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Cardiovascular Events With ADHD Medications

Cardiovascular Events With ADHD Medications

William T. Basco, Jr., MD

 

ADHD Drugs and Serious Cardiovascular Events in Children and Young Adults

Cooper WO, Habel LA, Sox CM, et al.
New Engl J Med. 2011;365:1896-1904

Study Summary

Background. Many pediatric providers are familiar with the controversy over recommendations to include ECGs before beginning stimulant treatment for patients with attention-deficit hyperactivity disorder (ADHD). These concerns were raised primarily on the basis of case reports and not on population-based data. Cooper and colleagues used data from 4 health plans in the United States, retrospectively reconstructing health histories to assess the association between initiation of ADHD medications and the risk for serious cardiovascular events.

Methods. The data were obtained from Tennessee Medicaid, Washington State Medicaid, Kaiser Permanente of California, and a private insurance health plan data warehouse. The data represented visits from 1986 through the end of 2005. Data included enrollment records, hospital and outpatient claims, and dispensed prescriptions. Participants were 2-24 years old and had continuous enrollment for 365 days prior to the dispensing of their first ADHD medication. The investigators included stimulants as well as atomoxetine or pemoline as ADHD medications. Patients with potentially life-threatening illnesses were excluded, except those with congenital heart disease, who were purposefully included for this study. Each child who received an ADHD medication was matched with 2 children who were not receiving ADHD medication and who did not have a serious illness. Children were matched according to health plan and day of qualifying use. Investigators classified every person-day of the period after the initial ADHD medication was prescribed as either current-use days, former-use days (after the prescribed medication would have run out based on prescription records), and non-use days. Three serious cardiac events were considered primary endpoints: sudden cardiac death, myocardial infarction, or stroke. When a claim for a primary endpoint was identified, additional records were reviewed to establish the validity of the case, including review of death certificate data if needed. The primary comparison between children taking ADHD medications and nonusers was the hazard ratio. The analysis for the hazard ratio included controlling for the study site, medical and psychiatric conditions, the degree to which the child used care, age, and the calendar year.

Findings. The study included 1.2 million children with a mean age of 11 years and a mean length of follow-up of 2.1 years. At baseline, the children who were current users of ADHD medications sought healthcare more often, had a greater prevalence of psychiatric illnesses, and were more likely to have asthma, seizures, and congenital heart defects. In all, 81 children had a serious cardiovascular event: 33 children experienced sudden cardiac death; 39 experienced acute myocardial infarction; and 39 experienced a stroke. For all serious cardiovascular events, there were 3.1 events per 100,000 person-years. In the multivariate regression model, older children, those who were currently using antipsychotic drugs or had a major psychiatric illness, and children with serious cardiovascular conditions or chronic illnesses experienced an increased risk for serious cardiovascular events. When comparing current users of ADHD medication with either former users or nonusers, the hazard ratios were not significantly different. For example, current users had a hazard ratio 0.75 (95% confidence interval [CI], 0.31-1.85) compared with those who had never used ADHD medications. In a similar fashion, risk was not increased for current users compared with former users (hazard ratio, 0.70; 95% CI, 0.29-1.72). When the 3 cardiovascular endpoints were considered separately, no increased risk was found. Equally, there was no increased risk found for children taking methylphenidate, the most frequently used ADHD drug. Alternative analyses were conducted to assess the robustness of these findings. Even when evaluating children who were new users of ADHD drugs and including those with serious underlying cardiac disease, no significant association between ADHD medication use and serious cardiovascular events was found.

Viewpoint

The full text of this article includes a review of the timeline of events that led to the American Heart Association's policy that ECGs were reasonable to obtain before beginning children on stimulant therapy for ADHD.

Although these data are not experimental, the rare incidence of serious cardiac events among children would make any sort of prospective trial impossible. As Cooper and colleagues emphasize, this is a very large cohort study, with many person-years of risk contained in the data set. Even when focusing on the highest-risk group (children with existing cardiovascular defects), the authors were unable to demonstrate a significant increased risk. The investigators were careful to state that the upper bound of the 95% CI for the point estimate of the hazard ratio was 1.85, meaning that it was possible that the rate was 85% higher among the children with ADHD treatment. However, the lower bound was 0.31, suggesting the possibility of a reduced risk for sudden cardiac death among children on ADHD medication. Either way, the absolute risk is quite small, a fact that was lost in the debate about whether to do baseline ECGs on children starting ADHD therapy. Perhaps now, future discussions on the topic will refer to this study, which offers a good quantification of that risk.


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Tamara Geovana Possari's comment, November 28, 2013 6:53 PM
is very interesting and extensive all this matter of medicine, including cardiovascular. I think very beautiful who are interested and tries to understand it all!
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Hospital in India Charges $800 for Heart Surgery - Opposing Views - Opposing Views

Hospital in India Charges $800 for Heart Surgery - Opposing Views - Opposing Views | Brenda Ramos | Scoop.it
Hospital in India Charges $800 for Heart Surgery - Opposing Views
Opposing Views
Shetty's first pioneering cardiac hospital opened in Bangalore, India in 2001. About 30 heart surgeries are performed in the Bangalore, India, at a cost of $1,800.

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Jeniffer Do Carmo Ramos's comment, November 14, 2013 11:13 AM
Muito legal a reportagem, é muito triste saber que os medicos demoram tanto para se formar pra ganharem tão pouco
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In Medical Education, Should Technology Lead or Follow?

In Medical Education, Should Technology Lead or Follow? | Brenda Ramos | Scoop.it

The latest rapidly expanding trend in online education is MOOCs (Massively Open Online Courses). These courses provide a forum for excellent lecturers to teach a large number of students simultaneously.


The same virtual class can have thousands or even hundreds of thousands of students.


MOOCs generally rely on lectures and frequent assessments. While MOOCs do encourage communities of students to participate and work with each other to learn the materials, most do not require such interactivity to complete the course. And, significantly, the objectives are those set and assessed by the instructors.


In other words, MOOCS are a new way to reach a lot of people so that we can do what we’ve always done.


Another trend in many medical schools is to provide iPads to students when they arrive on campus. While the practice may be effective at recruiting students and attracting media attention, a closer look reveals that students tend not to use the iPads to take notes or produce materials, and often abandon using them in courses that are not image intensive.


One might ask why someone who is seemingly so negative about new technologies is leading the educational informatics effort at a medical school.


Without question, I believe that new technologies are critical and essential elements of contemporary medical education. However, the technologies should not define the education we provide students; they should help the learning take place.


These are tools—important tools that will help us educate future generations of physicians who must be digitally literate—but still, tools only.


Tablets may not be effective tools for writing or producing new materials. But they are incredibly useful for looking up information, demonstrating information to patients in the clinical setting and gaining access to electronic medical records. Medical students across the country often complain that they do not know how to use these tools effectively; addressing that need ought to be one of our educational objectives.


Technology must be used to provide support for effective education. Educational objectives need to be clearly defined and the appropriate tools selected to meet those objectives. Our medical education ought not to be digital simply because it is digital at other institutions. The digital format needs to serve a greater purpose—the goal of helping students develop educational competencies.


- See more at: http://blogs.einstein.yu.edu/in-medical-education-should-technology-lead-or-follow/#sthash.bmDM4Qfb.dpuf


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Steph's Journalism Group 2013's curator insight, October 21, 2013 9:42 AM

This is one of the best insights. Technology has become very diverse and widespread in society but that doesnt mean we have to use all of it for teaching becasue even though some things are more modern or more ground breaking, it doesnt mean they are going to help students learn any faster. the right technolgy has to be selected to teach students.

Vinicius Cagnotto's comment, November 26, 2013 12:42 PM
the interesting news about health, and how this issue has repercurçao worldwide, and how various countries have problems in this area. lamentable! health should be a priority everywhere.
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The Virtual Doctor Project: how Bitcoin is helping to boost healthcare in rural Africa | Bitcoin Examiner

The Virtual Doctor Project: how Bitcoin is helping to boost healthcare in rural Africa | Bitcoin Examiner | Brenda Ramos | Scoop.it

Everyone in the Bitcoin community has already heard about the amazing opportunities cryptocurrency can help create in Africa, but The Virtual Doctor Project (VDP) is one of the best so far. The project has been under development since 2008, but only recently started working effectively on behalf of the Zambian health system.


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25 yeras ago = Modern treatment for ACS began: Aspirin, Heparin, or Both to Treat Acute Unstable Angina — NEJM

25 yeras ago = Modern treatment for ACS began: Aspirin, Heparin, or Both to Treat Acute Unstable Angina — NEJM | Brenda Ramos | Scoop.it
Original Article from The New England Journal of Medicine — Aspirin, Heparin, or Both to Treat Acute Unstable Angina

Major end points — refractory angina, myocardial infarction, and death — occurred in 23,12, and 1.7 percent of the 118 patients receiving placebo, respectively. Heparin was associated with a decrease in the occurrence of refractory angina (P = 0.002). The incidence of myocardial infarction was significantly reduced in the groups receiving aspirin (3 percent; P = 0.01), heparin (0.8 percent; P<0.001), and aspirin plus heparin (1.6 percent, P = 0.003), and no deaths occurred in these groups. There were too few deaths overall to permit evaluation of the effect of treatment on this end point. The combination of aspirin and heparin had no greater protective effect than heparin alone but was associated with slightly more serious bleeding (3.3 vs. 1.7 percent).

We conclude that in the acute phase of unstable angina, either aspirin or heparin treatment is associated with a reduced incidence of myocardial infarction, and there is a trend favoring heparin over aspirin. Heparin treatment is also associated with a reduced incidence of refractory angina.


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Seth Bilazarian, MD's curator insight, October 27, 2013 10:42 AM

#OnThisDay 25 years ago the modern treatment of Acute Coronary Syndromes  (#ACS) and Heart Attacks began.  This was the first study to look at the combined effects of using an antiplatelet drug (aspirin) and an anticoagulant (heparin) togehter.  The combination was felt to be  high risk for bleeding but the significant benefit of using both in conmbination had such suignificant benefit tht  it has become the standard of care for treatment. 

Twenty years ago (when I first began my practice) the adoption was still slow and unfamiliar in community hospitals (I remeber being criticized by the hospital pharmacists for using both drugs).

It is now the standard of care for high risk patients coming in with a heart attack (myocardial infarction, MI) or with a high risk threatened heart attack.  

Jeniffer Do Carmo Ramos's comment, November 14, 2013 9:07 AM
Eu gostei por que é muito eficiente saber o que acontece em sindromes do coração e oque os medicos administram nas pessoas
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China Interventional Cardiovascular Device Industry

China Interventional Cardiovascular Device Industry | Brenda Ramos | Scoop.it

The report “China Interventional Cardiovascular Device Industry Report, 2013-2015″ by Research in China is now available at chinamarketresearchreports.com. Contact sales@chinamarketresearchreports.com with Research Report on China Interventional Cardiovascular Device Industry Report, 2013-2015 in subject line and your contact details to purchase this report or get your questions answered.

 

The collection of ‘Life Sciences’ market research reports has a new addition of “China Interventional Cardiovascular Device Industry Report, 2013-2015”On chinamarketresearchreports.com .

 

Synopsis

With the accelerated aging, the prevalence of cardiovascular diseases in China increased year by year. According to statistics of National Health and Family Planning Commission of the People’s Republic of China, in 2012 cardiovascular disease deaths in China reached 3.5 million. The fast growing number of heart patient’s stimulated rapid growth in Chinese demand for interventional cardiac operation and coronary stent. China's PCI (percutaneous coronary intervention) surgeries increased from 25,000 cases in 2002 to about 531,000 cases in 2012; the number of coronary stent implantation rose from 40,000 units in 2002 to approximately 640,000 units in 2012. In 2007-2012 China's cardiovascular stent market size grew at an AAGR of 20.3%.

 

In China, interventional cardiovascular devices are dominated by cardiovascular stent. Currently, the top three companies in China's coronary stent market are respectively MicroPort, Lepu Medical and JW Medical; while supporting auxiliary devices such as catheter and guide wire feature low localization rate, mainly dependent on imports. In 2012, Chinese enterprises accounted for 66.8% of Chinese interventional cardiovascular device market share, followed by foreign counterparts with 33.2%.

 

Buy a copy of this report by Research in China @ http://www.chinamarketresearchreports.com/contacts/purchase.php?name=114663 .

 

Interventional cardiovascular device is a sunrise industry, there lies strong clinical demand for safer and more effective interventional products, and thus the world's major manufacturers have invested heavily in research and development of new products. Bio absorbable everolimus-eluting stent (BVS) has become the focus of attention. Abbott in September 2012 launched the world's first A bio absorbable everolimus-eluting coronary stent system (ABSORB), expected to bring a revolutionary change in coronary artery disease (CAD) treatment; MicroPort's third-generation completely biodegradable drug-eluting stent Firehawk has completed clinical trials in China; Lepu Medical's completely biodegradable drug-eluting stent is also in active research and development.

 

Complete report spread across [89] pages available @ http://www.chinamarketresearchreports.com/114663.html. Read more on “China Interventional Cardiovascular Device Industry Report, 2013-2015” report below.

 

China Interventional Cardiovascular Device Industry Report, 2013-2015 mainly covers the followings:

Development, market demand, competition pattern, profit level, etc. of the industry;Policy environment, impacts from upstream and downstream sectors, etc.;Market size, supply and demand, product price, etc. of industry segments (including coronary stent, balloon catheter, guide wire, sheath group and auxiliary device), etc.;Operation, interventional device cardiovascular business, operation in China, etc. of global companies (including Johnson & Johnson, Medtronic, Boston Scientific, Abbott Laboratories, B. Braun);Operation, interventional cardiovascular device business, etc. of Chinese companies (including MicroPort, Lepu Medical, Lifetech Scientific, JW Medical, Liaoning Bio-medical Technology, OrbusNeich, SCW Medicath, Amtech Biotech and Starway Medical).

 

For further information on “China Interventional Cardiovascular Device Industry Report, 2013-2015” report OR for any other business research / market intelligence need on the ‘Life Sciences’ market (http://www.chinamarketresearchreports.com/cat/life-sciences.html .), contact sales@chinamarketresearchreports.com / Call +1 888 391 5441.

 


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Social Media and Patient Self-Care

Social Media and Patient Self-Care | Brenda Ramos | Scoop.it

As more and more people use social media, ways to connect with others increase as well. One such use in recent years has been an increase in patients looking to social media for help in self-care. To see what role social media plays in this, we first have to look at what self-care means. A quick search for the term brings over 500,000 results.

Self care definition

While traditionally, this means taking time to relax and regroup (with my personal favorite way being to get a massage), joining an in-person support group, or even just going to regular doctor visits. Patients have now discovered social media as a very useful tool for them and their families.

What are some ways social media is being used for self-care?

Online Forums – Online forums have been around since the early 1970s in the form of online bulletin boards and electronic mailing lists. These have evolved over the years to very theme/topic specific forums. This gives groups of various sizes a chance to connect and exchange tips and tricks on how to deal with symptoms, find the best doctors for specific illnesses, and to simply connect with people who have the same diagnosis.

Facebook groups and pages – Facebook has also proven itself as a great way to connect. WEGO Health is one such place that connects people with various diagnoses with peer and professional support, as well as providing them with a large source of information gathered from across the Internet.Tweet Chats – Thanks to the use of hashtags, Twitter has become popular for various groups to connect for weekly Tweet Chats. Based on a pre-arranged hashtag, patients and health activists can chat about various issues. One such longstanding chat is the weekly #PPDChat, which connects moms and dads dealing with PPD (Post Partum Depression) and PPMD (Post Partum Mood Disorder).

Personal Blogs – The list of people sharing their own personal stories continues to grow as people reach out to help others dealing with similar situations. These bloggers often build a strong support system for each other to lean on and to help people new to whatever they are going through. The topics covered range from parents with children diagnosed with various illnesses, to patients blogging about their own struggle with diabetes, cancer or eating disorders.

How does this translate to self-care? Thanks to the often-strong connections, forged due to shared experiences, these patients and caretakers have turned into health activists by reaching out to a larger community. This allows them and others to continue to improve their own health by having access to a larger pool of information than they normally would without the use of social media. It helps patients find new ways to take care of themselves and discover additional methods of tracking and maintaining their health.

All of these are valuable tools in a large self-care arsenal needed to combat often-difficult situations and illnesses. For patients and caregivers located in remote locations and removed from more traditional methods, it is at times one of the few ways, sometimes the only way, to improve personal health maintenance.


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Helene Wild's curator insight, October 2, 2013 4:06 AM

who owns your health?

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ASCO's Guideline on Drugs to Lower Breast Cancer Risk

ASCO's Guideline on Drugs to Lower Breast Cancer Risk | Brenda Ramos | Scoop.it

"To help doctors provide the best possible care, the American Society of Clinical Oncology (ASCO) asks its medical experts to develop recommendations for specific areas of cancer care. This guideline was updated in 2013 to add new evidence about the benefits and risks of using medications (pills) as a way to lower the risk of breast cancer for women. In addition, a recommendation that doctors should discuss exemestane (Aromasin), as an alternative to tamoxifen and/or raloxifene, was added in this update. This guide is based on ASCO’s latest recommendations."


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Curated by A4BC.ORG's curator insight, August 19, 2013 8:44 AM


Key Messages:

  • Talk with your doctor about your risk of developing breast cancer and whether you could benefit from drugs to reduce your risk of breast cancer.
  • If you have a high risk of breast cancer and have been through menopause, your options for lowering your breast cancer risk include the drugs tamoxifen, raloxifene, and exemestane.
  • If you have not been through menopause and have a high risk of breast cancer, tamoxifen is an option for lowering your risk of breast cancer.
  • Talk with your doctor about the benefits and risks of taking each of these drugs before making a decision.
Elizandra Drews Forte's comment, November 14, 2013 8:21 AM
I like it because it's a way to help people not suffer more, and also stabilize the disease.