Symptoms of arterial hypotension

Symptoms of primary arterial hypotension in children are variable and varied. Patients often present numerous complaints reflecting concomitant changes in the central nervous system (headache, decreased physical and mental performance, dizziness, emotional lability, sleep disturbances, vegetative paroxysms), cardiovascular system (pain in the heart, palpitations), gastrointestinal tract (loss of appetite, pain in the epigastric region and along the intestines not associated with food intake, a feeling of heaviness in the stomach, aerophagia, vomiting, nausea, flatulence, constipation). Other complaints may include intolerance to travel by transport, prolonged subfebrile temperature, attacks of shortness of breath, arthralgia, myalgia.

The prevalence of various complaints in children and adolescents with arterial hypotension varies widely. The most common are cephalgia (90%), increased fatigue and weakness (70%), emotional lability (72%). In half of the cases, there is increased irritability (47%), decreased physical performance (52%), dizziness (44%), cardialgia (37%). Less often, patients complain of decreased appetite, abdominal pain, complaints associated with dyspeptic and dyskinetic intestinal disorders (22%), vegetative paroxysms (22%), increased body temperature (18%), nosebleeds (12%), fainting (11%). myalgia (8%). arthralgia (7%).

Despite the noticeable variability of complaints, it is possible to establish a certain pattern of the clinical picture, in which in each individual case (in various proportions) two main symptom complexes can be distinguished. The first unites various functional somatovegetative disorders, and the second - neuropsychic ones.

Among the somatovegetative syndromes, one can distinguish general neurotic, cerebral, cardiovascular and gastroenterological, which are caused by shifts in neurovegetative regulation.

Headache. Cephalgia in patients with arterial hypotension deserves a separate description, not only because it is the most common complaint, but also because it most accurately reflects disturbances in the sensory sphere. A typical feature of headache in children with arterial hypotension is its "morning" manifestation, it often occurs soon after waking up, accompanied by weakness and malaise, which is designated as a symptom of "morning asthenia". The pain is paroxysmal, intense, pulsating in nature, most often occurs in the frontal-parietal, less often in the occipital region. It intensifies during the first lessons at school, can occur against the background of changing weather conditions, in conflict situations.

Abdominal pain is observed in almost one third of cases. It most often occurs in the epi- and mesogastrium. It is vague, not associated with food intake, and does not have a constant localization.

Changes in the central nervous system. They are manifested by increased fatigue, weakness, lack of energy even after a long sleep, constant fatigue, which increases sharply at the end of classes, lethargy, apathy. Diurnal changes in well-being are characteristic. In most cases, patients with arterial hypotension feel lethargic and tired immediately after sleep, after 1-1.5 hours their well-being and mood improve, their working capacity increases, but by 2-3 pm fatigue appears again.

Mental exhaustion in children is manifested by weakening of memory, attention disorder, loss of ability to sustain prolonged stress, absent-mindedness, and decreased mental performance. A decrease in physical performance is associated with a decrease in the reserve capacity of the sympathetic nervous system. Changes in the central nervous system are largely due to a violation of autoregulation of cerebral circulation (arterial and venous).

Clinical variants of arterial hypotension

Considering the diverse clinical picture, variability in the number and characteristics of complaints, in children with arterial hypotension it is advisable to distinguish three variants of the course of the disease: severe, moderate and mild.

Criteria for the severity of clinical manifestations of arterial hypotension:

• the level of reduction in blood pressure, its stability or lability:
• intensity and duration of headaches;
• presence and frequency of vegetative paroxysms;
• presence of orthostatic disorders and fainting;
• degree of psychophysical maladaptation.

To determine the course of arterial hypotension, it is necessary to establish the degree of reduction in arterial pressure, as well as the stability or lability of these changes. This is important not only from a clinical point of view, but also for a differentiated approach to treatment tactics, which is of greater practical importance.

Characteristics of clinical variants of arterial hypotension depending on severity

Symptom	Severe course	Moderately severe course	Mild flow
Stability of arterial hypotension	Stable, weekly blood pressure score - 50-70 points	Stable, weekly blood pressure score - 40-50 points	Labile, weekly blood pressure score - 20-40 points
Cephalgia	Intense, sharply reducing work capacity; lasting more than 2 hours, can occur daily or up to 2-3 times a week, in the first half of the day, can only be relieved by medications; lead to maladaptation:	Moderate intensity, limit work capacity, last up to 2 hours, may occur 2-3 times a week or daily, in the afternoon, relieved by medications	Episodic, low intensity, lasting up to 1 hour, pass on their own
Vegetative paroxysms	Vagoinsular or mixed nature with a frequency of 1 time per month	Vagoinsular or mixed nature with a frequency of once per quarter	None
Orthostatic disorders and syncope	Dizziness, which occurs when changing body position or staying in a vertical position for a long time; orthostatic or vasovagal fainting due to emotional stress	Brief orthostatic dizziness; history of rare fainting spells	Dizziness is not typical, fainting is absent
Maladaptation	Severe, decreased physical and mental performance, deterioration in academic performance, decreased social contacts	Partial maladaptation with moderate decrease in mental and physical performance, improvement after rest	Moderate decrease in physical performance At the end of the day

An objective determination of the stable or labile nature of the course of arterial hypotension is made possible by scoring the level of arterial pressure during the week. Arterial pressure is measured three times, daily for 7 days. In this case, the level of systolic, diastolic and pulse arterial pressure is assessed. The values of systolic and diastolic arterial pressure below the 10th percentile of the distribution curve of this indicator are assessed with 2 points, from the 10th to the 25th percentile - 1 point, above the 25th percentile - 0 points. Pulse arterial pressure below 30 mm Hg is assessed with 2 points, from 30 to 40 mm Hg - 1 point. After that, the sum of points for the week is calculated.

A stable character of arterial hypotension is indicated by a score of more than 40, and a labile character is indicated by a score of less than 40. In severe cases of the disease, the score is 50-70, in moderate cases - 40-50, and in mild cases - 20-40.

Severe arterial hypotension

A sharp decline in the quality of life is typical, which is caused by the very poor health of patients. Children present a large number of complaints.

• Headache. Frequent, severe headaches come to the forefront of the clinical picture, sharply reducing the child's adaptive capabilities. They are often so severe that children cannot continue their usual activities, play, attend school, and usually go to bed. The pain occurs in the morning, soon after waking up, and intensifies significantly during the first lessons at school. The pain can occur daily up to 2-3 times a week. It usually stops only after taking analgesics. The headache is diffuse, often of a constantly pressing, less often pulsating, sometimes migraine nature.
• Dizziness occurs when changing body position, moving from a horizontal to a vertical position, or when doing gymnastic exercises. It often occurs when the body is in a vertical position for a long time or when staying in stuffy rooms. In some cases, dizziness is combined with vagotonic vegetative manifestations in the form of a sharp pallor of the skin, cold sweat, visual impairment (a veil before the eyes, flickering spots), tinnitus, nausea, and a sharp drop in blood pressure.
• Syncopal or fainting states are a common clinical symptom in severe cases of arterial hypotension. The duration of fainting is from 30 seconds to 5-7 minutes. Deep loss of consciousness often occurs, but unlike neurogenic fainting, they are not accompanied by convulsions. Fainting occurs against the background of psycho-emotional stress, when staying in an upright position for a long time. Often, psycho-emotional stress is associated with a fear reaction when taking blood, removing teeth and other painful manipulations.
• Vegetative paroxysms are a frequent clinical manifestation of arterial hypotension, especially in severe cases of the disease. In most cases, they are of a vagus-insular nature. They are characterized by a sharp deterioration in well-being, the appearance of sudden weakness, lethargy, nausea, salivation, paleness of the skin with cold sticky sweat, cramping abdominal pain, decreased blood pressure, in some cases accompanied by tachycardia.
• Reduced physical performance is manifested by rapid fatigue, the need for a long rest after school or light physical activity. In some cases, due to severe asthenic syndrome, children refuse to attend school.
• A decrease in mental performance is manifested in a deterioration in memory, ability to concentrate, easy distraction, absent-mindedness, slowing down of associative thinking, which negatively affects school performance and requires more time to complete homework.

Thus, in severe cases of arterial hypotension, social maladaptation and orthostatic disorders are most pronounced, and blood pressure is constantly reduced.

Moderate arterial hypotension

Headaches also predominate among complaints. However, compared to severe cases of the disease, they are less intense, occur more often in the afternoon, last 1-2 hours, pass after rest, and require analgesics less often. Typical symptoms include dizziness, presyncopal or syncopal states of vasodepressor nature.

Children often complain of discomfort or pain in the chest area (cardialgia). The pain is usually stabbing, less often pressing, lasting from a few seconds to a few minutes, and occurs mainly in the afternoon due to emotional stress. As a rule, these sensations occur in children with a high level of anxiety and various fears.

Mild arterial hypotension

For a mild course of arterial hypotension, complaints of a psycho-emotional nature are characteristic: frequent mood swings, resentment, tearfulness, restless sleep. irascibility. Cardialgia often occurs. Headache is not intense, occurs against the background of emotional overstrain. Dizziness, fainting, vegetative paroxysms are absent.

Thus, there is a clear relationship between the persistence and degree of reduction in blood pressure and the severity of orthostatic disorders, headache intensity, psychoemotional and physical maladaptation.

Cardiovascular health

Changes in the cardiovascular system with arterial hypotension are minimal and have a functional vago-dependent nature. As a rule, the boundaries of relative cardiac dullness are within the age norm, only in 25% of cases is there a tendency to expand the boundaries of the heart to the left. Auscultation can reveal muffled heart sounds, a third tone is often heard, there is a tendency to bradycardia. The above changes in the heart fit into the concept of "vagotonic heart", proposed by Zelenin.

In arterial hypotension, there are no structural changes in the heart, which is confirmed by echocardiography data. At the same time, there is a compensatory restructuring of intracardiac hemodynamics aimed at maintaining the average hemodynamic pressure. This is evidenced by an increase in the left ventricular end-diastolic volume at the level of the 75-95th percentile in combination with a normal left ventricular end-systolic volume, which reflects an increased ability of the myocardium to relax. These changes are combined with an increase in the contractile and pumping function of the myocardium (high ejection fraction and velocity of circular fiber contraction).

Central hemodynamics in arterial hypotension can be represented by both hyperkinetic and eu- and hypokinetic types of blood circulation. The most frequently detected is the hyperkinetic type (69%) with high values of the minute volume of blood circulation, especially in severe arterial hypotension. The listed changes are often accompanied by a marked decrease in total peripheral vascular resistance in combination with low values of mean hemodynamic pressure, which reflects disturbances in the intracardiac and vascular mechanisms of compensation for low blood pressure. In patients with moderate arterial hypotension, the hypokinetic type of blood circulation is more often detected. In children with labile arterial hypotension, there are no differences in the prevalence of central hemodynamic types compared to healthy children.

The ECG may reveal sinus bradycardia, pacemaker migration, first-degree AV block, and early repolarization syndrome. Bradycardia disappears in the vertical position. A drug test with atropine eliminates first-degree AV block. The above changes are due to excessive vagotonic influence.

The combination of widening of the heart borders, moderate muffled heart sounds, the presence of a third sound at the apex, pronounced bradycardia, and first-degree AV block often causes erroneous diagnosis of rheumatism, myocarditis, and sick sinus syndrome. The results of electro- and echocardiography allow us to exclude the organic nature of heart damage and indicate a functional vagal-dependent origin of these changes.

State of the central nervous system

In children with arterial hypotension, changes in the central nervous system manifest themselves as mild cerebral insufficiency. Thus, a neurological examination can reveal a combination of 5-7 minor symptoms reflecting disorders of craniocerebral innervation. These include weakness of convergence, asymmetry of skin folds, nystagmus at extreme abduction of the eyeballs, eyelid tremor, paresthesia, a feeling of "crawling ants", restlessness of the hands in the Romberg pose, general muscle hypotonia. Anxiety, frequent regurgitation, tremor of the limbs and chin are indirect signs of past perinatal encephalopathy, detected at an early age.

The presence of a characteristic intracranial hypertension syndrome is confirmed by echoencephaloscopy, craniography, and examination of the fundus. The combination of mild neurological symptoms and intracranial hypertension syndrome in children with primary arterial hypotension indicates the presence of residual organic cerebral insufficiency, which is most pronounced in severe arterial hypotension.

To confirm neurological changes, an electroencephalogram must be performed.

State of the autonomic nervous system

Vegetative manifestations in children with arterial hypotension include symptoms reflecting the predominance of parasympathetic influences. The number of vagotonic symptoms averages 17, while in healthy children their number does not exceed 6. The most frequently detected are marbling of the skin, acrocyanosis, persistent red dermographism, increased sweating and chilliness, a tendency to tissue pastosity, sinus bradycardia, the third heart sound at the apex, intolerance of stuffy rooms, deep prolonged sleep, a slow transition to wakefulness, and a violation of thermoregulation.

The vagotonic orientation of the vegetative tone is confirmed by cardiointervalography data. The Baevsky stress index, as a rule, does not exceed 30 conventional units, which indicates excessive vagotonic influences in the cardiovascular system. Vegetative reactivity in severe arterial hypotension also reflects insufficiency of sympathetic influences. Asympathicotonic reactivity is detected in 20% of children.

The simplest and most informative method for assessing the vegetative support of the body's activity is the clinoorthostatic test. It is mandatory when examining children with arterial hypotension, as it allows identifying orthostatic disorders. In severe arterial hypotension, in 28% of cases, a sympathoasthenic variant of the clinoorthostatic test is detected with a sharp drop in systolic and diastolic blood pressure for 4-5 minutes in a vertical body position. In this case, children experience dizziness, sometimes up to a short-term loss of consciousness.

Acute changes in the condition in the form of paroxysmal pictures reflecting vegetative crises are possible. Vegetative paroxysms (vagoinsular, sympathoadrenal and mixed) are considered as a syndrome of somatovegetative or psychovegetative disorders. With vagoinsular paroxysms, a feeling of general weakness, darkening in the eyes suddenly arises and intensifies, breathing becomes difficult as if there is a "lump in the throat", noise in the ears appears, the extremities become cold and damp, there is a sharp pallor, bradycardia, sweating, blood pressure decreases, sometimes nausea, abdominal pain, polyuria.

Psycho-emotional and personal characteristics

According to modern concepts, vegetative-vascular dystonia is considered a psychovegetative syndrome, in the origin of which psychoemotional stress and psychological characteristics of the individual are of great importance. In this regard, the assessment of microsocial conditions that contribute to the formation of psychotraumatic circumstances, which, when affecting an individual with limited psychological adaptation capabilities, acquire the character of chronic psychological trauma, is of particular importance. For this reason, a detailed collection of information plays a special role, which will allow us to assess the child's attitude to the disease, how it affects his behavior, performance, relationships with friends, teachers.

It is necessary to collect data on the most difficult events in the child's life (illness, loss of loved ones, long separation) and clarify the child's reaction to them. To assess the psychological conditions in which the child is raised, it is necessary to clarify the composition of the family, the relationship between the parents, as well as between each parent and the child, the number of quarrels and conflicts in the family, the degree of emotional interaction between parents and children, the child's upbringing style. It is necessary to find out whether the parents have bad habits. In families with children with arterial hypotension, especially in severe cases, there are often numerous psychotraumatic circumstances (single-parent families, serious illnesses or death of one of the parents, alcoholism, quarrels in the family).

Conflicts in the microsocial sphere and communication difficulties also serve as a source of psycho-emotional stress. The unfinished sentences test helps to objectively assess these difficulties. The results of this test indicate that for children with arterial hypotension, the most important are disturbances in relationships with the father, teenagers of the opposite sex, and peers. Children develop fears, concerns, lack of self-confidence, dissatisfaction with the past, a negative assessment of the future, and an increased sense of guilt.

A large number of interpersonal conflicts indicates a state of psychological and social maladjustment in children with arterial hypotension.

The Spielberger test allows an objective assessment of the anxiety level, which largely determines the severity of psychovegetative manifestations. In children with arterial hypotension, not only the level of reactive (situational) anxiety is increased, but also personal anxiety. In this case, anxiety is a characteristic psychological personality trait, while children tend to perceive a wide range of circumstances as a direct threat to their well-being and respond to them with a state of stress, subjectively experiencing emotional tension, concern, and anxiety.

Thus, children with arterial hypotension have certain constitutional and acquired personality traits: introversion, emotional variability, melancholic temperament, high level of personal and reactive anxiety, asthenic type of response, increased concern about their health, low level of motivation to achieve goals, decreased energy resources of the individual. The listed traits are most characteristic of children with pronounced stable arterial hypotension.

Children with pronounced psychological maladjustment should be examined by a psychiatrist in order to identify psychopathological disorders. The psychopathological symptom complex is mainly represented by functional sensitivity disorders: sensory disorders, manifested by numerous subjective complaints. Cephalgias predominate, more often in the frontal-parietal region, less often in the occipital region. Somewhat less often, there is a pressing or bursting pain in the forehead, the peculiarity of which consists in a kind of irradiation to the eye sockets, which can be accompanied by a painful sensation of squeezing out the eyeballs. Often there is a sudden stabbing pain in the left half of the chest, intensifying during inhalation. The appearance of these sensations is accompanied by a psychologically understandable reaction of tension, alertness. Children attempt to hold their breath, take a resting position, and with more pronounced pain, they actively express their complaints, try to attract the attention of adults, ask for help. The pain may be accompanied by a feeling of palpitations, cardiac arrest, fright, fear of death, a feeling of difficulty breathing, pallor or flushing of the face, sweating, chill-like hyperkinesis (i.e. cardiophobic raptures, known as panic attacks, develop). In some cases, these changes are accompanied by a feeling of general physical discomfort and low mood. Unpleasant sensations from the abdomen have no specific location, are fleeting in nature, and are not associated with food intake.

Frequently there are fleeting dull or aching pains in the limbs, a feeling of compression in the area of large joints of the legs, in the shoulder girdle, calf muscles. The symptom of "restless legs" is characteristic, which in modern psychiatry is considered as a sensory equivalent of anxiety. It occurs in the evening before falling asleep.

Symptoms of widespread sensitivity disorders include complaints of general weakness, fatigue, lethargy, vague heaviness in the whole body, desire to lie down, increased sleepiness, vague feeling of general ill health, physical discomfort. At the same time, a feeling of slight heaviness in the head, "a veil before the eyes" may arise in combination with a feeling of swaying, internal rotation, which patients regard as dizziness. Sometimes in such cases, complex depersonalization and derealization pictures unfold: a feeling of flying, a feeling of losing one's own body, a feeling of unusual and incomprehensible change in the environment, phenomena of "already seen", "already experienced". In this case, a feeling of "loss" of thinking, a break and chaos of thoughts may arise. The listed symptoms are unstable, changeable, their occurrence is clearly associated with external and internal influences. In the overwhelming majority of cases, a more or less pronounced daily and seasonal dependence of the course of the disease remains.

Psychoemotional disorders are also variable and diverse. Affective disorders come to the fore. They are masked, which makes it difficult to identify and evaluate them correctly. At the same time, specific forms of psychological defense arise with a pronounced ability to repress through primitive hysterical mechanisms, a desire to transfer one's own problems and conflicts to others and loved ones. Typically, the personal sphere is underdeveloped (in particular, a relatively narrow range of expressive forms of affect). All this contributes to the formation of erased atypical, reduced and masked forms of affective disorders.

Emotional disorders most often have the character of a kind of dysthymia, in which the affect of discontent prevails with the experience of a feeling of loss of vivacity, freshness, loss of joy with a weakly expressed personal oppression with vague mental discomfort. In rare cases, depressive states close to classical depression are formed.

All patients experience more or less pronounced neurotic disorders in the course of the disease development, which represent personality changes in response to the emerging disorders of well-being, the characteristics and degree of expression of the violation of microsocial connections brought about by the disease. Such disorders include dissatisfaction with oneself and others with manifestations of capriciousness, negativism, sometimes aggressiveness, reduced workload with limitation of interests, decreased play activity, avoidance of school activities up to the formation of "school phobia". It is possible to develop somatic self-absorption, alertness regarding one's health, fear of the disease, its relapses, concerns for one's life, mental health. In the most pronounced cases, hypochondriacal experiences become the main component of social maladjustment, aggravate the course of the disease and require special psycho- and socio-correctional work.

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