Symptoms of vegetative-vascular dystonia in children

The severity of subjective and objective symptoms of vegetative-vascular dystonia varies widely: from monosymptomatic, often observed in the hypertensive type of vegetative-vascular dystonia (increased arterial pressure in the absence of complaints), to the unfolded picture with an abundance of complaints indicating dysfunction of the cardiovascular system.

In the clinical picture of vegetative-vascular dystonia, hypotensive and hypertensive variants are distinguished, the main manifestation of which are changes in arterial pressure, as well as a cardiological variant with predominance of pain in the region of the heart.

The severity of the course of vegetative-vascular dystonia is determined by a complex of various parameters: severity of tachycardia, frequency of vegetative-vascular crises, pain syndrome, tolerance to physical exertion.

The hypotensive type of vegetative-vascular dystonia is established in cases when the magnitude of systolic blood pressure varies within the limits of 110-80 mm Hg, and diastolic - 45-60 mm Hg. And there are clinical signs of chronic vascular insufficiency.

Complaints of patients, the most significant for the diagnosis, are chilliness of the hands, feet and propensity to orthostatic disorders (dizziness when changing the position of the body, sharp turning of the head, trunk), intolerance of transport. There are manifestations of asthenovegetative syndrome: rapid exhaustion of mental and physical activity, memory loss, concentration of attention, weakness, increased fatigue. Children with hypotensive type of vegeto-vascular dystonia are characterized by lability of mood, high anxiety, conflictness, propensity to hypochondria.

When examined, the asthenic physique, the pallor of the skin, marbling, the pastosity of the tissues, the temperature of the skin of the extremities, the humidity of the palms and feet, and tachycardia are determined. The listed set of symptoms is typical for reducing cardiac output (the so-called hypokinetic type of hemodynamics), which is detected in more than 60% of patients with hypotensive type of vegetative-vascular dystonia. In most cases, the pathogenetic basis of hemodynamic disorders is the systemic hypotension of the veins, which is determined by plethysmography and indirectly by the dynamics of arterial pressure and heart rate during the orthostatic test. Characteristic decrease in systolic and pulsatile arterial pressure and a significant increase in heart rate (sometimes the appearance of extrasystoles). Usually in these cases, the tone of the small arteries of the skin and muscles is significantly increased (compensatory "centralization" of the circulation). If the compensatory vascular reaction and the increase in heart rate with orthostatic loading are insufficient (in patients with asympticotonia), in the process of orthostatic test, especially in the variant with passive orthostasis, the patients develop a sudden weakness, a feeling of dizziness. If the test does not stop in time, a syncope occurs, which is usually preceded by a sharp blanching of the facial skin, the appearance on it of small drops of sweat. A more rare, pathogenetic variant of arterial hypotension is associated with a decrease in the total peripheral resistance to blood flow at a normally normal or even increased cardiac output. Circulatory disorders with this option are minimal, and patients' complaints more often reflect a neurotic state or correspond primarily to regional circulatory disorders (most often in the form of hemicrania or another type of vascular headache). With an orthostatic test, these patients show a predominantly increased heart rate without a significant additional reduction in blood pressure, and at the beginning of the sample, even a slight increase is possible.

Often in children with hypotensive type of vegetative-vascular dystonia, a decrease in appetite, nausea, unrelated to food intake, periodic abdominal pain and spastic character constipation, migraine-like cephalgia with localization in the temporal and frontotemporal areas are revealed.

Hypertensive type of vegetative-vascular dystonia is established when transient increase in arterial pressure is revealed in children of older age, adolescents and young people, if other symptomatic forms of arterial hypertension are excluded and there are not enough grounds for the diagnosis of hypertension.

The presence and nature of complaints, as well as other manifestations of the disease, except for increasing blood pressure, are of importance mainly for differential diagnosis and pathogenetic analysis of arterial hypertension. Most adolescents with a hypertensive variant of vegetative-vascular dystonia do not complain for a long time. And only with increasing blood pressure can appear cephalgia, pain in the heart, dizziness, palpitations, flies flies before the eyes, feelings of heat, flushes to the head and neck. The headache occurs mainly with psychoemotional or physical overloads, it is aching, sometimes pulsating, with predominant localization in the occipital region, and rarely covers the entire head. Children with hypertensive type of vegetative-vascular dystonia often complain about pain in the region of the aching heart that appear more often after physical exertion. In patients noted emotional lability, increased fatigue, irritability, sleep disorders, hypochondria, meteorology.

The majority of patients are instrumentally determined to increase cardiac output (the so-called hyperkinetic type of hemodynamics) in the absence of a physiologically adequate reduction in the overall peripheral resistance to blood flow, although the tone of the arterioles of the skin and skeletal muscles often slightly deviates from the norm. In such cases, systolic and pulsatile arterial pressure usually increase, and the hemodynamic response in the clinoortostatic test, which these patients usually tolerate well, corresponds to the hypersympathicotonic type. In rare cases, the hypertensive type of vegetative-vascular dystonia is characterized by a predominant increase in diastolic blood pressure due to systemic hypertension of arterioles with normal or reduced cardiac output. In the latter case, complaints of fatigue, chilliness, sometimes shortness of breath, dizziness with prolonged standing (in transport, queues, guard posts, etc.) are possible. In such patients in the orthostatic sample, the increase in systolic blood pressure is usually small and short-lived, after 2-3 min of standing it can decrease, and the diastolic blood pressure rises and the pulse blood pressure decreases with a parallel increase in the heart rate (sympathetic-type).

Cardiological type of vegetative-vascular dystonia is established if there are no significant fluctuations in blood pressure, complaints about palpitation or heart failure, pain in the heart, dyspnea (without myocardial damage).

Objectively reveal abnormalities in the work of the heart - tachycardia, pronounced sinus arrhythmia (in patients older than 12 years), or supraventricular extrasystole or paroxysms of tachycardia, the presence of which is confirmed by ECG.

The cardiac output is explored and a phase analysis of the cardiac cycle is performed to help identify the so-called hyperhypokinetic types of hemodynamics, which is important for the pathogenetic diagnosis. Often the main manifestation of a cardial variant of vegetative-vascular dystonia is pain in the chest. There are three degrees of severity of the cardialgic variant.

• I degree - pain in the region of the heart, as a rule, stitching occurs rarely and mainly after psychoemotional stress. Pass independently or after psychotherapy.
• II degree - pains more often of a noisy character lasting 20-40 minutes appear several times a week and irradiate into the left shoulder, scapula, the left half of the neck. Pass after psychotherapeutic measures, sometimes after sedatives.
• III degree - dull aching pains lasting up to 1 hour or more appear daily and even repeatedly throughout the day. Pass after drug treatment.

Disorders of the function of the cardiovascular system in the form of a variety of clinical manifestations of a subjective and objective-functional nature without the presence of organic changes on the part of the cardiovascular system, according to the latest classification of vegetative disorders [Wayne AM, 1988], should be attributed to secondary cerebral (nassegmental) vegetative disorders.

In the analysis of clinical symptoms in patients with neurocirculatory dystonia (the term most often used in therapeutic practice and denoting a private cardiovascular variant of a broader concept - autonomic dystonia syndrome), heart pain was observed in 98% of patients.

Coronary angiography, considered the latest scientific achievement in the study of cardialgia, is performed annually in 500,000 patients in the US, with 10-20% of these studies showing the presence of normal, unchanged coronary arteries. Special studies conducted in patients with pain in the region of the heart with unchanged coronary arteries revealed in 37-43% of them signs of panic disorders. These data emphasize the frequency of disorders of the cardiovascular system, associated with a violation of the vegetative, more precisely - psycho-vegetative, sphere. An analysis of the phenomenological manifestations of neurogenic cardiovascular disorders makes it possible to identify their various variants: diesthetic, dysdynamic, and dysrhythmic in the framework of psychovegetative disorders.

Cardiological syndrome

As is known, the concept of "pain" is one of the most popular in the minds of people from all the physical sensations existing in a person (while the heart in antiquity seemed to be the "central organ of the senses"). The concept of "heart" - one of the main ideas that symbolize the main body that ensures human life. These two views are combined in patients' complaints in the form of one of the leading manifestations of autonomic dysfunction - "pain in the heart." Often, with a careful phenomenological analysis, it turns out that various sensations (for example, paresthesia, feelings of pressure, compression, etc.) are generally referred to by patients as "pain," and the territory of the left half of the chest, sternum, and sometimes even the right half of the chest, is generalized are designated by the patients as "heart".

To define these phenomena, there are several terms: "pain in the heart" (cardialgia), "pain in the heart" and "chest pain" (chest pain). The latter term is most often found in English-language publications.

Different concepts usually reflect certain pathogenetic representations of the relevant researchers.

Pain in the heart can have a different genesis. In the psycho-vegetative syndrome, pain can be a reflection of "purely" mental disorders (eg, depression) with a projection on this area or reflect vegetative dysregulation of heart function. Pain can also be of a muscular origin (due to increased breathing, hyperventilation). In addition, outside the psycho-vegetative and muscular mechanisms, situations occur that also cause pain in the heart. For example, the pathology of the esophagus and other organs of the gastrointestinal tract, radicular syndromes of a spondylogenic nature, lesion of the intercostal nerves can be a source of pain in the heart or a background for the development of algic manifestations, realized through psycho-vegetative mechanisms.

From the point of vegetological analysis of pain in the heart (this is the most appropriate term for us, although for the sake of brevity we put this meaning in the notion of "cardialgia"), we should divide it into two classes: cardialgia in the structure of the autonomic dystonia syndrome, clinically manifested by psycho-vegetative disorders, and cardiac syndrome with minimal concomitant vegetative disorders.

Cardialgia in the structure of pronounced manifestations of autonomic dystonia

This is the most frequent variant of pain in the heart, which is that the phenomenon of pain itself, being for a period of time leading in the clinical picture, is simultaneously in the structure of various affective and autonomic disorders (psychovegetative syndrome), pathogenetically associated with pain in heart. The ability of the doctor to "see", in addition to the phenomenon of cardialgia, also regularly accompanying her psycho-vegetative syndrome, as well as the ability to conduct a structural analysis of these manifestations allows to penetrate, at the clinical stage, the pathogenetic nature of these disorders for their adequate evaluation and therapy.

An analysis of the phenomenon of pain in the region of the heart makes it possible to determine in patients various variants of them with a large phenomenological scope according to the criteria being analyzed.

The localization of pain is most often associated with the projection zone on the skin of the apex of the heart, with the region of the left nipple and the precordial region; in some cases, the patient points with one finger to the place of pain. Pain can also be located behind the breastbone. In some patients, the phenomenon of "migration" of pain is observed, in other pains there is a stable localization.

The nature of pain can also fluctuate in large limits and is expressed by the presence of aching, stitching, pricking, pressing, burning, compressive, pulsating pain. Patients also indicate piercing blunt, plucking, cutting pains or diffuse, poorly delineated sensations, which, according to their real estimate, are far enough from the assessment of the actual pain. So, for example, a number of patients experience discomfort and an unpleasant sensation of "feeling of the heart". The fluctuation in the latitude of the range of sensations can be expressed in different degrees, in a number of cases, the pain is sufficiently stereotyped.

Cardiologists distinguish five types of cardialgia in patients with neurocirculatory dystonia: simple cardialgia (aching, pinching, piercing pains) that occur in 95% of patients; angioneurotic (compressive, pressing) pain, the genesis of which is postulated as associated with disorders of the tone of the coronary arteries (25%); cardialgia of the vegetative crisis (paroxysmal, pressing, aching, protracted pain) (32%); sympathetic cardialgia (19%); pseudostenocardia of stress (20%).

Such a classification of the nature of pain is focused on internist doctors and is built on the principle of phenomenological identity with known cardiological (organic) diseases. From the neurological standpoint, the allocated "sympathetic cardialgia" seems rather controversial due to the fact that, according to modern views, the role of "sympathies" associated with the real involvement of the peripheral autonomic nervous system is negligible. Clinical significance is the degree of brightness of hyperventilation disorders, which are often the direct determinant in the appearance of pain. The course of pain is often wavy. For pains in the syndrome of autonomic dysfunction, it is less typical to reduce them under the influence of nitroglycerin and disappear when physical activity stops (stopping when walking, etc.). Similar phenomena are typical for angina pectoris. Cardialgia of a dystonic genesis, as a rule, are reduced successfully by the use of Validol and sedatives.

Duration of pain in the heart area is usually quite long, although fleeting, short-term pain can also occur quite often. The most "disturbing" for a doctor are the pain of a paroxysmal type lasting 3-5 minutes, especially behind the sternum: they require the exclusion of angina pectoris. Cardiac evaluation requires also protracted pain, first arising in individuals older than 40-50 years: it is necessary to exclude myocardial infarction.

Irradiation of pain in the left arm, left shoulder, left hypochondrium, under the scapula, axillary region is a fairly regular situation in the case of cardial diseases under consideration. In this case, pain can spread to the lumbar region, as well as to the right half of the chest. Uncharacteristic irradiation of pain in the teeth and lower jaw. The latter variant of irradiation is more often observed with pain of stenocardic genesis. The prescription of cardialgia undoubtedly plays an important role in the diagnosis of their genesis. The presence of pain for many years, most often from adolescence, in women increases the likelihood that pain in the heart is not associated with organic diseases.

An important and fundamental issue is the evaluation of the vegetative, or rather, psycho-vegetative background, in which the phenomenon in the heart region is played out. Analysis of the existing syndromic "environment" of cardialgia allows, as noted, already at the clinical level to build realistic diagnostic hypotheses, which is of great importance from the point of view of both psychology and deontology. Diagnostic orientation solely on this or that paraclinical method of research is not a correct approach in this matter.

Mental (emotional, affective) disorders in patients manifest themselves in different ways. Most often - these are manifestations of an anxious-hypochondriacal and phobic plan. It should be emphasized that the presence of anxious, panic manifestations in patients with pain in the heart, the establishment of their personality (most often neurotic disorders) is one of the criteria for diagnosing the psychogenic genesis of the manifestations present in patients.

Positive criteria for diagnosing pain phenomena in the heart are fundamentally similar to the criteria for diagnosing the phenomenon of pain in the abdomen, so they can be used in the case of cardialgia.

Disturbances of the hypochondriacal character sometimes increase to a state of severe anxiety, panic. In these situations, a sharp increase in these manifestations is expressed in the emergence of fear of death - an integral part of the vegetative crisis.

An important feature of emotional stress in these situations is considered a close connection with pain and vegetative manifestations. As a rule, patients in their complaints do not distinguish one or other of the three phenomena they have: pain, affective and vegetative manifestations. Most often they build their own series of complaints, where in the same verbal and semantic plane there are sensations of different types. Therefore, the ability to feel the "specific gravity" of these three subjective manifestations, different in their phenomenology, but united by common pathogenetic mechanisms of the psychovegetative nature, is an important point in the clinical analysis of cardialgia. True, the perception of their symptoms as more or less dangerous to health can change significantly even after the first conversation with a doctor who can "target" the patient to the phenomenon of pain. In addition, from a variety of symptoms, the patient independently identifies the phenomenon of pain in the heart area as corresponding to the notion of the importance of the heart as a "central" organ.

It is also necessary to analyze the patient's views about his illness (internal picture of the disease). In a number of cases, the determination of the degree of "elaboration" of the internal picture of the disease, the degree of its fantasy, mythology, the correlation of ideas about one's suffering and the degree of their realization in one's behavior allow one to establish the cause of certain feelings in patients, the degree of expression of endogenous mechanisms in the structure of afferent disorders, and also outline the problems and points of psychological corrective therapy.

Vegetative disorders are obligate in the structure of the suffering analyzed. They should also be the subject of a special, focused analysis. It is important to note that the core of autonomic disorders in patients with pain in the heart area is the manifestation of hyperventilation syndrome. Virtually all publications devoted to heart pain associated with autonomic dysfunction emphasize the presence of respiratory sensations: lack of air, dissatisfaction with inspiration, lump in the throat, non-passage of air into the lungs, etc.

Respiratory sensations, being a subtle indicator of anxiety disorders, have long been mistakenly regarded by physicians as associated with changes in the heart indicating a certain degree of heart failure. Most patients (and, unfortunately, some doctors) are still deeply convinced of this; Naturally, this dramatically intensifies anxious-phobic manifestations, thus maintaining a high level of psycho-vegetative tension - a necessary condition for the persistence of pain in the heart. In view of this interpretation of respiratory sensations, dyspnea has always been conceived in the context of cardiac problems, beginning with the historical work of J. D'Acosta; 1871 to our days.

In addition to respiratory disorders, other manifestations closely associated with hyperventilation are also encountered in patients with pain in the heart: paresthesia (numbness, tingling, crawling sensation) in the distal limbs, face area (tip of nose, perioral region, tongue), changes in consciousness (lipotymia, fainting), muscle information in the hands and feet, dysfunction of the gastrointestinal tract. All these and other vegetative disorders can be permanent and paroxysmal. The latter are most common.

Cardial syndrome in patients with non-expressed autonomic disorders

The pains in the heart differ in this case by some peculiarity. Most often they are localized in the heart area in the form of a "patch", they are permanent, monotonous. A detailed analysis of the phenomenon of pain often indicates that the term "pain" is sufficiently conditional on the feelings experienced by the patient. It is rather a synestopic manifestation within the hypochondriacal fixation on the heart region. Detection in the patient of his ideas about the disease (internal picture of the disease) reveals, as a rule, the presence of a developed concept of the disease, with difficulty or not at all amenable to psychotherapeutic correction. Despite the fact that most of the pain is insignificant, the patient is embraced and concerned with his feelings so much that his behavior, his way of life, his capacity for work are roughly changed.

In the literature, similar phenomena have been called cardiophobic and cardiosynostatic syndromes. Most often in our practice, such manifestations were found in young men. Special analysis, as a rule, allows to establish the leading psychic endogenous mechanisms of symptom formation. Vegetative disorders are poorly represented in clinical symptoms, except in cases where phobic disorders are sharply aggravated, acquiring a panic character, and manifest as a panic attack.

Thus, pain in the heart with autonomic dystonia can have a fairly wide range of clinical manifestations. It is important to analyze not only the phenomenon of pain, but also the affective and vegetative environment and accompaniment, which are observed in this case.

Most often, there are two types of cardialgia, combined in the same patient, but the isolation of the leading type has a certain clinical significance.