Cardiac Screening in Infants with Infantile Hemangiomas before Propranolol Treatment

Abstract

There is no uniform pretreatment cardiac evaluation for infants treated with oral propranolol, which is now the drug of choice for hemangiomas of infancy requiring systemic medical intervention. The aim of this study was to report and evaluate the findings of pretreatment cardiac evaluation. Data were reviewed for patients evaluated by a single hemangioma specialist and a single pediatric cardiologist prior to initiation of propranolol for infantile hemangioma. Cardiac evaluation included a complete echocardiogram. From July 2009 through January 2013, 239 consecutive patients 12 months of age or younger (median 2.7 months) were screened. No patients had cardiac contraindications to propranolol. However, 50 patients (21%) had an abnormal echocardiogram: 39 atrial septal defects (5 associated with right heart enlargement), 6 ventricular septal defects, 2 patent ductus arteriosus, 1 aortic coarctation, 1 pulmonary valve stenosis, and 1 aberrant subclavian artery. Overall, 69 patients had an audible heart murmur, 44 of which were not associated with pathologic findings on echocardiogram. All patients with a ventricular septal defect and 16 of 39 with an atrial septal defect had a murmur. Two of seven patients with PHACE syndrome had cardiac anomalies. None of the findings precluded the use of propranolol. Assisted reproductive technologies were used in 18% of pregnancies, including in vitro fertilization in 12%. Cardiac contraindications to propranolol treatment are uncommon in patients with infantile hemangioma. However, anatomic abnormalities were more common than reported in the general population. Further study is necessary to determine whether there is a pathogenic relationship between cardiac defects and nonsyndromic infantile hemangioma.

Treatment of infantile haemangiomas: recommendations of a European expert group

“…In these cases, consultation with a paediatric cardiologist is mandatory. Since all other possible cardiac contraindications can be detected by history, physical examination, a routine echocardiography, is not essential unless there is a specific clinical indication [7,18]. Obviously, baseline values are required for heart rate and blood pressure.…”

“…The standard dose in the majority of studies reported to date is 2 mg/kg/day [3,4,7,26,28,32,44,50,54,56] with a range of dosing between 0.5 and 3.0 mg/kg. As demonstrated in the multicenter study [40], 3 mg/kg/day is superior to 1 mg/kg/day, but studies comparing 2 and 3 mg/kg/day have not been reported yet.…”

“…Another dose-related issue is the dosing interval. Again, in the majority of studies, three equal doses were applied [4,7,18,26,28,32,44,50,54,56] as opposed to two in the multicenter study [40]. Mean serum levels are about 12 % higher (67.1 vs. 60.1 ng/ml, range 24-127 and 26-140 ng/ml, respectively) with two instead of three doses [14].…”

Diagnosis and Management of Infantile Hemangioma

“…However, pretreatment cardiac screening appears to be of limited value in patients with an unremarkable cardiac history and examination. [176][177][178][179] Relative contraindications to the use of propranolol for IH include cardiogenic shock, sinus bradycardia, hypotension, heart block greater than the first degree, heart failure, bronchial asthma, and known hypersensitivity to the drug (Table 5). 161 Special precautions have been suggested for children diagnosed with PHACE syndrome and significant intracranial vascular anomalies because of the theoretically increased risk of acute ischemic stroke.…”

“…The use of b-blockers can be also be associated with adverse cardiac effects, including bradycardia and hypotension, both of which are generally asymptomatic and do not require intervention. 177 Less common complications include bronchospasm and hypoglycemia, the latter of which has the potential to induce seizures. 159,161,180,181 In a systematic review of propranolol treatment of IH, there were 371 total adverse effects reported in 1189 patients.…”