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UDC.
616.12 - 008.311: 615.03.
PREVALENCE OF PREMATURE VENTRICULAR EXCITATION SYNDROME IN
SCHOOL-AGED CHILDREN
I.T. Abdurakhmonov,
A.T. Arifkhuzhaev,
R.M. Abdulkhakova,
M.G.Djuraev.
Andijan State Medical Institute
ABSTRACT:
The clinical significance of PVES is determined by the fact that almost 80.0% of
patients sooner or later develop tachyarrhythmic attacks, which under certain conditions are
transformed into atrial and ventricular fibrillation, posing a threat to the patient’s life. Objective.
To study the prevalence of various forms of premature ventricular excitation of the heart in
school-age children. To establish the frequency and structure of premature ventricular excitation
of the heart in school-age children. Material and methods. To identify cases of PVES in school-
age children, 1733 children aged 7-14 years (827 girls, 906 boys) were examined. Results.
Summarizing the results of the study and clinical observation of children with PVES, it can be
stated that the manifestations of the latter are not a rare pathology for children in our region.
PVES have a number of clinical and electrocardiographic features associated with the health and
pre- and postnatal development of children, they have impaired electrophysiological features of
the myocardium, asynchronism of the depolarization phases of the atria and ventricles,
disproportion in the ECG intervals of de- and repolarization of the ventricles, which leads to
inhibition of the contractility of the myocardium with the development of hypertrophy of the
heart, an increase in the risk of developing supraventricular tachyarrhythmias. Conclusion. For
early diagnostics and prevention of life-threatening arrhythmias caused by premature ventricular
excitation (PVES), it is recommended to conduct systematic targeted preventive examinations
among school-age children. Clinical, anamnestic and ECG criteria for PVE syndromes and
phenomena, their types WPW, CLC, Mahaim are presented. Additional information
characterizing the electromechanical activity of the atria is presented for doctors.
Keywords:
rhythm and conduction disturbances; premature ventricular excitation; additional
impulse conduction pathways; prevalence.
РАСПРОСТРАНЕНОСТЬ СИНДРОМ ПРЕЖДЕВРЕМЕННОГО ВОЗБУЖДЕНИЯ
ЖЕЛУДОЧКОВ СЕРДЦА У ДЕТЕЙ ШКОЛЬНОГО ВОЗРАСТА
И.Т. Абдурахмонов,
А.Т. Арифхужаев,
Р.М. Абдулхакова,
М.Г.Джураев.
Андижанский Государственный Медицинский Институт
Резюме:
Клиническое значение ПВЖ определяется тем, что почти у 80,0% больных рано
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или поздно развиваются тахиаритмические приступы, которые при определенных
условиях трансформируются в фибрилляции предсердий и желудочков, представляющие
угрозу для жизни больного. Цель. Исследовать распространенность различных форм ПВЖ
сердца у детей школьного возраста в аспекте дополнительных диагностических
возможностей электрокардиографии и выявить распределение синдромов и феноменов
ПВЖ в
зависимости от места выявления от возраста и пола. Оценить
анамнестические
данные матерей больных детей с ПВЖ, с акцентом на течение
беременности и
родов, изучить соматического развития больных детей с ПВЖ.
Материал и методы. По выявлению случаев ПВЖ у детей школьного возраста было
обследовано 1733 детей в возрасте 7-14 лет (девочек - 827, мальчиков - 906). Результаты.
Обобщая результаты исследования и клинического наблюдения детей с ПВЖ можно
утверждать, что проявления последнего не является редкой патологией для детей нашего
региона. ПВЖ имеют целый ряд клинико-электрокардиографических особенностей,
связанных со здоровьем и пре- и постнатальным развитием детей, у них нарушены
электрофизиологические особенности миокарда, выявляются асинхронизм фаз
деполяризации предсердий и желудочков, несоразмерность в ЭКГ интервалах де- и
реполяризации желудочков, что приводит к угнетению сократительной способности
миокарда с развитием гипертрофии отделов сердца, увеличению риска развития
наджелудочковых тахиаритмий. Заключение. Для ранней диагностики и профилактики
жизнеугрожаемых аритмий обусловленных преждевременным возбуждением желудочков
(ПВЖ), рекомендуется проводить систематические целенаправленные профилактические
осмотры среди детей школьного возраст, представлены клинико-анамнестические и ЭКГ
критерии синдромов и феноменов ПВЖ, их типов WPW, CLC, Махайма. Для врачей
представлены дополнительные сведения, характеризующие электромеханическую
активность предсердий.
Ключевые слова:
нарушение ритма и проводимости; преждевременное возбуждение
желудочков; дополнительные пути проведения импульса; распространенность.
INTRODUCTION
Every year, more than 2 million cases of death from arrhythmia are registered in the world. Heart
rhythm disorders, in particular ventricular ones, are one of the most common causes of sudden
death [1, 2, 7]. According to the American Heart Association, cardiac arrhythmias take from 300
to 600 thousand lives, which is one death per minute. Cardiovascular diseases are the leading
causes of death in young people (25 to 64 years old). The main insidiousness of this group of
diseases is that they are often asymptomatic, and a person learns that he has heart problems when
he can no longer be helped.
The problem of heart rhythm disorders and complications associated with them has become
especially relevant in pediatrics in recent years [3, 5, 9, 10]. There are a number of heart diseases,
such as premature ventricular excitation syndrome (PVS), these cardiac arrhythmias are based on
re-entry mechanisms caused by the presence of the AP impulse, the ECG expression of which
are varieties of PVS (syndromes and phenomena: WPW, CLC, Mahaima-Levi). This pathology
is the result of congenital disorders in the cardiac conduction system. WPW syndrome (Wolff-
Parkinson-White syndrome) occurs in approximately 2% of the population, LGL syndrome
(Lown-Ganong-Levine syndrome) in an average of 0.6% of the adult population. Approximately
30% of people with tachyarrhythmia have additional conduction pathways. Pathology can be
observed at any age. APs are quite common in the pediatric population (up to 0.5-0.8%). [4, 5,
10]. Objective of the study. To study the prevalence of various forms of cardiac PVH in school-
age children in terms of additional diagnostic capabilities of electrocardiography and to identify
the distribution of PVH syndromes and phenomena depending on the place of detection, age and
gender. To evaluate the anamnestic data of mothers of sick children with PVH, with an emphasis
on the course of pregnancy and childbirth. Also, to study the somatic development of sick
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children with PVH and timely diagnosis of rhythm and conduction disorders, conducting
treatment and preventive measures aimed at preventing the transformation of PVH into life-
threatening arrhythmias. Material and methods. In the course of the work, an epidemiological
approach was used to select and analyze the material for identifying cases of PVH in school-age
children. 1733 children aged 7-14 years (girls - 827, boys - 906) were examined. They were
selected from the general population of schoolchildren (17,330 children) in the Izbaskent district
of the Andijan region by simple randomization (A - girls, B - boys), which formed the basis of a
10% sample (Dvoyrin V.V., Klimenkov A.A. 1985). The compiled 10% sample of students of
comprehensive schools to identify cases of PVZh were examined with maximum coverage
(90.2% girls, 91.1% boys) of the children included in it. The examination was conducted in the
shortest possible time (2 - 3 months) to eliminate the time factor for the studied ECG parameters.
The examination program was carried out in two stages: Stage I was conducted according to the
following program: 1. standard survey, objective examination of children, and standard survey of
parents (Rose questionnaire) for the purpose of identifying attacks of tachyarrhythmia or its
equivalents; 2. Study of blood pressure (three times), pulse counting; 3. Anthropometric studies
and assessment of puberty of the examined children; 4. Electrocardiography (in 12 standard
leads). To exclude random fluctuations in ECG parameters (P–R(Q), ORS, ST–T), the identified
children with syndromes and phenomena of PVZ were again subjected to ECG examination for
2–4 weeks after the 1st stage of the examination. Children who had the same ECG changes,
anamnestic data indicating a history of cardiac pathologies, were hospitalized and subjected to a
more in-depth clinical and instrumental examination. This stage of the comprehensive study
constituted the second observation period.
In the work, a selective statistical method was used by simple randomization of the school
population. Klimenkov A.A. 1985). To determine the sample size, we used the formula n=t2p
(100 – p)/2; where p is the proportion (in %); is the maximum size of the sampling error (=4%);
t–confidence coefficient (t=2) with confidence probability (pt=0.95). The proportion of children
with heart rhythm and conduction disorders according to literature data is on average 4.33%.
Then according to the formula: P=224.33(100–4.33)/42=104. In order for the interval within
which the prevalence of these types of pathology is within 4.33±4.0% (0.33%–8.33%), the
required number of observations should be 104 children (82 with rhythm disorders and 22 with
conduction disorders).Results and discussion. Cases of WPW were identified based on
observation of sick children in stages I and II of the study. The criteria for diagnosing the WPW
syndrome and phenomenon were: the presence of a shortened P-Q interval (<0.11-0.12 sec),
prolongation of the ORS interval (>0.08-0.09 sec), -wave and secondary changes in the ST-T
segment on the ECG. If shortening of the ECG interval (<0.11-0.12 sec) was detected, we
diagnosed the CLC syndrome or phenomenon. The Mahaim phenomenon was diagnosed upon
detection of -wave with widening of the QRS complex (>0.08-0.09 sec) with normal P-Q(R)
values (>0.12 sec). If only -wave without widening of the QRS complex was detected in the
ECG, we regarded this phenomenon as partial Mahaim phenomenon [11]. We identified (12
cases) cases of Mahaim phenomenon in 11 cases were assessed as partial, since the -wave was
not combined with the widening of the QRS complex. We also analyzed ECG data of children
who received treatment in the pediatric cardiology department of Andrei GosMI for cardiac and
extracardiac pathology, where out of 30 cases (36.6%) of all identified cases of PVZ (82 cases),
only in 5 cases (16.7%) were they assessed as primary pathology, and in 25 cases (83.3%) as a
complication of the underlying disease. Distribution of syndromes and phenomena of PVZ
depending on the place of detection (in hospital or professional examination) showed (Table 1)
that 63.4% of children with syndrome and phenomenon of PVZ are detected for the first time
during preventive examinations of schoolchildren and only in 36.6% of children (p < 0.01) in
clinical conditions, more often against the background of other diseases.
Table 1.
Distribution of syndromes and phenomena of PVZ in children
depending on the place of detection.
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№ Синдром или феномен
ПВЖ
Всего
При проф.
осмотрах
В клинике
абс
%
Абс
%
1 Синдром WPW
9
5
55,5/6,09
4
44,4/2,38
2 Феномен WPW
17
6
35,3/7,52
11
64,7/13,4
3 Синдром CLC
24
18
75,0/21,9
6
25,0/7,32
4 Феномен CLC
20
11
55,0/13,4
9
45,0/10,9
5 Феномен Махайма
12
12
100,0/14,6 -
-
Всего:
82
52
63,4+6,68 30
36,6+8,79
PVZ were detected more often during preventive examinations (63.4%±6.68%) than in a clinical
setting (36.6%±8.79%). During preventive examinations, the most frequently detected were the
Mahaim phenomenon (100%), CLC syndrome (75%), less frequently WPW syndrome (55.5%)
and CLC phenomenon (55.0%). Among 30 children (36.6%) with PVZ syndromes and
phenomena detected in a clinical setting, the WPW phenomenon was predominant (64.7%), less
frequently CLC phenomenon (45.0%) and WPW syndrome (44.4%), and in one quarter of cases
CLC syndrome (25.0%). Thus, in most cases, PVZ manifestations among school-age children are
detected during preventive examinations, which necessitates dynamic dispensary examinations
among them. In clinical settings, syndromes or phenomena of PVG are not recognized by
pediatricians in a timely manner in most cases (83.4%), targeted diagnostic studies are not
conducted (functional ECG, drug tests, etc.), which leads to missed opportunities for treatment
correction in order to prevent complications of PVG (attacks of tachyarrhythmia, arrhythmogenic
cardiomyopathy, etc.) [13]. The distribution of sick children with manifestations of PVG
depending on gender and age showed (Table 2) that PVG is often found among boys - 58
(70.7%), than girls (29.3%), more often at the age of 11-14 years - 42 (51.2%), than at the age of
7-10 years (42.7%). PVG were detected often among boys aged 7-10 years - 23 (65.7%), and 11-
14 years - 35 (74.5%), than in girls of similar ages (34.3% and 25.5%).
Table 2.
Distribution of sick children with syndromes and phenomena of PVZ depending on age and
gender
№
Контингент обследованных
7-10 лет
11-14 лет
Всего
Д
М
Д
М
Д
М
1
Контрольная группа
25
25
25
25
50
50
2
Синдром WPW
1
3
1
4
2
7
3
Феномен WPW
1
6
2
8
3
14
4
Синдром CLC
4
5
5
10
9
15
5
Феномен CLC
6
5
4
5
10
10
6
Феномен Махайма
-
4
-
8
-
12
Всего больных детей
12
23
12
35
24
58
We have assessed the anamnestic data of mothers of sick children with PVZh, with an emphasis
on the course of pregnancy and childbirth (Table 3). Analyzing these complications of pregnancy
and childbirth in mothers of sick children, it should be noted that the detection of a relatively low
number of girls with PVZh syndrome (30.5%) versus boys (69.5%) is apparently not a random
fact, in the latter, the ante- and intranatal periods are burdened by pathologies of pregnancy and
childbirth on the part of their mothers [14].
Table 3.
Complications of pregnancy and childbirth in mothers
of sick children with PVZh syndrome (%)
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№ ВИДЫ ОСЛОЖНЕНИЙ
Контрольная
группа
Дети с ПВЖ
Д
n=50
M
n=50
Д
n-25
M
n-57
1
Ранний токсикоз
6,0
4,00
12,0
10,3
2
Поздний токсикоз:
Водянка
Нефропатия
Преэкламсия
Эклампсия
8,0
10,0
4,0
2,0
6,0
8,0
2,0
2,0
8,0
12,0
8,0
4,0
12,3
14,04
12,3
3,51
3
Кровотечения в I и II-й половине беременности 4,0
2,0
4,0
3,51
4
Ph и АВО изосенсибилизация
2,0
-
-
3,51
5
Многоводие
8,0
2,0
12,0
12,3
6
Маловодие
6,0
2,0
4,0
7,02
7
Многоплодие
2,0
4,0
-
1,75
8
Тазовое и ножноя предлежание плода
-
2,0
4,0
8,77
9
Слабость родовой деятельности
2,0
10,0
12,0
12,3
10
Длительные роды
2,0
2,0
12,0
10,3
11
Стремительные роды
2,0
4,0
4,0
14,04
12
Патология плаценты и пуповины
6,0
4,0
8,0
8,77
13
Преждевременное излитие околоплодных вод
8,0
4,0
12,0
15,8
14
Акушерские пособия в родах
4,0
4,0
12,0
14,04
15
Гипоксия плода
4,0
12,0
8,0
12,3
16
Асфиксия новорожденных
16,0
14,0
28,0
29,8
The examined children with manifestations of PVZ presented a wide variety of complaints
related to age, gender and had different vegetative coloring. Some clinical symptoms in sick
children with PVZ are given in Table 4.
Table 4.
Some clinical symptoms in examined healthy and
sick children with manifestations of PVZ (%)
№
Клинические симптомы
Девочки
Мальчики
Здоровые
N=50
Больные
n=25
Здоров
ые
n=50
Больны
е
N=57
1
Вялость
8,0
24,0*
14,0
7,02
2
Подвижность, тревожность
6,0
16,0
12,0
21,1
3
Увеличение щитовидной железы I-II
степени
12,0
24,0
4,0
19,3*
4
Повышенная
потливость
конечностей, акроцианоз
14,0
20,0
6,0
26,3
5
Гиперемия лица, ладоней, подошв
8,0
12,0
6,0
8,77
6
Дермографизм красный
Дермографизм белый
6,0
12,0
24,0*
16,0
6,0
8,0
17,5
19,3*
7
Усиленная
пульсация
шейных
сосудов (визуально)
12,0
28,0*
12,0
24,6*
8
Симптом Хвостека I и II степени
8,0
24,0*
10,0
26,3
9
Гипотония мышц рук и ног
10,0
20,0
12,0
28,1*
10
Сухожильные рефлексы на руках:
Повышено
Понижено
8,0
6,0
24,0*
12,0
2,0
12,0
14,0*
16,5
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11
Сухожильные рефлексы на ногах:
Повышено
Понижено
4,0
8,0
24,0
20,0
14,0
4,0
21,1
15,8
12
Брюшные рефлексы вызываются
Вызываются слабо
84,0
16,0
76,0
14,0
80,0
20,0
80,7
19,3
13
Границы
сердца
расширены
(перкуторно)
6
16,0
10,0
12,3
14
Тоны сердца приглушены: на
верхушке
На основании
4,0
2,0
16,0*
12,0*
2,0
10,0
12,3*
19,3
15
Тоны сердца усилены: на верхушке
на аорте и V-точке
6,0
6,0
16,0
12,0
10,0
8,0
17,5
12,3
16
Тоны сердца
расщеплены:
на
верхушке
На основании
8,0
4,0
24,0*
12,0
12,0
6,0
15,8
8,77
17
Систолический шум: на верхушке
на основании, V-точке
12,0
6,0
20,0
8,0
14,0
8,0
17,5
10,6
18
Разлитая
болезненность
в
эпигастрии, вокруг пупка, по ходу
толстого кишечника
10,0
16,0
12,0
24,6*
Note: * According to Fisher's exact method p<0.05-0.01.
It was shown that these clinical symptoms depended on the initial vegetative tone and more often
had a vagotonic orientation, more pronounced in girls than in boys. [7, 8].
Taking into account the literature data, it should be noted that retardation and disharmony in the
anthropometric indicators of children closely depend on their somatic development. We studied
the distribution of cases of normal (meso-), advanced (macro-) and retardated (microsomatotype)
development of sick children in a comparative aspect with healthy ones (Fig. 1).
Figure 1.
Distribution of somatic types among healthy and sick children with PVZh.
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Note: З – healthy B – general group of sick children, I-V respectively WPW: WPW syndrome (I),
WPW phenomenon (II), CLC syndrome (III), CLC phenomenon (IV) and Mahaim phenomenon
(V).
The data in Fig. 1. show that among children with WPW, the proportion of the mesosomatic type
of development is significantly reduced (39.0+5.38%) and the proportion of the microsomatic,
i.e. retarded type of development is increased (51.2+5.52%). In terms of severity, cases of the
microsomatic type in the structure of WPW predominate over cases of WPW syndrome
(66.7+5.2%), Mahaim phenomenon (50.0+5.52%), WPW phenomenon (47.1+5.51%), than CLC
syndrome (45.8+5.50%) and CLC phenomenon (40.0+5.41%).
Thus, the analysis of the obtained materials on the study of the physical development of children
with PVH allows us to say that the latter are significantly behind in many anthropometric
indicators, and their rates of biological maturation are reduced [15]. It has been shown that the
somatic immaturity of children with PVH is mediated by their pre- and perinatal periods of
development) and a burdened heredity for diseases of trophotropic orientation than ergotropic
genesis.
CONCLUSION
1. Syndrome of premature ventricular excitation (PVH) in school-age children is significantly
more often detected during targeted preventive examinations (63.4%) than in a clinical setting
(36.6%).
2. The population frequency of PVH is on average 0.47 per 1000 examined, and is significantly
more often detected in boys (0.69) than in girls (0.26). The proportion of this syndrome and
phenomenon among sick children with cardiac pathologies is 1.47%, and 7.42% of all cases of
heart rhythm and conduction disorders.
3. The main structure of PVZ is syndrome (29.3%), CLC phenomenon (24.4%) and WPW
phenomenon (20.7%), than Mahaim phenomenon (14.6%) and WPW syndrome (11.0%).
4. Sick children with PVZ are significantly retarded and disharmonious in general somatic
development - in 51.2% of cases their development corresponds to the microsomatic type of
development, often detected in PVZ by the WPW type (66.6%). Somatic immaturity of children
with PVG is often associated with immaturity of the myocardium of the atria and ventricles,
mediated by their pre- and perinatal periods of development and a burdened heredity for diseases
more often of trophotropic than ergotropic orientation.
5. PVG syndrome significantly determines the development of central hemodynamic disorders,
characterized by the cardiac type of self-regulation (42.7%), and a prehypertensive state of the
cardiac type (26.8%), the development of "phase syndrome of hyperdynamics" - an increase in
the volumetric ejection rate (IEV, ml / kg / min), external work of the heart (IA kgm), the power
of cardiac contractions (PCC, Bt).
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