Symptoms of arterial hypotension

Symptoms of primary arterial hypotension in children are variable and diverse. Often, patients present numerous complaints that reflect concomitant changes in the central nervous system (headache, decreased physical and mental performance, dizziness, emotional lability, sleep disturbance, autonomic paroxysms), cardiovascular system (pain in the heart, palpitation), gastrointestinal tract (loss of appetite, pain in the epigastric region and along the bowels, not associated with food intake, a feeling of heaviness in the stomach, aerophagia, vomiting, nausea, flatulence, constipation). Among other complaints may be intolerance of travel on transport, prolonged subfebrile condition, attacks of feeling lack of air, arthralgia, myalgia.

The prevalence of these or other complaints in children and adolescents with arterial hypotension is within wide limits. The most common are cephalalgia (90%), fatigue and weakness (70%), emotional lability (72%). In half of cases, there are increased irritability (47%), decreased physical performance (52%), dizziness (44%), cardialgia (37%). Less frequently, patients complain of decreased appetite, abdominal pain, complaints related to dyspeptic and dyskinetic intestinal disorders (22%), vegetative paroxysms (22%), fever (18%), epistaxis (12%), syncope (eleven%). 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 different ratios) two main symptoms can be distinguished. The first combines a variety of functional somatovegetative disorders, and the second - neuropsychic.

Among somatovegetative syndromes, it is possible to isolate obshenevrotichesky, cerebral, cardiovascular and gastroenterological, which is caused by shifts in neurovegetative regulation.

Headache. Separate descriptions deserve cephalgia in patients with arterial hypotension, not only because this is the most common complaint, but also because they most accurately reflect disorders in the sensory sphere. A typical feature of a headache in children with arterial hypotension is its "morning" manifestation, it often appears shortly after awakening, accompanied by weakness and malaise, which is referred to as a symptom of "morning asthenia." Pain paroxysmal, intense, pulsating in nature, often occurs in the fronto-parietal, less often in the occipital region. It increases in the first lessons in the school, can occur against the background of changing weather conditions, in conflict situations.

Pain in the abdomen is noted in almost one third of cases. More often it occurs epi- and mesogastric. It is indistinct, does not involve eating, does not have permanent localization.

Changes from the central nervous system. They are manifested by increased fatigue, weakness, lack of vivacity even after prolonged sleep, constant fatigue, sharply increasing at the end of lessons, lethargy, apathy. Characteristic diurnal changes in well-being. In most cases, patients with arterial hypotension immediately after sleep feel sluggish, tired, after 1-1.5 h, well-being and mood improve, working capacity increases, but by 14-15 h again fatigue appears.

Mental exhaustion in children is manifested by a weakening of memory, a disturbance of attention, a loss of ability to prolonged stress, distraction, a decrease in mental capacity for work. Reduction in physical performance is associated with a decrease in the reserve capabilities 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 options for the course of arterial hypotension

Given 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 severity of clinical manifestations of arterial hypotension:

• the level of blood pressure lowering, its stability or lability:
• intensity and duration of headaches;
• the presence and frequency of autonomic paroxysms;
• presence of orthostatic disorders and fainting;
• degree of psychophysical disadaptation.

To determine the course of arterial hypotension, it is necessary to determine the degree of reduction in blood pressure, as well as the stability or lability of these changes. This is important not only from the 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	Heavy Current	Medium-heavy current	Light current
Stability of arterial hypotension	Stable, a score of blood pressure per week - 50-70 points	Stable, a score of blood pressure for the week - 40-50 points	Labile, a score of blood pressure per week - 20-40 points
Cephalgia	Intense, dramatically reducing efficiency; duration of more than 2 hours, can occur daily or up to 2-3 times a week, in the morning, are stopped only by medicines; lead to maladaptation:	Moderate intensity, limit working capacity, duration up to 2 hours, can arise from 2-3 times a week or daily, in the afternoon, are stopped by medications	Episodic, low intensity, duration up to 1 hour, pass independently
Vegetative paroxysms	Vagoinsular or mixed character with a frequency of 1 time per month	Vagoinsular or mixed character with a frequency of 1 time per quarter	None
Orthostatic disorders and syncope	Dizziness occurs when the body position is changed or when it is in the vertical position for a long time; Syncope of orthostatic or vasovagal character on the background of emotional stress	Short-term dizziness of orthostatic character; a history of rare syncope	Dizziness is not typical, there is no fainting
Disadaptation	Expressive, reduced physical and mental performance, deterioration in academic performance, reduced social contacts	Partial disadaptation with moderate decrease in mental and physical performance, improvement after rest	Moderate decline in physical performance At the end of the day

Objectively determine the stable or labile nature of the course of arterial hypotension allows a scoring of the blood pressure level within a week. Blood pressure is measured three times daily for 7 days. At the same time, the level of systolic, diastolic and pulse arterial pressure is assessed. The systolic and diastolic blood pressure values below the 10th percentile of the distribution curve of this indicator are estimated by 2 points, from the 10th to the 25th percentile by 1 point, above the 25th percentile by 0 points. The pulsatile arterial pressure is below 30 mm Hg. 2 points, from 30 to 40 mm Hg. - 1 point. After that, the sum of points for the week is counted.

On the stable nature of arterial hypotension, the sum of scores is more than 40, the labile one is less than 40. In case of severe disease, the sum of the scores corresponds to 50-70, with an average weight of 40-50, with a light weight of 20-40.

Severe course of arterial hypotension

A sharp decrease in the quality of life is characteristic, which is due to the very poor health of patients. Children make a large number of complaints.

• Headache. At the forefront in the clinical picture is a frequent severe headache, sharply reducing the adaptive capabilities of the child. It is often so pronounced that children can not continue their usual activities, play, attend school classes, usually go to bed. The pain occurs already in the morning hours, soon after awakening, is greatly enhanced in the first lessons at school. Pain may occur daily up to 2-3 times per week. It usually stops only after taking analgesics. Headache diffuse, more often constantly pressing, less often pulsating, sometimes migraineous.
• Vertigo occurs when you change the position of the body, moving from a horizontal position to a vertical position, while performing gymnastic exercises. Often it occurs with a prolonged vertical position of the body, staying in stuffy rooms. In a number of cases, dizziness is combined with vagotonic vegetative manifestations in the form of sharp pallor of the skin, cold sweat, visual impairment (a veil before the eyes, flashing of flies), noise in the ears, nausea, a sharp drop in blood pressure.
• Syncope, or syncope, is a frequent clinical symptom in severe arterial hypotension. The duration of syncope is 30 seconds to 5-7 minutes. Often there is a deep loss of consciousness, but unlike neurogenic fainting, they are not accompanied by cramps. Fainting occurs on the background of psychoemotional stress, with a prolonged stay in an upright position. Often psychoemotional stress is associated with a reaction of fear when taking blood, removing teeth and other painful manipulations.
• Vegetative paroxysms are a frequent clinical manifestation of arterial hypotension, especially in severe disease. In most cases, they are of a vagoinsular character. Typical for them is a sharp disturbance of health, the appearance of sudden weakness, lethargy, nausea, salivation. Pallor of the skin with a cold sticky sweat, cramping pain in the abdomen, lowering blood pressure, in some cases accompanied by tachycardia.
• Decrease in physical working capacity is manifested by fast fatigue, the need for long rest after school hours or a small physical load. In some cases, due to severe asthenic syndrome, children refuse to attend school.
• Decreased mental performance manifests itself in memory impairment, ability to concentrate attention, quick distraction, absent-mindedness, slower associative thinking, which adversely affects school performance, requires more time to complete the lessons.

Thus, with severe arterial hypotension the most pronounced social maladaptation, orthostatic disorders, arterial pressure is constantly reduced.

Moderately severe course of arterial hypotension

Among the complaints, headaches are also prevalent. However, compared with the severe course of the disease, they are less intense, occur more often in the second half of the day, last for 1-2 hours, pass after rest, less often there is a need for taking analgesics. Typical symptoms include dizziness, presyncopal or syncopal conditions of vasodepressor nature.

Often children complain of discomfort or pain in the chest (cardialgia). Pain usually stitching, less pressing, for a duration of a few seconds to several minutes, occurs mainly in the afternoon against a background of emotional overstrain. As a rule, these feelings occur in children with a high level of anxiety, various fears.

Light current of arterial hypotension

For an easy variant of the course of arterial hypotension, psychoemotional complaints are typical: frequent mood swings, touchiness, tearfulness, restless sleep. Short temper. Cardialgia often occurs. The headache is not intense, it arises against the background of emotional overstrain. Dizziness, fainting, vegetative paroxysms are absent.

Thus, there is a distinct relationship between persistence, as well as the degree of reduction in blood pressure and severity of orthostatic disorders, intensity of headache, psycho-emotional and physical disadaptation.

Cardiovascular system condition

Changes in the cardiovascular system with arterial hypotension are minimal and are of a functional dependent nature. As a rule, the boundaries of relative cardiac dullness are within the age limit, only in 25% of cases there is a tendency to expand the boundaries of the heart to the left. With auscultation, you can identify muffled heart tones, often a third tone is heard, there is a tendency to bradycardia. The above changes on the part of the heart fit into the concept of "vagotonic heart", suggested by Zelenin.

With arterial hypotension there are no structural changes in the heart, which is confirmed by the data of EchoCG. At the same time, there is a compensatory reconstruction of the intracardiac hemodynamics, aimed at maintaining the mean hemodynamic pressure. This is evidenced by an increase in the final diastolic volume of the left ventricle at the level of 75-95th percentile in combination with the normal terminal systolic volume of the left ventricle, which reflects the increased ability of the myocardium to relax. These changes are combined with an increase in the contractile and pumping functions of the myocardium (high values of the ejection fraction and the rate 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 hyperkinetic type (69%) with high rates of minute circulation, especially in severe arterial hypotension. These changes are often accompanied by a marked decrease in the overall peripheral vascular resistance in combination with low mean hemodynamic pressure, which reflects violations of intracardiac and vascular mechanisms to compensate for low blood pressure. In patients with a moderate course of arterial hypotension, the hypokinetic type of circulation is more often detected. In children with a labile course of arterial hypotension, there are no differences in the prevalence of types of central hemodynamics in comparison with healthy ones.

On the ECG, you can identify sinus bradycardia, migration of the pacemaker, AV blockade of the 1st degree, syndrome of early repolarization. The bradycardia disappears in an upright position. The drug with atropine eliminates the AV blockade of the first degree. These changes are due to excessive vagotonic influence.

The combination of the expansion of the borders of the heart, moderate muffled heart tones, the presence of a third tone on the apex, pronounced bradycardia, AV blockade of the I degree often causes the erroneous diagnosis of rheumatism, myocarditis, and sinus node weakness syndrome. The results of electro- and echocardiography make it possible to exclude the organic character of the heart lesion and indicate the functional vagal dependent origin of these changes.

The state of the central nervous system

In children with arterial hypotension, changes in the central nervous system manifest themselves as a severe cerebral insufficiency. So, with a neurological examination, you can identify a combination of 5-7 minor symptoms, reflecting violations of craniocerebral innervation. These include weakness of convergence, asymmetry of skin folds, nystagmus with extreme leads of eyeballs, tremor of the eyelids, parasthesia, a feeling of "crawling crawling," restlessness in Romberg's posture, general muscle hypotension. Anxiety, frequent regurgitation, tremor of limbs and chin are indirect signs of transferred perinatal encephalopathy, revealed at an early age.

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

To confirm the neurological changes, it is necessary to perform electroencephalography.

The state of the autonomic nervous system

To vegetative manifestations in children with arterial hypotension are symptoms that reflect the predominance of parasympathetic influences. The number of vagotonic symptoms on average is 17, while in healthy children their number does not exceed 6. The most frequently revealed marbling of the skin, acrocyanosis, persistent red dermographism, increased sweating and chilliness, a tendency to pastose tissue, sinus bradycardia, III tone on the apex of the heart , intolerance of stuffy rooms, deep prolonged sleep, slow transition to wakefulness, violation of thermoregulation.

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

The most simple and informative method for evaluating the vegetative maintenance of the organism's activity is the clinoortostatic test. Her conduct is mandatory in the examination of children with arterial hypotension, as it allows to identify orthostatic disorders. In severe arterial hypotension, in 28% of cases a sympatoasthenic variant of a clinoortostatic test with a sharp drop in systolic and diastolic arterial pressure for 4-5 min of the vertical position of the body is detected. In this case, children get dizzy, sometimes up to a brief loss of consciousness.

There are sharp changes in the state in the form of paroxysmal pictures that reflect vegetative crises. Vegetative paroxysms (vagoinsular, sympathoadrenal and mixed) are considered as a syndrome of somatovegetative or psychovegetative disorders. With vagoinsular paroxysms, a sensation of general weakness suddenly appears and intensifies, darkening in the eyes, breathing is difficult as a sensation "lump in the throat", there is a noise in the ears, limbs become cold, wet, sharp pallor, bradycardia, sweating, low blood pressure, sometimes nausea, abdominal pain, polyuria.

Psycho-emotional and personal characteristics

According to modern ideas, vegeto-vascular dystonia is considered as a psycho-vegetative syndrome, in the origin of which psychoemotional stress and psychological features of personality are of great importance. In this regard, particular importance is attached to the evaluation of microsocial conditions that contribute to the formation of psychotraumatic circumstances that, when exposed to a person with limited opportunities for psychological adaptation, acquire the character of a chronic psychotrauma. For this reason, a particular role is played by the detailed collection of information that will allow us to assess the child's attitude to the disease, how it affects his behavior, efficiency, relationships with his friends, teachers.

It is necessary to collect data on the most serious events in the life of the child (illness, loss of loved ones, long separation) and clarify the reaction to them on his part. To assess the psychological conditions in which the child is brought up, the family composition, 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 style of child upbringing should be clarified. It is necessary to find out the bad habits of parents. In families with children with arterial hypotension, especially in severe conditions, there are often numerous psychotraumatic circumstances (incomplete families, serious illnesses or the death of one of their parents, alcoholism, quarrels in the family).

Also, the source of psychoemotional tension is the conflicts in the microsocial sphere, difficulties in communicating. The test of unfinished sentences helps to evaluate these difficulties objectively. The results of this test indicate that for children with arterial hypotension, the most important are violations of relationships with the father, adolescents of the opposite sex, peers. Children have fears, fears, unbelief in their strength, dissatisfaction with the past, a negative assessment of the future, an increased sense of guilt.

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

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

Thus, children with arterial hypotension have certain constitutional and acquired personality characteristics: intraversion, emotional variability, melancholic temperament type, high level of personal and reactive anxiety, asthenic type of response, increased concern about their health, low level of motivation to achieve the goal, resources of the individual. These features are most characteristic of children with severe stable arterial hypotension.

Children with a pronounced psychological inappropriateness should be examined by a psychiatrist in order to identify psychopathological disorders. The psychopathological symptom complex is mainly represented by functional disorders of sensitivity: sensory disorders, which are manifested by numerous subjective complaints. Prevail cephalgia, most often in the fronto-parietal region, less often in the occipital region. Less often there is oppressive or burgeoning pain in the forehead, the feature of which is a kind of irradiation into the orbit, which can be accompanied by a painful feeling of squeezing out the eyeballs. Often there is a sudden stitching pain in the left half of the chest, increasing during inspiration. The appearance of these sensations is accompanied by a psychologically understandable reaction of tension, alertness. Children make attempts to hold their breath, take a resting pose, and with more severe pain they actively express their complaints, try to attract the attention of adults, ask for help. Pain can be accompanied by sensations of palpitations, cardiac arrest, fright, fear of death, a feeling of shortness of breath, pallor or flushing of the face, sweating, osteoporotic hyperkinesis (that is, cardiopathic raptus known as panic attacks develop). In some cases, these changes are accompanied by a feeling of general bodily discomfort and a reduced mood. Unpleasant sensations on the part of the abdomen do not have a definite disposition, they are of a volatile character, they are not connected with the ingestion of food.

Often there are volatile dull or aching pains in the limbs, a feeling of compression in the area of large joints of the legs, in the shoulder girdle, and the calf muscles. Characteristic of the "restless legs", which in modern psychiatry is considered as a sensitive equivalent of anxiety. It occurs in the evening before falling asleep.

To the manifestations of a widespread violation of sensitivity include complaints of general weakness, fatigue, lethargy, undefined heaviness in the whole body, a desire to lie, increased drowsiness, an indeterminate feeling of general ill health, physical discomfort. At the same time, a feeling of slight gravity in the head, "swaddling eyes", combined with a feeling of wiggle, inner turning, that the patients are regarded as dizziness can arise. Sometimes in such cases, complex depersonalization and derealization patterns unfold: the feeling of flight, the sense of loss of one's own body, the sensation of the unusual and incomprehensible change in the environment, the phenomena of "already seen", "already experienced". Thus there can be a sensation of "loss" of thinking, breakage and chaos of thoughts. The listed signs are unstable, variable, their occurrence is clearly connected with external and internal influences. In the overwhelming majority of cases, the more or less pronounced daily and seasonal dependence of the course of the disease persists.

Psychoemotional disorders are also variable and diverse. At the forefront are disorders of the affective sphere. They are masked in nature, which makes it difficult to identify them and evaluate them correctly. In this case, there are unique forms of psychological protection with a pronounced ability to displace by primitive hysterical mechanisms, the desire to transfer their own problems and conflicts to surrounding and close people. Typically insufficient development of the personal sphere (in particular, a relatively narrow range of expressive-expressive forms of manifestations of affect). All this contributes to the formation of erased atypical, reduced and masked forms of affective disorders.

Emotional disturbances most often have the character of a peculiar dysthymia, in which the affect of discontent predominates with the experience of a loss of vivacity, freshness, loss of joy with a mildly expressed oppression with unclear mental discomfort. In rare cases, depressive states are formed that are close to classical depression.

All patients develop more or less pronounced neurotic disorders during the development of the disease, which represent changes in the personality to the resulting impairment of the state of health, the peculiarities and severity of the disturbance of the microsocial connections brought about by the disease. Such disorders include discontent with oneself and others with manifestations of capriciousness, negativism, sometimes aggressiveness, reduction of loads with restriction of interests, a decrease in gaming activity, avoidance of school activities up to the formation of "school phobia". It is possible to develop somatic self-awareness, alertness to one's health, fear of the disease, its relapses, fears for one's life, mental health. In the most pronounced cases, hypochondriacal experiences become the main component of social inaccessibility, weight the course of the disease and require special psycho- and sociocorrectional work.

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