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Assessment of the functional state of the cardiovascular system in children and adolescents



Exercise makes great demands on the child's body. Therefore, specialists, most often pediatricians and rheumatologists, should clearly know the contraindications to classes in sports sections. The following is a pathology in which children are not recommended to engage in great sports:

1. Congenital and acquired heart defects, valve prolapse II and III degree and other minor abnormalities of the heart.

2. Carditis (myocarditis) of any etiology in history.

3. Congenital anomalies of the conductor system of the heart - syndromes of WPW, CBC, shortened PQ interval, syndromes of weakness (and dysfunction) of the sinus node, syndrome of extended Q-T interval; cardiac arrhythmias and conduction.

4. Chronic somatic diseases.

5. Foci of chronic infection (chronic tonsillitis, adenoiditis, sinusitis, periodontitis). It is believed that increased blood circulation during physical exertion contributes to the active leaching of microbes and their toxins from foci of infection into the blood, which leads to intoxication and myocardial dystrophy.

6. The syndrome of autonomic dysfunction with a crisis course, especially sympathicotonia with hypersympathicotonic autonomic reactivity.

7. Children with a “drip or hypoevolutionary” heart. 8. The age of a child under 6 years old is a relative contraindication to playing sports, since only by the age of 7 years does the formation of a child’s organs and systems basically end.

To resolve the issue of admitting a child to classes in the sports section, it is necessary to eliminate the above contraindications to classes, for which, along with a physical examination, general clinical tests and a detailed biochemical blood test, ECG, cardiointervalography, ultrasound of the heart are recorded, and the reaction of the cardiovascular system to the test is evaluated with dosed physical activity (1 W / kg for 5 min) on a bicycle ergometer or treadmill test (“treadmill” track), less often a step test is used for this.

Clinical functional tests of the cardiovascular system are of great diagnostic importance for characterizing the functional state of the cardiovascular system in healthy and sick children, identifying the degree of their fitness, assessing the reserve capabilities of the heart and the whole organism, and the limit of the functional capacity of the circulatory system. In addition, with the help of functional tests, it is possible to give a prognostic assessment and characterize the results of conservative or surgical treatment. Functional tests are of great diagnostic value in assessing their dynamics in combination with clinical data.

In pediatrics, tests with a physical standardized load (on a bicycle ergometer, treadmill test, step test) are more often used, during which ECG can be recorded. Other types of exercise samples (a sample with a dosed load according to Shalkov, a Kushelevsky test, a clino-orthostatic test) that do not allow accurate dosing of physical activity can be used only for indicative studies.

Samples with dosed physical activity allow:

• objectively assess the functional state of the cardiovascular system;

• identify preclinical changes in the cardiovascular system in the form of latent coronary insufficiency, vascular hyperreactivity, cardiac arrhythmias (including life-threatening arrhythmias), conduction and the process of repolarization;

• determine the effectiveness of antiarrhythmic, antihypertensive and other drugs;

• predict the course of some cardiovascular diseases;

• develop a rehabilitation program and evaluate its effectiveness;

• assess the physical performance and features of adaptation of the cardiorespiratory system to muscle load.

Indications for the tests: cardialgia, ECG changes (nonspecific changes of the T wave and ST segment at rest), arrhythmias (extrasystole, a history of paroxysmal tachycardia, etc.), arterial hyper- and hypotension (to detect latent vascular hyperreactivity), conditions after transferred cardiovascular diseases (myocarditis, rheumatism, etc.) and cardiac surgery, lipid metabolism disorders, left ventricular outlet tract obstruction (sub- and supravalvular aortic stenosis, hypertrophic cardiomyopathy, coarctation of the aorta), chronic overload of the right or left ventricle with volume (insufficiency of the mitral, tricuspid or lunate valves).

Contraindications to the test: circulatory failure of stage IEB-III, active inflammatory processes in the heart muscle, convalescence period after acute infectious or chronic diseases, severe rhythm disturbances (atrial fibrillation and flutter, ventricular extrasystoles of high gradations) and conduction (complete atrioventricular block, intraventricular block, blockade), history of ventricular tachycardia and fibrillation combined with or without syncope, high arterial hypertension (blood pressure above 180/100 m Hg. Art.).

Termination of the sample. If there are signs (clinical, electrocardiographic, hemodynamic), indicating the limit of tolerance of the load, the sample with dosed physical activity is stopped.

Clinical signs: pain in the region of the heart (even in the absence of ECG changes), headache, dizziness, increased paleness or cyanosis of the skin, fainting, the appearance of severe shortness of breath (up to 60 per minute), suffocation, patient refusal from further research in connection with discomfort (fear, weakness in the muscles of the lower extremities, etc.). The sample is stopped for clinical signs even without negative dynamics on the ECG.

Hemodynamic signs: excessive increase in blood pressure (systolic above 200 mm Hg. Art., Diastolic - above 120 mm Hg. Art.) Or decrease (systolic by 20 mm Hg. Art. With a load after its increase, diastolic more than 30 mm Hg. Art. from the source), the appearance of the phenomenon of infinite tone.

Electrocardiographic signs: the development of heart block (a pronounced violation of atrioventricular or intraventricular conduction), oblique, oblique, trough-like or horizontal displacement of the BT segment downward by more than 2 mm and in more than one or more leads, an upward shift by 1 mm in one or more leads, the appearance of threatening arrhythmias (paroxysmal tachycardia, atrial fibrillation, ventricular extrasystole), an increase in voltage and the expansion of Q waves Eyes from baseline shift tooth Q QS in a decrease of the amplitude R, R-wave voltage increase in leads V5-6.

Sample loading. It is customary to apply loads of maximum or submaximum power. The maximum load power for each subject is individual. It depends on age, gender, health and fitness. The achievement of maximum load power is indirectly indicated by the maximum heart rate that occurs during exercise.

The test with maximum load can be used in perfectly healthy and trained children, for example, young athletes. In children with heart disease or with a suspicion of it, with functional impairment, the maximum load is contraindicated.

When bicycle ergometry in children is most often used submaximal load, which is 70-85% of the maximum. The magnitude of the submaximal load is also judged by the heart rate, which should be 70-85% of the maximum characteristic for a given age. In children, it is recommended to use the PWC170 test, when during bicycle ergometry, a load is given such a power that the heart rate reaches 170 beats / min. Maximum or submaximal load is achieved by applying physical load of constant or increasing power. Under constant load, its level does not change throughout the entire study period (for example, 1 W (1 W = 6 kgm / min) or 1.5 W per 1 kg of the child’s body weight). Children usually easily endure such a load. This level may be the same for all subjects or individual - taking into account the age, gender, health status, level of physical fitness of the child.

The load of the growing power can be stepwise, with short periods of rest, continuous stepwise increase without a period of rest and continuous, but gradually increasing. The load of increasing power with rest periods is initially given for 4-5 minutes (by this time, the pulse rate is relatively stabilized). Then, rest is offered for 5-10 minutes and a more powerful load is given (usually doubled), and then the increase in load power is equal to the initial level. The load is sequentially increased until a submaximal heart rate is reached.

With a continuous step-like load, there are no rest periods, and the load power every 2-3 minutes without a break doubles until the submaximal rhythm frequency is reached. With a continuously smoothly increasing load, its increase is more gradual.

In children with heart disease, even a submaximal load may be excessive. Therefore, it is better for them to apply the so-called threshold load, which is stopped immediately when shortness of breath, fatigue, dizziness, and heart rhythm disturbance occur.

Sample rules. When carrying out bicycle ergometry, as well as other tests with physical activity, inadequate reactions of the cardiovascular system are possible (up to the occurrence of ventricular fibrillation), therefore, ECG monitoring on an oscilloscope is necessary, and resuscitation equipment should always be ready.

The study is carried out 1.5-2 hours after eating at a room temperature of 18-22 ° C. The ECG is recorded before the breakdown, then the ECG is continuously monitored on a monitor with periodic recording on the device. Two people should participate in the examination - a doctor and a nurse, which will allow you to correctly perform the load and notice symptoms in a timely manner, indicating the need to stop the sample. Doctors who are familiar with electrocardiography and have undergone special training in emergency cardiology are allowed to conduct the study.

Functional tests require an ergometer (bicycle ergometer, step for step test, treadmill test), electrocardiograph, oscilloscope, defibrillator, portable respirator for mechanical ventilation, scales, stadiometer, sterile tray with syringes and needles, medications (promedol, nitroglycerin, mezaton or adrenaline, lidocaine, novocainamide, obzidan, isoptin, atropine, panangin, isotonic sodium chloride solution, 10% ammonia solution).

With adequate selection of patients and observing the rules for conducting tests, complications are relatively rare, however, staff should be familiar with them, know preventive measures and treatment. A calm and friendly atmosphere helps to eliminate fear and negative emotions in the subject.

ECG changes during exercise. Regardless of the method of conducting the test with physical activity on the ECG, according to S.I. Ignatova and M.S. Ignatova (1994), certain changes in the teeth and intervals occur:

1. The magnitude of the increase in heart rate at a threshold load indicates the functional activity of the sinus pacemaker, an inadequate increase

pulse, the appearance of ectopic atrial and atrioventricular rhythms indicate organic weakness of the sinus node. Most arrhythmias associated with neurovegetative dysregulation of the heart rhythm disappear when conducting a test with physical activity.

2. At a load proportionally to heart rate, the amplitude of the P wave increases, the PR interval is shortened. The duration of the QRS ventricular complex does not change, but the amplitude of its teeth changes (the amplitude of the R wave on the ECG during the load period reflects the volume of the left ventricle). A decrease in the amplitude of the R wave in leads V5-6 indicates an adaptive response, a good fitness of the left ventricle to load. However, if a decrease in the R wave is accompanied by a broadening of the Q wave and a transition to QS, as well as in cases of common cardiosclerosis, this symptom may indicate ischemia. In this regard, an increase in the R wave in the left thoracic leads should be regarded as the inability of the heart to isometrically cope with the increased load, which leads to an increase in the end-systolic volume of the left ventricle and can be considered a sign of initial heart failure. The appearance of ventricular arrhythmias on the load in cases of an unobstructed course of the syndrome of an extended QT interval dictates the need for the appointment of P-blockers. Normalization of the QT interval during exercise is typical for patients with secondary lengthening of the QT interval and is absent in primary forms of the syndrome.

3. The electrical axis of the heart usually deviates to the right, but no more than 30 ° from the original.

4. Normally, under load, the T wave either does not change or decreases slightly. The amplitude of the U wave usually increases.

5. With a significant increase in heart rate, fusion of the T and P teeth is possible, which makes it difficult to determine the isoelectric line, then the nature and magnitude of the ST segment displacement and the amplitude of the T wave are presumably determined. The occurrence of a negative T wave in standard and chest leads in children during exercise does not always indicate ischemia and is more often associated with autonomic dysfunction. The appearance of negative T waves in leads V4-6 for 1-2 minutes of the test reflects the initial myocardial reaction (response to inclusion), subsequently it disappears and in this situation is not a pathological sign.
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