A 4% annual increase in cardiovascular disease risk per year of ADHD medication use
A narrative review published in International Health Sciences Review in March 2026 by Lima, Marzari, Heck, and Librelotto synthesises the current evidence on cardiovascular safety of psychostimulants in adult ADHD. The review is conventional in its structure — pharmacology, pre-treatment screening, monitoring protocols, risk stratification — and reaches the conventional conclusion that psychostimulants can be used safely in most adults with appropriate screening.
The most substantive finding in the review is one the authors cite rather than generate. Zhang et al. (2024), published in JAMA Psychiatry, found that each additional year of ADHD medication use was associated with a 4% increase in the risk of cardiovascular disease, with the risk most pronounced for hypertension and arterial disease. Lima et al. integrate this finding into their review and use it to argue for “lifelong vigilance” — but they do not let it disturb the broader framing that long-term stimulant use is safe with monitoring.
A 4% annual cumulative increase is not a small number when treatment now extends over decades. Five years of treatment compounds to roughly 22% increased risk. Ten years compounds to roughly 48%. Twenty years — well within the expected treatment duration for adults diagnosed in their twenties or thirties — compounds to over 119% increased risk. The review notes these numbers in passing. It does not engage with what they mean.
Why "modest" hemodynamic changes are misleading when treatment now lasts decades
The clinical safety literature consistently describes psychostimulant hemodynamic effects as “modest” — typically 2 to 5 mmHg increases in systolic and diastolic blood pressure and 3 to 6 bpm increases in heart rate. In healthy individuals, these are clinically insignificant in the short term. Lima et al. accept this framing throughout their review.
The framing was developed when ADHD was primarily diagnosed and treated in childhood, with treatment often stopping in adolescence or early adulthood. The cumulative exposure profile in that population was bounded. The framing has not been substantially updated for the population now receiving treatment — adults diagnosed in their twenties, thirties, or later, with no clinical expectation that treatment will end.
A persistent state of mildly elevated sympathetic tone over five years differs from the same state over twenty-five years. The review acknowledges this implicitly when it notes that “the cumulative effect of even modest elevations in BP and HR may contribute to the development of structural cardiovascular changes, such as left ventricular hypertrophy or accelerated atherosclerosis.” It does not pursue the implication that the standard “modest hemodynamic change” reassurance was constructed for a different treatment duration than the one now being prescribed.
The clinical review framing assumes lifetime treatment without questioning lifetime treatment
Lima et al. recommend pre-treatment cardiovascular assessment, ongoing monitoring every three to six months, and consultation with cardiology in patients with pre-existing conditions. They mention “medication holidays” and “periodic re-evaluation of the ongoing need for medication” as appropriate strategies. These recommendations are reasonable. They are also embedded within a framing that treats long-term stimulant use as the default and discontinuation as the exception requiring justification.
The structural question the review does not ask is whether the cumulative cardiovascular exposure profile of ADHD medication should change how clinicians approach the duration of treatment in the first place. If a treatment carries a 4% annual compounding cardiovascular risk, the question of how long that treatment continues is not separable from the question of whether the underlying condition could be managed by other means after a period of pharmacological support. The review treats medication continuation as a clinical default to be monitored, not as a decision to be re-evaluated against accumulating cardiovascular cost.
This matters because the cohort now being prescribed stimulants in adulthood is NOT the cohort the safety literature was developed around. Late diagnosis is increasingly common. Adults diagnosed at thirty who continue treatment to typical retirement age would accumulate over thirty years of exposure. The Zhang et al. finding suggests this is not a trivial cumulative profile. The clinical review framing does not pause on this.
What this means for the cohort now being prescribed stimulants in their twenties
For adults currently in the early years of stimulant treatment, the practical implications are worth taking seriously. The cardiovascular risk is not high in any given year. The risk compounds over treatment duration. Monitoring blood pressure and heart rate as Lima et al. recommend is necessary but not sufficient — it detects acute hemodynamic changes, not the slow structural changes that cumulative exposure may produce.
The harder question is the one clinical reviews tend to defer: what does an exit strategy from long-term stimulant treatment look like, and is anyone clinically supporting patients in developing one? The literature on ADHD medication discontinuation in adults is thin. The infrastructure for supporting patients through reduction or cessation is thinner. Most adults on stimulants are not offered a planned trajectory toward eventual discontinuation. They are offered indefinite continuation with periodic monitoring.
The cumulative cardiovascular evidence suggests this default deserves more scrutiny than it currently receives. The Zhang et al. finding is four years old. Yet clinical practice has not visibly adjusted. I am glad that I am now reporting on this, as someone who is personally over four years into stimulant treatment.
Citations
Lima, B. S. de, Marzari, M., Heck, L. L., & Librelotto, I. R. (2026) — Use of psychostimulants in adult ADHD: Cardiovascular safety assessment in clinical practice
Zhang, L., Yao, H., Li, L., et al. (2024) — Attention-deficit/hyperactivity disorder medications and long-term risk of cardiovascular diseases
