Cardiac Arrest with Pulseless Electrical Activity Associated with Methylphenidate in an Adolescent with Normal Baseline Echocardiogram

Recent concerns of adverse cardiac events associated with drugs used to treat attention-deficit-hyperactivity disorder (ADHD) have prompted debate over whether these drugs are truly safe. We describe a 17-year-old boy with a normal baseline echocardiogram who had been taking methylphenidate for ADHD for 18 months and experienced cardiac arrest. Emergency personnel attempted to resuscitate him, performing defibrillation twice for ventricular fibrillation, with subsequent pulseless electrical activity. The patient was immediately taken to the hospital where he received continued resuscitation, intravenous boluses of cardiac drugs, and additional defibrillation. A persistent pulsatile rhythm returned about 2 minutes after arrival. Overall, the patient was pulseless for 22 minutes. Emergency cardiac catheterization revealed wall motion abnormalities without coronary lesions. He was mechanically ventilated and was transferred to the intensive care unit, where he remained comatose. Neurologic studies performed the next day revealed diffuse encephalopathy due to anoxic brain injury. An echocardiogram on day 3 showed slightly improved left ventricular systolic function, which improved further by day 15. As the patient did not regain purposeful movement, he was discharged to a rehabilitation facility on day 33. The patient's methylphenidate therapy had been started at an appropriate dose of 18 mg/day and titrated over a period of 3 months up to 36 mg/day, which he continued until the event. The drug had been discontinued on admission, was not restarted, and for the next 2 years, the patient experienced no further cardiac events, although his severe mental deficiencies persisted. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patient's adverse cardiac event and methylphenidate. To our knowledge, this is the first case report of a patient with documentation of a normal baseline echocardiogram who experienced cardiac arrest with pulseless electrical activity while taking methylphenidate for ADHD. Clinicians should be aware that despite performing a comprehensive cardiac examination before prescribing a stimulant for ADHD, patients may still be at risk for a serious cardiac event. The risks and benefits of using these drugs must be assessed by clinicians, parents, and patients.