| BackgroundUnctional cardiovascular disease is caused by the dysfunction of the autonomic nervous system,not with a group of organic disease of cardiovascular system diseases,main show is orthostatic intolerance(OI),including vasovagal syncope(VVS),postural orthostatic tachycardia syndrome(POTS),orthostatic hypertension(OHT),orthostatic hypotension(OH),OI is the most common type which seriously affects the physical and mental health of children.Typical clinical symptoms include syncope,cognitive impairment(memory loss,decreased attention),blurred vision,headache,dizziness,chest tightness,nausea,abdominal discomfort,pale face,sweating,palpitations even disturbance of consciousness,etc[1].As the disease is very common in pediatric clinical work,more and more attention has been paid to it.Head-up tilt test(HUTT)is a key technology for the diagnosis and differential diagnosis of functional cardiovascular diseases in children[2].The HUTT inspection was carried outdomestically in 1995.In 2004 our country take the lead to SNHUTT to improve the efficiency of diagnosis,2009 for the first time in our country has issued a guide to the children diagnose syncope,subsequently issued "diagnostics guide children syncope(2016 revision)",With reference to this "standard",the unified and standardized implementation of children’s HUTT operation scheme has further improved the diagnostic level of syncope in Chinese children[2,3].ObjectFrom May 2016 to December 2018,599 children with orthostatic intolerance who suffered from recurrent symptoms of headache,dizziness,chest tightness,nausea,palpitation,blurred vision,syncope and other threatening syncope or unconscious syncope but could recover spontaneously were admitted to the Pediatric Clinic of Qilu Hospital of Shandong University and confirmed by the orthostatic tilt test.The purpose of this study is to analyze the hemodynamic differences,types and clinical manifestations of children with different OI(orthostatic intolerance),so as to facilitate early intervention and correct identification by pediatric clinicians,avoid the risk of HUTT examination,prevent and reduce the incidence of children’s functional cardiovascular diseases,and improve the quality of life of children.Quantity and prognosis.Materials and methods1.A retrospective analysis was made of 559 children with positive results of BI-IUTT(baseline head-up tilt test)or SNHUTT(sublingual nitroglycerin-provocated head-up tilt test)in Qilu Hospital of Shandong University from May 2016 to December 2018.Among them,231 were males and 328 were females,the ratio of males to females was 1:1.42;the age ranged from 5 to 16 years,with an average age of 138.68±24.57 months.The HUTT method.positive reaction criteria and diagnostic criteria of VVS,POTS,OHT and OH in all children were referred to the Guidelines for the Diagnosis of Childhood Syncope(2016 Revised Editorial Board)formulated by the Cardiovascular Group of the Chinese Society of Pediatrics and the Editorial Board of the Chinese Journal of Pediatrics in April 2016.The children with positive HUTT results were compared according to their clinical characteristics.2.Selection criteria:All children were enquired about their medical history in detail,and no abnormality was found in physical examination.Cardiogenic,vasculogenic and neurogenic factors were excluded by measuring blood pressure,body weight,12-lead routine electrocardiogram,24-hour Holter,electroencephalogram,chest plain film,cardiac Doppler ultrasound,craniocerebral CT or MRI and renin-angiotensin-aldosterone tests.All patients had erect intolerance symptoms,and the results of vertical tilt test(HUTT)were positive.3.The clinical data of 559 children with orthostatic intolerance were processed by statistical software SPSS25.0.Among them,the counting data were expressed as cases(percentage)[n(%))].The inter-group comparison of the counting data was performed by test.The measurement data were expressed as mean±standard deviation),(X±SD).The independent sample t test was used for comparison,and 95%was taken as the confidence interval,and P<0.05 was chosen as the confidence interval.The difference has statistical significance.Results1.General information:A total of 559 children with HUTT-positive 01 were collected in this study,of which 231(41.3%)were male,with an average age of 137.39 ± 25.63 months;328(58.7%)were female,aged 5-16 years,with an average age of 139.60± 23.65 months.There was no significant difference in the age of onset between men and women(P>0.05)2.Hemodynamic classification of OI children:379 cases(67.8%)in VVS group,161 cases(28.8%)in POTS group,10 cases(1.8%)in OHT group and 9 cases(1.6%)in OH group.Of 231 male children,165(71.4%)were in VVS group,57(24.7%)in POTS group,6(2.6%)in OHT group and 3(1.3%)in OH group.Of 328 female children,214(65.2%)were in VVS group,104(31.7%)in POTS group,4(1.2%)in OHT group and 6(1.8%)in OH group.There was no significant difference between VVS group and POTS group(P>0.05).3.Comparisons of predisposing factors of syncope in children with orthostatic intolerance patients:402 cases(71.9%)had predisposing factors before seizures,including 186 males(46.3%)and 216 females(53.7%)and 51 males(27.4%)had standing for a long time,41(22.0%)had vigorous or prolonged exercise and 30(16.1%)had sultry environment.The top three common causes of female patients were standing for a long time in 63 cases(29.2%),emotional agitation in 53 cases(24.5%)and sultry environment in 38 cases(17.6%).4.Comparison of syncope precursors between VVS group and POTS group:HUTT hemodynamic types and syncope precursors:In HUTT,syncope precursors were dizziness,pallor,chest tightness,nausea,palpitation,sweating,blurred vision,choking,headache,chest pain,abdominal discomfort,fatigue and abnormal hearing.Among them,pale complexion,chest tightness,blurred vision,abdominal discomfort and sweating were the six presenting signs of syncope between VVS and POTS groups.Chi-square test was used,P<0.05,with statistical significance5.Comparison of VVS,POTS and HUTT test methods:Among 559 children with positive HUTT results,there were 540 children with VVS and POTS;379 children with VVS,246 children with positive BHUTT(64.9%)and 133 children with positive SNHUTT(35.1%),161 children with POTS,26 children with positive BHUTT(16.1%)and 135 children with positive SNHUTT(83.9%),P<0.05.The difference was significant.6.Changes of blood pressure and heart rate in children with different positive reaction types:Comparing the changes of heart rate,SBPand DBP before and after the experiment in children with different hemodynamic 01,the results showed that SBP and DBP in arteries of children with VVS were significantly decreased compared with those before the experiment,P<0.05 by t test,and the difference was statistically significant;161 cases in POTS group(28.8%).The heart rate before and after the experiment was significantly different(P<0.05);blood pressure in OHT group was higher than that before the experiment(P<0.05);blood pressure in OH group was lower than that before the experiment(P<0.05).7.Heart arrhythmia score and other treatment during HUTT test:HUTT results of 559 children showed that 487 cases(87.1%)had sinus tachycardia during the test.Among them,321 cases(65.9%)in VVS group,161 cases(33.1%)in POTS group,3 cases(0.6%)in OHT group and 2 cases(0.4%)in OH group.There was significant difference between VVS group and POTS group(P<0.05).Sinus tachycardia occurred in all patients.103 cases(18.4%)had sinus bradycardia and 21 cases had other types of arrhythmia.In addition,complications such as syncope,temporary aphasia after syncope and convulsion may occur during HUTT.8.Follow-up study on the treatment of OI children:381 cases were divided into three groups according to different treatment schemes:142 cases in the simple functional exercise group,170 cases in the functional exercise + oral rehydration salt group,69 cases in the functional exercise + Betaloc group.Statistics showed that the negative conversion rate of HUTT in the three groups after 3 months of treatment was good.The negative conversion rate in the functional exercise + Betaloc group was better than that in the other two groups.The P values were all<0.01.The negative conversion rate of functional exercise + Betaloc group was better than that of functional exercise + oral rehydration salt group in 3 months(P<0.05).Compared with the incidence of adverse reactions of the latter two groups,the difference was significant(P<0.05).Hypotension and bradycardia were the main causes.Conclusion1.The case study showed that VVS and POTS were the main types of children’s orthostatic intolerance.There was no significant difference in gender and age between the two groups.2.Continuation of the SNHUTT experiment with BUTT negative children can improve the POTS positive rate in OI children,and the POTS positive rate is significantly higher than the POTS with VVS.3.In the VVS group,blood pressure and heart rate were mainly decreased in the hemodynamic manifestations of HUTT;POTS group has a higher heart rate but less change in blood pressure(bp).In the OHT group,the blood pressure was increased but the heart rate did not change significantly.The change of heart rate was not significant in the OH group.The results of hemodynamic analysis have guiding significance for the clinical treatment of OI.4.HUTT may induce arrhythmia,cardiac arrest and convulsion.It is necessary to identify the symptoms of syncope and positive reaction as early as possible and terminate the test in time. |
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