported and linked to ADHD medications, but it’s never been proven to have any causal association."

The AHA’s 2008 ADHD medication cardiac screening recommendation contributed to the confusion about the necessity of an ECG for these children, Dr. Snyder said. "It’s not mandatory, and it’s left to the physician’s discretion," but the guideline suggests that an ECG will strengthen the accuracy of any cardiac risk screening.

The minimal screen before starting a stimulant medication should include looking for cardiac structural abnormalities, heart murmurs, hypertension, palpitations, arrhythmia, syncope, signs of Marfan syndrome, and family history, the guideline noted. But, it added, "Some of the cardiac conditions associated with sudden cardiac death might not be detected on a routine physical examination. Therefore it can be useful to add an ECG, which may increase the likelihood of identifying significant conditions ... that are known to be associated with sudden cardiac death."

Despite suggesting ECGs, the AHA guideline gave them a class IIa recommendation and a C evidence level. It also recommended that the test be read by a pediatric cardiologist, and that it might need to be repeated after the onset of puberty, if symptoms develop, or if cardiac problems develop in a family member.

Shortly after the AHA recommendation came out, the American Academy of Pediatrics (AAP) published its own guideline, which called the cardiology paper "controversial" and made clear its disagreement with the guideline.

"The AAP and its constituent groups disagree with the AHA statement as to both the classification and the level of evidence. ... Moreover, the substantial expert opinion and reasoning outlined in the AHA statement suggests that harm outweighs the benefit of recommending routine ECGs for healthy children who are starting stimulant medication for ADHD. Accordingly, the AAP would recommend against such routine ECG screening."

There’s no good evidence that sudden death occurs any more frequently among children taking the medications, AAP asserted. Therefore, a targeted cardiac personal and family history, combined with a thorough physical, is adequate not only to identify any cardiac risk factors, but to pinpoint any other health concerns that might warrant attention.

"Electrocardiography or echocardiography in this population would not otherwise be routine or recommended," according to the AAP statement.

Dr. Snyder did not disclose any relevant financial conflicts.