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Figure.
Flow Diagram of Study Patients
Flow Diagram of Study Patients

The flow diagram outlines the cardiac screening for patients in our study population requiring treatment of complicated infantile hemangiomas (IHs) with propranolol hydrochloride. A total of 198 patients received propranolol treatment. Four patients with PHACE syndrome were excluded from the study. There were no patients who did not receive propranolol treatment owing to an electrocardiogram (ECG) screening. ECHO indicates echocardiogram; NSR, normal sinus rhythm; and PDA, patent ductus arteriosus.

1.
Haggstrom  AN, Drolet  BA, Baselga  E,  et al.  Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment.  Pediatrics. 2006;118(3):882-887.PubMedGoogle ScholarCrossref
2.
Drolet  BA, Frommelt  PC, Chamlin  SL,  et al.  Initiation and use of propranolol for infantile hemangioma: report of a consensus conference.  Pediatrics. 2013;131(1):128-140.PubMedGoogle ScholarCrossref
3.
Raphael  MF, Breugem  CC, Vlasveld  FA,  et al.  Is cardiovascular evaluation necessary prior to and during beta-blocker therapy for infantile hemangiomas?: a cohort study.  J Am Acad Dermatol. 2015;72(3):465-472.PubMedGoogle ScholarCrossref
5.
Anderson  KR, Schoch  JJ, Lohse  CM, Hand  JL, Davis  DM, Tollefson  MM.  Increasing incidence of infantile hemangiomas (IH) over the past 35 years: correlation with decreasing gestational age at birth and birth weight.  J Am Acad Dermatol. 2016;74(1):120-126.PubMedGoogle ScholarCrossref
6.
Hamilton  BE, Martin  JA, Osterman  MJ, Curtin  SC, Matthews  TJ.  Births: final data for 2014.  Natl Vital Stat Rep. 2015;64(12):1-64.PubMedGoogle Scholar
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Research Letter
September 2016

Reevaluating the Need for Electrocardiograms Prior to Initiation of Treatment With Propranolol for Infantile Hemangiomas

Author Affiliations
  • 1Section of Dermatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
JAMA Pediatr. 2016;170(9):906-907. doi:10.1001/jamapediatrics.2016.0824

Infantile hemangioma (IH) is a benign vascular tumor, which is usually managed conservatively. However, in approximately 24% of cases, complications such as ulceration, functional impairment, or cosmetic deformity necessitate evaluation for systemic therapy.1 Propranolol hydrochloride is a first-line treatment for complicated IHs. Guidelines regarding initiation, treatment indications, and safety monitoring have been established; however, there was no consensus on whether an electrocardiogram (ECG) should be part of the pretreatment evaluation.2 A survey of prescribers of propranolol for IH showed that 81% of prescribers ordered an ECG before initiating treatment with propranolol.2 A cohort study to evaluate the necessity of a cardiovascular evaluation prior to initiating therapy with β-blockers found ECG abnormalities in 6.5% of patients, but none of these findings were contraindications to β-blocker therapy.3 We sought to evaluate the cost of routine pretreatment ECG screening and determine whether testing led to significant management changes for 198 patients evaluated for initiation of treatment with propranolol over a 2-year period at our institution.

Methods

A retrospective medical record review of patients with IHs who presented to the dermatology clinic at the hospital between 2013 and 2015 was completed. Patients with PHACE syndrome were excluded. The Children’s Hospital of Philadelphia institutional review board approved the study. Informed consent was waived because the data from the retrospective medical records were deidentified.

Results

During the study period, 567 patients received a diagnosis of IH (Figure). Of these patients, 202 (36%) were considered to have complicated IHs requiring treatment with propranolol with ECG screening completed. Four patients were excluded from the study because they received a diagnosis of PHACE syndrome. Of the 198 patients remaining, 49 (25%) were found to have ECG abnormalities either via screening or workup for heart murmurs, 35 (18%) had symptoms that were discussed among or evaluated by cardiology consultants, and 26 (13%) had echocardiograms. Further details are provided in the Figure. Ultimately, no contraindications to propranolol were discovered, and all 198 patients began treatment.

Although it is difficult to estimate the reimbursement for pediatric health care services, Medicare data provide a benchmark for understanding health care spending attributed to cardiac screening. The average Medicare reimbursements for an ECG and an echocardiogram are $53.36 and $640.77, respectively.4 Using these Medicare charges, in just 2 years at our center, we found that routine ECG screening led to $10 000 in health care spending and that the echocardiograms resulting from routine ECG screening led to $2000 in health care spending, for total expenditures of approximately $12 000. These numbers do not include patients who completed a PHACE syndrome workup because we would still recommend a cardiac evaluation for those patients, nor do they include patients who received an evaluation for a heart murmur. Overall, this is a low estimate because these reimbursements are for adult ECGs and do not include the cost of cardiology consultation and follow-up. While this may seem inexpensive, when considering a 2% incidence of IH5 with approximately 4 million births per year in the United States6 and a conservative estimate of 10% of these cases requiring propranolol,1 the health care expenditure is greater than $425 000 per year for a study that rarely changes management.

Discussion

During a 2-year period at our institution, the routine ECG screenings prior to initiation of treatment with propranolol found no contraindications, with all patients receiving treatment with no reported significant adverse events. The cost to the health care system, the work time lost for families, and the risk of further delaying the initiation of propranolol treatment due to the requirement of ECG screening does not justify its broad application in our opinion because it rarely, if ever, changes medical management.

We propose reserving pretreatment ECG for those patients with bradycardia, with features concerning for PHACE syndrome, or who have a history of arrhythmia, a family history of early cardiac death or congenital heart disease, or a maternal history of connective tissue disease. Routine screening with ECG prior to initiating treatment with propranolol is costly, and there is no adequate evidence for its use given the low probability of detecting a contraindication.

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Article Information

Corresponding Author: Jenna L. Streicher, MD, Section of Dermatology, Department of Pediatrics, Children’s Hospital of Philadelphia, 3550 Market St, 2nd Floor Dermatology, Philadelphia, PA 19104 (streicherj@email.chop.edu).

Published Online: July 25, 2016. doi:10.1001/jamapediatrics.2016.0824.

Author Contributions: Dr Streicher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Streicher, Riley.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Streicher, Castelo-Soccio.

Statistical analysis: Streicher, Riley.

Administrative, technical, or material support: Streicher, Castelo-Soccio.

Study supervision: Streicher, Castelo-Soccio.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 42nd Annual Meeting of the Society for Pediatric Dermatology; July 17, 2016; Minneapolis, Minnesota.

References
1.
Haggstrom  AN, Drolet  BA, Baselga  E,  et al.  Prospective study of infantile hemangiomas: clinical characteristics predicting complications and treatment.  Pediatrics. 2006;118(3):882-887.PubMedGoogle ScholarCrossref
2.
Drolet  BA, Frommelt  PC, Chamlin  SL,  et al.  Initiation and use of propranolol for infantile hemangioma: report of a consensus conference.  Pediatrics. 2013;131(1):128-140.PubMedGoogle ScholarCrossref
3.
Raphael  MF, Breugem  CC, Vlasveld  FA,  et al.  Is cardiovascular evaluation necessary prior to and during beta-blocker therapy for infantile hemangiomas?: a cohort study.  J Am Acad Dermatol. 2015;72(3):465-472.PubMedGoogle ScholarCrossref
5.
Anderson  KR, Schoch  JJ, Lohse  CM, Hand  JL, Davis  DM, Tollefson  MM.  Increasing incidence of infantile hemangiomas (IH) over the past 35 years: correlation with decreasing gestational age at birth and birth weight.  J Am Acad Dermatol. 2016;74(1):120-126.PubMedGoogle ScholarCrossref
6.
Hamilton  BE, Martin  JA, Osterman  MJ, Curtin  SC, Matthews  TJ.  Births: final data for 2014.  Natl Vital Stat Rep. 2015;64(12):1-64.PubMedGoogle Scholar
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