Cardiovascular Disease Risk May Increase with Long-Term ADHD Medication Use

December 6, 2023

Long-term use of ADHD medications may increase the risk of cardiovascular disease (CVD) in children and adults, according to a new study published in JAMA Psychiatry.¹ However, ADHD experts caution against changing ADHD treatment based on these findings.

“The substantial improvement in ADHD impairments significantly outweighs the study’s risk, which is easily monitored and addressed by the prescribing clinician,” David W. Goodman, M.D., LFAPA, assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine, told ADDitude. “I hope that patients and prescribers don’t overemphasize the study’s findings by stopping effective medication or not prescribing when clinically indicated.”

The case-control study suggests that the potential for cardiovascular disease increases by an average of 4% each year a patient takes ADHD medication (stimulants and non-stimulants). The percentage rose to 23% for some people who used ADHD medication for more than five years compared with those who did not.¹

Patients who used methylphenidate (brand names: Ritalin, Concerta, Focalin, etc.) and lisdexamfetamine (brand name: Vyvanse) had a higher risk of hypertension and arterial disease compared with people who did not take ADHD medication. The non-stimulant medication atomoxetine (brand name: Strattera) was statistically significant only for the first year of use.

The study’s cohort comprised more than 278,000 individuals with ADHD, aged 6 to 64, identified from the Swedish National Inpatient Register and the Swedish Prescribed Drug Register. Researchers monitored the patients for hypertension, heart failure, arrhythmias, and ischemic, cerebrovascular, and thromboembolic diseases for an average of four and up to 14 years between 2007 and 2020. During the follow-up period, slightly less than 5% of the study’s cohort had received a CVD diagnosis.

“The conclusion of this study sounds really scary, but it’s not,” ADHD expert Russell A. Barkley, Ph.D., said on his YouTube channel, Weekly Research Update. “The vast majority [95%] had no risk for CVD. These small increases in CVD risk are well outweighed by the benefits of treatment compared to no treatment at all.”

Barkley considered an alternative explanation for the findings: “The study did not control in any way the severity of ADHD,” he said. “This is important because we know that the more severe your ADHD, the more likely you’re going to be prone to various cardiovascular problems, specifically hypertension, arterial disease, and so on. It is possible that people with more severe ADHD take medications for longer periods than people with less severe ADHD. So, it may not be the duration of medication use that’s the issue. Duration could be a marker for the severity of your disorder.”

Further, the observational nature of the study means that the researchers “could not prove causality” between ADHD medication and cardiovascular disease.

Peter Jensen, M.D., Founder of the REACH Institute, which trains clinicians in the diagnosis and treatment of mental health disorders in children, told ADDitude that patients in the JAMA Psychiatry study could have had co-occurring conditions like diabetes or obesity that raised their risk of cardiovascular disease.

“If a child diagnosed with ADHD has a family history of unusual heart rhythms, then it could make sense for that child to have an EKG before being prescribed a stimulant to manage symptoms. Otherwise, an EKG would not be necessary for children because the risk for a cardiac event is trivial,” he said, likening it to the odds of getting hit by lightning.

“This is what I’d say to parents of my patients: The impact of ADHD causes all kinds of problems if it’s untreated,” Jensen said. “School failure, substance use, and as an adult, not doing well in a job or getting fired, breakups in marriages — these are known risks when ADHD is not well managed.”

He said the JAMA Psychiatry study is relevant in older populations because the risk for cardiovascular disease generally increases with age. “But even then, I would say to my patients, ‘How’s your diet, exercise, sleep, other health habits?’ These are the risks (for heart problems) as best as we know. The study didn’t look at these things,” Jensen said. “The risk from stimulant use is basically less than the risk of being obese, of having sleep problems, and less than the risk of not getting regular exercise. So, if you’re thinking, what is the risk of cardiovascular disease? By far, obesity is worse than years of exposure to stimulants.”

Jensen headed up the National Institute of Mental Health study, the Multimodal Treatment of Children with ADHD (MTA), which followed nearly 600 children taking stimulants to manage symptoms for 16 years — from elementary school to young adulthood — beginning in 1992. He said those study findings detected no meaningful change in cardiovascular risk.²

In addition, a November 2022 meta-analysis of 19 observational studies from the last 15 years, including 3.9 million participants, found no statistically significant association between ADHD medications and cardiovascular disease, even among middle-aged and older adults. ³

That study, published in JAMA Network Open, was the most comprehensive systematic review and meta-analysis of longitudinal observational studies to date on the association between ADHD medication use and the risk of CVD and included patients from the United States, South Korea, Canada, Denmark, Spain, and Hong Kong.

The American Academy of Pediatrics (AAP) recommends treating ADHD in children and adolescents aged 6 to 18 with FDA-approved medications, plus parent training in behavior modification and behavioral classroom interventions. Research studies like this one conducted by scientists at McGill University have found that “stimulant medications are most effective, and combined medication and psychosocial treatment is the most beneficial treatment option for most adult patients with ADHD.” Patients should make all ADHD treatment decisions in consultation and coordination with a licensed medical provider.

The findings of the JAMA Psychiatry study underscore the importance of carefully weighing potential benefits and risks when making ADHD treatment decisions. “Clinicians should be vigilant in monitoring patients, particularly among those receiving higher doses, and consistently assess signs and symptoms of CVD throughout the course of treatment,” the researchers wrote.

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