People taking ADHD medications should closely monitor their heart health, study suggests

Long-term use of ADHD medications can raise the risk of cardiovascular disease in both children and adults, according to a study published Wednesday in JAMA Psychiatry. Experts say that the benefits of treatment still outweigh the risks for many, but heart heath should be carefully considered and monitored when making individual decisions.

Researchers in Sweden followed the medical records of thousands of individuals with attention deficit/hyperactivity disorder — known as ADHD — for an average of four years, and up to 14 years, between 2007 and 2020. The patients, ages 6 to 64, were monitored for a range of cardiovascular disease diagnoses. The researchers found that people taking ADHD medications had a higher risk of hypertension and arterial disease, and the risk increased over time.

Each additional year of ADHD medication use elevated the risk of heart disease by an average of 4%, stabilizing after more substantial increases in the first three years of treatment. Overall, the results suggest that heart disease risk was 23% higher for people who have used ADHD medication for more than five years compared with those who did not take medication — but that’s lower than previously reported findings.

Careful attention to the heart health of patients with ADHD is not new, experts say. Earlier research has found that adults with ADHD have a higher risk of cardiovascular disease overall. And stimulants, which are commonly prescribed to treat ADHD, are known to elevate blood pressure as arousal to the nervous system makes the heart work harder.

Heart disease is so rare in children that pediatricians can often manage younger ADHD patients without the involvement of a cardiologist, said Dr. Mitch Elkind, chief clinical science officer for the American Heart Association. Children with specific concerns based on their medical history and adults with underlying risk factors may benefit a more cautious approach to use of ADHD medication, but there’s not a one-size-fits-all approach.

“It’s really a balancing act,” he said.

About 1 in 10 children ages 3 to 17 have been diagnosed with ADHD, according to data from the US Centers for Disease Control and Prevention. And diagnoses are becoming more common among adults.

Patients should be aware of the risks associated with ADHD medications, but not alarmed, experts say.

“When we get into clinical practice, these changes are relatively insignificant in ordinarily healthy adults,” said Dr. David Goodman, an assistant professor in the department of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine. “You need to measure the benefit of the treatment against the relatively small risks, and patients will say benefits are tremendous and I wouldn’t want to give this up.”

Goodman, who is also on the executive board of the American Professional Society for ADHD and Related Disorders, is part of a steering committee that is developing the first published guidelines for the diagnosis and management of ADHD in adults, and the group plans to address the best practices for assessing and monitoring cardiovascular risk in that documentation.

“I don’t want to minimize this,” he said, highlighting the importance of screening for heart health in ADHD patients before starting treatment and checking in regularly.

“But if an adult comes in with hypertension and they’re on medication for that, I would still treat them with stimulant medication and just be more mindful to monitor the blood pressure and pulse,” he said. “I have patients in their early 80s on stimulant medications who would tell you, ‘I would not like you to stop prescribing medication because you’re concerned about my high blood pressure.’”

ADHD patients can monitor and care for their own heart health using the American Heart Association’s “Life’s Essential 8,” a set of key health behaviors and factors that can affect an individual’s risk for heart disease.

“I would say that keeping blood pressure under control is the most important one for somebody on a stimulant,” Elkind said. “Also keeping track of blood sugar and cholesterol levels, eating a healthy diet, exercising, not smoking, getting enough sleep.”

The risk for cardiovascular disease may be underestimated in the new study, the researchers wrote, as some heart disease that does not yet require medical care may not be diagnosed. And some patients who did not take their medication as prescribed could skew results.

While the study was not able to prove that ADHD medications caused heart disease, the findings “highlight the importance of carefully weighing potential benefits and risks when making treatment decisions on long-term ADHD medication use.”

“Clinicians should be vigilant in monitoring patients, particularly among those receiving higher doses, and consistently assess signs and symptoms of (cardiovascular disease) throughout the course of treatment,” the researchers wrote.