ECG Screening Before Propranolol in Infantile Hemangioma: Yes or No?

William T. Basco, Jr, MD, MS


December 30, 2016

ECG Screening Before Propranolol Therapy

Infantile hemangioma requires treatment or intervention, owing to complications, in about one fourth of cases, and propranolol is a first-line therapy.[1] Although a consensus report for the safe use of propranolol in infants has been published,[2] the workgroup could not reach agreement on whether ECG should be routinely ordered.

Streicher and colleagues[1] conducted a study to evaluate the cost of routine prescreening with an ECG before propranolol treatment in infants with hemangioma. This study was a case series of 198 children seen at a single institution from 2013 to 2015 who had ECGs before initiation of propranolol therapy.

Among the children who received an ECG, an ECG abnormality was found in 25% of the infants. Moreover, 13% of all infants had an echocardiogram. After complete evaluation, it was determined that none of the children had a problem that would preclude propranolol treatment, and all were begun on therapy.

Using local costs, the researchers calculated that the cost of pretherapy screening was an additional $53 for every child who had an ECG and $641 for every child who had an echocardiogram. They concluded that in this cohort, routine ECG screening before initiating propranolol therapy revealed no abnormalities and added considerable cost. They suggest that ECG testing should be limited to children with bradycardia; those with arrhythmia; those who require evaluation for PHACE syndrome[3]; and those with a family history of early cardiac death, congenital heart disease, or connective tissue disease.


It would certainly be difficult to make a blanket conclusion that ECGs are not indicated before propranolol therapy on the basis of experience from one institution, but it is vitally important that these data are shared. The study authors are appropriately cautious when discussing their study.[1] In some ways, the data show the problems that arise when one does testing, and positive results that end up being false-positive lead to further testing, cost, family inconvenience, child discomfort, and family anxiety. The study suggests that we rely on history and physical exam findings to guide testing, and that's never bad advice.

One of the reasons I reviewed this article was to remind people of the availability of consensus-derived best practices for when to consider treatment, when to consider an ECG, doses for initiation and maintenance of propranolol therapy, side effects to watch for, and recommendations for monitoring. The recommendations also cover the initiation of therapy in inpatients vs outpatients. Check them out here.


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