Symptoms of vegeto-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 blood pressure in the absence of complaints), to a full-blown 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 leading manifestation of which is changes in blood pressure, as well as a cardiological variant with a predominance of pain in the heart area.

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

The hypotensive type of vegetative-vascular dystonia is established in cases where the value of systolic blood pressure fluctuates within the range of 110-80 mm Hg, and diastolic - 45-60 mm Hg and there are clinical signs of chronic vascular insufficiency.

The most significant complaints of patients for diagnosis are coldness of the hands, feet and a tendency to orthostatic disorders (dizziness when changing body position, sharply turning the head, body), intolerance to transport. Manifestations of asthenovegetative syndrome are observed: rapid exhaustion of mental and physical activity, decreased memory, concentration, weakness, increased fatigue. Children with the hypotensive type of vegetative-vascular dystonia are characterized by mood lability, high anxiety, conflict, and a tendency to hypochondria.

During examination, asthenic constitution, pale skin, marbling, pastosity of tissues, decreased skin temperature of the extremities, dampness of the palms and feet, and tachycardia are determined. The listed set of symptoms is characteristic of decreased cardiac output (the so-called hypokinetic type of hemodynamics), detected in more than 60% of patients with the hypotensive type of vegetative-vascular dystonia. Moreover, in most cases, the pathogenetic basis of hemodynamic disorders is systemic venous hypotension, which is determined using plethysmography and indirectly - by the dynamics of arterial pressure and heart rate during the orthostatic test. A decrease in systolic and pulse arterial pressure and a significant increase in heart rate (sometimes the appearance of extrasystoles) are characteristic. Usually in these cases, the tone of small arteries of the skin and muscles is significantly increased (compensatory "centralization" of blood circulation). If the compensatory vascular response and heart rate increase during orthostatic load are insufficient (in patients with asympathicotonia), then during the orthostatic test, especially in the variant with passive orthostasis, patients experience sudden weakness and a feeling of dizziness. If the test is not stopped in time, fainting occurs, which is usually preceded by a sharp pallor of the skin of the face, the appearance of small beads of sweat on it. A rarer, pathogenetic variant of arterial hypotension is associated with a decrease in total peripheral resistance to blood flow with a usually normal or even increased cardiac output. Circulatory disorders in this variant are minimal, and patient complaints often reflect a neurosis-like condition or correspond predominantly to regional circulatory disorders (most often in the form of hemicrania or another type of vascular headache). During the orthostatic test, these patients predominantly experience an increase in heart rate without a significant additional decrease in blood pressure, and at the beginning of the test, even a slight increase is possible.

Often, children with the hypotensive type of vegetative-vascular dystonia experience decreased appetite, nausea not associated with food intake, periodic abdominal pain and constipation of a spastic nature, migraine-like cephalgia localized in the temporal and frontotemporal regions.

The hypertensive type of vegetative-vascular dystonia is established when a transient increase in blood pressure is detected in older children, adolescents and young people, if other symptomatic forms of arterial hypertension have been excluded and there are insufficient grounds for a diagnosis of arterial hypertension.

The presence and nature of complaints, as well as other manifestations of the disease, except for increased blood pressure, are important mainly for differential diagnostics and pathogenetic analysis of arterial hypertension. Most adolescents with the hypertensive variant of vegetative-vascular dystonia do not present complaints for a long time. And only with an increase in blood pressure may cephalgia, pain in the heart, dizziness, palpitations, flashing spots before the eyes, a feeling of heat, hot flashes to the head and neck appear. Headache occurs mainly with psychoemotional or physical overload, is aching, sometimes pulsating in nature with predominant localization in the occipital region, less often covers the entire head. Children with the hypertensive type of vegetative-vascular dystonia often complain of aching pain in the heart, which appears more often after physical exertion. Patients experience emotional lability, increased fatigue, irritability, sleep disorders, hypochondria, and weather dependence.

In most patients, an increase in cardiac output (the so-called hyperkinetic type of hemodynamics) is determined instrumentally in the absence of a physiologically adequate decrease in total peripheral resistance to blood flow, although the tone of the skin arterioles and skeletal muscles often deviates insignificantly from the norm. In such cases, mainly systolic and pulse arterial pressure increases, and the hemodynamic reaction in the clinoorthostatic 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 arterial 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 during prolonged standing (in transport, in queues, at a security post, etc.) are possible. In such patients, in the orthostatic test, the increase in systolic blood pressure is usually small and short-lived; after 2-3 minutes of standing, it may decrease, while diastolic pressure increases and pulse blood pressure falls with a parallel increase in heart rate (sympathoasthenic type).

The cardialgic type of vegetative-vascular dystonia is established if there are no significant fluctuations in blood pressure, there are complaints of palpitations or interruptions in the heart, pain in the heart area, shortness of breath (without myocardial damage).

Objectively, abnormalities in the functioning of the heart are detected - tachycardia, pronounced sinus arrhythmia (in patients over 12 years old), or supraventricular extrasystole or paroxysms of tachycardia, the presence of which is confirmed using an ECG.

Cardiac output is examined and a phase analysis of the cardiac cycle is performed, which helps to identify the so-called hyperhypokinetic types of hemodynamics, which is important for pathogenetic diagnosis. Often, the main manifestation of the cardialgic variant of vegetative-vascular dystonia is chest pain. Three degrees of severity of the cardialgic variant are distinguished.

• I degree - pain in the heart area, usually of a stabbing nature, occurs rarely and mainly after psycho-emotional stress. Passes on its own or after psychotherapy.
• II degree - pains, usually of a nagging nature, lasting 20-40 minutes, appear several times a week and radiate to the left shoulder, shoulder blade, left half of the neck. They pass after psychotherapeutic measures, sometimes after sedatives.
• Stage III - dull aching pain lasting up to 1 hour or more appears daily and even repeatedly during the day. Passes after drug treatment.

Disorders of the cardiovascular system in the form of various clinical manifestations of a subjective and objective-functional nature without the presence of organic changes in the cardiovascular system, according to the latest classification of autonomic disorders [Vein AM, 1988], should be classified as secondary cerebral (suprasegmental) autonomic disorders.

When analyzing clinical symptoms in patients with neurocirculatory dystonia (a term most often used in therapeutic practice and denoting a particular cardiovascular variant of a broader concept - vegetative dystonia syndrome), pain in the heart region was observed in 98% of patients.

Coronary angiography, considered the latest achievement of science in the study of cardialgia, is performed annually on 500,000 patients in the United States, and in 10-20% of them this study shows the presence of normal, unchanged coronary arteries. Special studies conducted on patients with pain in the heart with unchanged coronary arteries revealed signs of panic disorders in 37-43% of them. The data presented emphasize the frequency of cardiovascular disorders associated with a violation of the vegetative, or more precisely, psychovegetative, sphere. An analysis of the phenomenological manifestations of neurogenic cardiovascular disorders allows us to identify their various variants: diesthetic, dysdynamic, dysrhythmic within the framework of psychovegetative disorders.

Cardialgic syndrome

As is known, the concept of "pain" is one of the most popular in the minds of people of all existing human bodily sensations (while the heart in ancient times was considered the "central organ of the senses"). The concept of "heart" is one of the main ideas symbolizing the main organ that ensures human life. These two ideas are combined in the complaints of patients in the form of one of the leading manifestations of vegetative dysfunction - "heart pain". Often, with careful phenomenological analysis, it turns out that various sensations (for example, paresthesia, feelings of pressure, compression, etc.) are generally designated by patients as "pain", and the territory of the left half of the chest, the sternum, and sometimes even the right half of the chest are generally designated by patients as the "heart".

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

Different concepts usually reflect certain pathogenetic ideas of the corresponding researchers.

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

From the standpoint of vegetological analysis, pain in the heart region (this term seems to us to be the most adequate, although for brevity we put the same meaning into the concept of “cardialgia”) should be divided into two classes: cardialgia in the structure of vegetative dystonia syndrome, clinically manifested by psychovegetative disorders, and cardialgic syndrome with minimal accompanying vegetative disorders.

Cardialgia in the structure of pronounced manifestations of vegetative dystonia

We are talking about the most common type of heart pain, which consists in the fact that the phenomenon of pain itself, being for some period of time the leading one in the clinical picture, is simultaneously in the structure of various affective and vegetative disorders (psychovegetative syndrome), pathogenetically associated with heart pain. The ability of the doctor to "see", in addition to the phenomenon of cardialgia, also the psychovegetative syndrome that naturally accompanies it, as well as the ability to conduct a structural analysis of these manifestations allows one to penetrate already at the clinical stage into the pathogenetic essence of the said disorders for their adequate assessment and therapy.

Analysis of the phenomenon of pain in the heart area allows us to determine various variants of pain in patients with a large phenomenological range according to the analyzed criteria.

Localization of pain is most often associated with the projection zone of the apex of the heart on the skin, with the area of the left nipple and precordial region; in some cases, the patient points with one finger to the site of pain. Pain may also be located behind the sternum. Some patients experience the phenomenon of "migration" of pain, while in others the pain has a stable localization.

The nature of pain sensations can also fluctuate within wide limits and is expressed by the presence of aching, stabbing, pricking, pressing, burning, squeezing, pulsating pains. Patients also indicate piercing dull, pinching, cutting pains or diffuse, poorly defined sensations that, according to their actual assessment, are quite far from the assessment of pain itself. For example, a number of patients experience discomfort and an unpleasant sensation of "heart feeling". Fluctuations in the breadth of the range of sensations can be expressed to varying degrees; in a number of cases, the pains are quite stereotypical.

Cardiologists distinguish five types of cardialgia in patients with neurocirculatory dystonia: simple cardialgia (aching, pinching, piercing pain), occurring in 95% of patients; angioneurotic (squeezing, pressing) pain, the genesis of which is postulated as associated with disorders of the tone of the coronary arteries (25%); cardialgia of vegetative crisis (paroxysmal, pressing, aching, lingering pain) (32%); sympathetic cardialgia (19%); pseudo-angina of effort (20%).

Such rubrication of the nature of pain is oriented towards internists and is based on the principle of phenomenological identity with known cardiac (organic) diseases. From a neurological standpoint, the identified "sympathetic cardialgia" seems to be quite controversial due to the fact that, according to modern views, the role of "sympathalgia" associated with the real involvement of the peripheral autonomic nervous system is insignificant. Of clinical significance is the degree of brightness of hyperventilation disorders, which are often a direct determinant in the occurrence of pain. The course of pain is most often wave-like. For pain within the framework of the syndrome of autonomic dysfunction, their reduction under the influence of nitroglycerin and disappearance upon cessation of physical activity (stop while walking, etc.) are less typical. Similar phenomena are characteristic of pain in angina pectoris. Cardialgia of dystonic genesis, as a rule, is successfully reduced by taking validol and sedatives.

The duration of pain in the heart area is usually quite long, although fleeting, short-term pains can also occur quite often. The most "alarming" for a doctor are paroxysmal pains lasting 3-5 minutes, especially those located behind the sternum: they require exclusion of angina pectoris. Prolonged pains that first occur in people over 40-50 years of age also require a cardiological assessment: it is necessary to exclude myocardial infarction.

Irradiation of pain to the left arm, left shoulder, left hypochondrium, under the scapula, axillary region is a fairly natural situation in the case of cardialgia under consideration. In this case, pain can also spread to the lumbar region, as well as to the right half of the chest. Irradiation of pain to the teeth and lower jaw is not typical. The latter type of irradiation is more often observed in pain of angina pectoris genesis. The duration of cardialgia, undoubtedly, plays an important role in the diagnosis of its genesis. The presence of pain for many years, most often since adolescence, in women increases the likelihood that pain in the heart area is not associated with organic diseases.

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

Mental (emotional, affective) disorders in patients manifest themselves in different ways. Most often, these are manifestations of an anxious-hypochondriac and phobic nature. It is necessary to emphasize that the presence of anxious, panic manifestations in patients with pain in the heart area, the establishment of their personality traits (most often these are 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 region are fundamentally similar to the criteria identified for diagnosing the phenomenon of pain in the abdominal region, so they can also be applied in the case of cardialgia.

Hypochondriacal disorders sometimes intensify to the point of severe anxiety and panic. In these situations, a sharp increase in the above-mentioned 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 to be a close connection with pain and vegetative manifestations. As a rule, patients do not single out one or another of the three phenomena they have in their complaints: pain, affective and vegetative manifestations. Most often, they build their own series of complaints, where sensations of different types are located in the same verbal and semantic plane. Therefore, the ability to feel the "specific weight" of these three subjective manifestations, different in their phenomenology, but united by common pathogenetic mechanisms of a psychovegetative nature, is an important point in the clinical analysis of cardialgia. True, the perception of one's symptoms as more or less dangerous to health can change significantly even after the first conversation with a doctor, who can "aim" the patient at the phenomenon of pain. In addition, from a multitude of symptoms, the patient independently singles out the phenomenon of pain in the heart as corresponding to the idea of the importance of the heart as a "central" organ.

It is also necessary to analyze the patient's ideas about his illness (internal picture of the illness). In some cases, determining the degree of "elaboration" of the internal picture of the illness, the degree of its fantastical nature, mythological nature, the relationship between ideas about one's suffering and the degree of their implementation in one's behavior allows one to establish the cause of certain sensations in patients, the degree of expression of endogenous mechanisms in the structure of afferent disorders, and also to outline problems and points of psychological correctional therapy.

Vegetative disorders are obligatory in the structure of the analyzed suffering. They should also be the subject of a special targeted analysis. It is important to note that the core of vegetative disorders in patients with pain in the heart region is considered to be the manifestation of hyperventilation syndrome. Almost all publications devoted to pain in the heart region associated with vegetative dysfunction emphasize the presence of respiratory sensations: lack of air, dissatisfaction with inhalation, a lump in the throat, obstruction of air into the lungs, etc.

Breathing sensations, being a subtle indicator of anxiety disorders, have long been mistakenly regarded by doctors as related to 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 sharply increases anxiety-phobic manifestations, thus maintaining a high level of psychovegetative tension - a necessary condition for the persistence of pain in the heart. In view of this interpretation, breathing sensations, dyspnea have always been thought of in the context of cardiac problems, beginning with the historical work of J. d'Acosta in 1871 and up to the present day.

In addition to respiratory disorders, patients with heart pain also experience other symptoms closely related to hyperventilation: paresthesia (numbness, tingling, crawling sensation) in the distal extremities, in the face (tip of the nose, perioral area, tongue), changes in consciousness (lipothymia, fainting), muscle contractions in the arms and legs, and gastrointestinal dysfunction. All of the above and other autonomic disorders can be permanent or paroxysmal. The latter are the most common.

Cardialgic syndrome in patients with mild vegetative disorders

Heart pains in this case are distinguished by some peculiarity. Most often they are localized in the heart area in the form of a "patch" and are constant and monotonous. A detailed analysis of the pain phenomenon often shows that the term "pain" is quite conditional in relation to the sensations experienced by the patient. Rather, we are talking about synestopathic manifestations within the framework of hypochondriacal fixation on the heart area. Identification of the patient's ideas about the disease (internal picture of the disease) usually reveals the presence of a developed concept of the disease, which is difficult or not at all amenable to psychotherapeutic correction. Despite the fact that most often the pain is insignificant, the patient is so overwhelmed and preoccupied with his sensations that his behavior and lifestyle change drastically, and his ability to work is lost.

In the literature, such phenomena are called cardiophobic and cardiosinestropathic syndromes. In our practice, such manifestations were most often encountered in young men. A special analysis, as a rule, allows us to establish the leading mental endogenous mechanisms of symptom formation. Vegetative disorders are poorly represented in clinical symptoms, except for those cases when phobic disorders sharply worsen, acquiring the character of panic, and manifest themselves in the form of a panic attack.

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

Most often, we are talking about two types of cardialgia, combined in the same patient, however, identifying the leading type has a certain clinical significance.