New NICE guidelines for ADHD diagnosis and management came out on 14th March.

So 1.7.4 states that physical health should be reviewed before starting treatment and the last element of this is an ECG ‘if the treatment may affect the QTc interval’. Atomoxetine has some effect on QTc but methylphenidate and amphetamines do not. As stimulants are recommended first line, it’s likely that not too many patients will receive atomoxetine and therefore require an ECG.

Then 1.7.5 recommends a cardiology opinion if there is a family history of early sudden cardiac death, symptoms suggestive of heart failure, ischaemic heart disease or arrhythmia. This seems absolutely right as there is some evidence that those with existing cardiovascular disease may be at increased risk of a cardiovascular event just after starting a stimulant (see BMJ 2016 – Google Jackson cardiovascular BMJ and it should come up – open access). Stimulants have a very modest effect on pulse and BP and thinking is that for some, this may be enough to trigger an event now rather than later. So not more events but just sooner than would otherwise have happened.

Then NICE say refer on if hypertensive – >140/90. As most of the patients we see are relatively young, hopefully this isn’t too much of a problem. I think this recommendation sitting alone is very over-cautious.

The contrast with the CADDRA guidelines, where it is recommended that ADHD be diagnosed and managed in primary care, is very stark.